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By X. Silvio. Cabrini College.

The paired bones are the maxilla order seroquel 50mg medications beginning with z, palatine seroquel 50mg without prescription medications 25 mg 50 mg, zygomatic buy cheap seroquel 200mg on-line treatment diabetic neuropathy, nasal, lacrimal, and inferior nasal conchae bones. Although classified with the brain-case bones, the ethmoid bone also contributes to the nasal septum and the walls of the nasal cavity and orbit. Maxillary Bone The maxillary bone, often referred to simply as the maxilla (plural = maxillae), is one of a pair that together form the upper jaw, much of the hard palate, the medial floor of the orbit, and the lateral base of the nose (see Figure 7. The curved, inferior margin of the maxillary bone that forms the upper jaw and contains the upper teeth is the alveolar process of the maxilla (Figure 7. On the inferior skull, the palatine process from each maxillary bone can be seen joining together at the midline to form the anterior three-quarters of the hard palate (see Figure 7. The hard palate is the bony plate that forms the roof of the mouth and floor of the nasal cavity, separating the oral and nasal cavities. Palatine Bone The palatine bone is one of a pair of irregularly shaped bones that contribute small areas to the lateral walls of the nasal cavity and the medial wall of each orbit. The plates from the right and left palatine bones join together at the midline to form the posterior quarter of the hard palate (see Figure 7. Inside the mouth, the palatine processes of the maxilla bones, along with the horizontal plates of the right and left palatine bones, join together to form the hard palate. If an error occurs in these developmental processes, a birth defect of cleft lip or cleft palate may result. Cleft lip is a common development defect that affects approximately 1:1000 births, most of which are male. This defect involves a partial or complete failure of the right and left portions of the upper lip to fuse together, leaving a cleft (gap). It is formed during embryonic development by the midline fusion of the horizontal plates from the right and left palatine bones and the palatine processes of the maxilla bones. It results from a failure of the two halves of the hard palate to completely come together and fuse at the midline, thus leaving a gap between them. In severe cases, the bony gap continues into the anterior upper jaw where the alveolar processes of the maxilla bones also do not properly join together above the front teeth. Because of the communication between the oral and nasal cavities, a cleft palate makes it very difficult for an infant to generate the suckling needed for nursing, thus leaving the infant at risk for malnutrition. Each of the paired zygomatic bones forms much of the lateral wall of the orbit and the lateral-inferior margins of the anterior orbital opening (see Figure 7. The short temporal process of the zygomatic bone projects posteriorly, where it forms the anterior portion of the zygomatic arch (see Figure 7. Nasal Bone The nasal bone is one of two small bones that articulate (join) with each other to form the bony base (bridge) of the nose. Lacrimal Bone Each lacrimal bone is a small, rectangular bone that forms the anterior, medial wall of the orbit (see Figure 7. The anterior portion of the lacrimal bone forms a shallow depression called the lacrimal fossa, and extending inferiorly from this is the nasolacrimal canal. The lacrimal fluid (tears of the eye), which serves to maintain the moist surface of the eye, drains at the medial corner of the eye into the nasolacrimal canal. In the nasal cavity, the lacrimal fluid normally drains posteriorly, but with an increased flow of tears due to crying or eye irritation, some fluid will also drain anteriorly, thus causing a runny nose. Inferior Nasal Conchae The right and left inferior nasal conchae form a curved bony plate that projects into the nasal cavity space from the lower lateral wall (see Figure 7. The inferior concha is the largest of the nasal conchae and can easily be seen when looking into the anterior opening of the nasal cavity. Vomer Bone The unpaired vomer bone, often referred to simply as the vomer, is triangular-shaped and forms the posterior-inferior part of the nasal septum (see Figure 7. The vomer is best seen when looking from behind into the posterior openings of the nasal cavity (see Figure 7. A much smaller portion of the vomer can also be seen when looking into the anterior opening of the nasal cavity. At the time of birth, the mandible consists of paired right and left bones, but these fuse together during the first year to form the single U-shaped mandible of the adult skull. Each side of the mandible consists of a horizontal body and posteriorly, a vertically oriented ramus of the mandible This OpenStax book is available for free at http://cnx. The outside margin of the mandible, where the body and ramus come together is called the angle of the mandible (Figure 7. The more anterior projection is the flattened coronoid process of the mandible, which provides attachment for one of the biting muscles. The posterior projection is the condylar process of the mandible, which is topped by the oval-shaped condyle. The condyle of the mandible articulates (joins) with the mandibular fossa and articular tubercle of the temporal bone. Together these articulations form the temporomandibular joint, which allows for opening and closing of the mouth (see Figure 7. Important landmarks for the mandible include the following: • Alveolar process of the mandible—This is the upper border of the mandibular body and serves to anchor the lower teeth. The muscle that forms the floor of the oral cavity attaches to the mylohyoid lines on both sides of the mandible. The sensory nerve and blood vessels that supply the lower teeth enter the mandibular foramen and then follow this tunnel. Thus, to numb the lower teeth prior to dental work, the dentist must inject anesthesia into the lateral wall of the oral cavity at a point prior to where this sensory nerve enters the mandibular foramen. A ligament that anchors the mandible during opening and closing of the mouth extends down from the base of the skull and attaches to the lingula. The Orbit The orbit is the bony socket that houses the eyeball and contains the muscles that move the eyeball or open the upper eyelid. Each orbit is cone-shaped, with a narrow posterior region that widens toward the large anterior opening. To help protect the eye, the bony margins of the anterior opening are thickened and somewhat constricted. The medial walls of the two orbits 272 Chapter 7 | Axial Skeleton are parallel to each other but each lateral wall diverges away from the midline at a 45° angle. The medial floor is primarily formed by the maxilla, with a small contribution from the palatine bone. The ethmoid bone and lacrimal bone make up much of the medial wall and the sphenoid bone forms the posterior orbit. At the posterior apex of the orbit is the opening of the optic canal, which allows for passage of the optic nerve from the retina to the brain. Lateral to this is the elongated and irregularly shaped superior orbital fissure, which provides passage for the artery that supplies the eyeball, sensory nerves, and the nerves that supply the muscles involved in eye movements. Opening into the posterior orbit from the cranial cavity are the optic canal and superior orbital fissure.

Deferoxamine in iron poisoning color urine red or methylene blue given in treatment of nitrate poisoning may color urine blue) seroquel 200mg discount medications parkinsons disease. Strong-smelling poisons such as methylsalicylate can sometimes recognized in urine since they are excreted in part unchanged seroquel 50mg without a prescription medicine 665. Turbidity may be due to underlying pathology (blood buy seroquel 50mg fast delivery treatment zone tonbridge, microorganisms, casts, epithelial cells), or carbonates, phosphates or urates (in amorphous or microcrystalline forms). Such findings should not be ignored, even though they may not be related to the poisoning. Stomach contents and scene residues Some characteristic smells can be associated with particular poisons (e. Very low or very high pH may indicate ingestion of acid or alkali, while a green/blue color suggests the presence of iron or copper salts. Microscopic examination using a polarizing microscope may reveal the presence of tablet or capsule debris. Undegraded tablets or capsules and any plant remains or specimens of plants thought to have been ingested should be examined separately. Apparatus Analytical toxicology services can be provided in clinical biochemistry laboratories that serve a local hospital or accident and emergency unit. In addition to basic laboratory equipment, some specialized apparatus, such as that for thin-layer chromatography, ultraviolet and visible spectrophotometry and microdiffusion, is needed. No reference has been made to the use of more complex techniques, such as gas-liquid and high-performance liquid chromatography, atomic absorption spectrophotometry or immunoassays, even if simple methods are not available for particular compounds. Although such techniques are more selective and sensitive than many simple methods, there are a number of factors, in addition to operator expertise, that have to be considered before they can be used in individual laboratories. The standards of quality (purity or cleanliness) of laboratory reagents and glassware and of consumable items such as solvents and gases needs to be considerably higher than for the tests described in this manual if reliable results are to be obtained. Additional complications, which may not be apparent when instrument purchase is contemplated, include the need to ensure a regular supply of essential consumables (gas chromatographic septa, injection syringes, chromatography columns, solvent filters, chart or integrator paper, recorder ink or fibre-tip pens) and spare or additional parts (detector lamps, injection loops, column packing materials). Similarly, immunoassay kits are relatively simple to use, although problems can arise in practice, especially in the interpretation of results. Moreover, they are aimed primarily at the therapeutic drug monitoring and drug abuse testing markets and, as such, have limited direct application in clinical toxicology. Reference compounds and reagents A supply of relatively pure compounds for use as reference standards is essential if reliable results are to be obtained. However, expensive reference compounds of a very high degree of purity, such as those marketed for use as pharmaceutical quality control standards, are not normally needed. Some drugs, such as barbiturates, caffeine and salicylic acid, and many inorganic and organic chemicals and solvents are available as laboratory reagents with an adequate degree of purity through normal laboratory chemical suppliers. Such a reference collection is a valuable resource, and it should be stored under conditions that ensure safety, security and stability. Although the apparatus required to perform the tests described in this manual is relatively simple, several unusual laboratory reagents are needed in order to be able to perform all the tests described. At last, it is beyond the scope of the lecture note to cover all the reagents (See annex I). General laboratory tests in clinical toxicology 36 Toxicology Many clinical laboratory tests can be helpful in the diagnosis of acute poisoning and in assessing prognosis. More specialized tests may be appropriate depending on the clinical condition of the victim, the circumstantial evidence of poisoning and the past medical history. Biochemical tests Blood glucose: Determination of blood glucose is essential to know those toxic substances that affect blood glucose biotransformation. A toxicant that causes hypoglycemia includes insulin, iron, acetyl salicylic acid & so on. Hyperglycemia is a less common complication of poisoning than hypoglycemia, but has been reported after over dosage with acetylsalicylic acid, salbutamol and theophylline. Electrolytes, blood gases and pH Toxic substances or their metabolites, which inhibit key steps in intermediary biotransformation, are likely to cause metabolic acidosis owing to the accumulation of organic acids, notably lactate. Cholinesterase activity Plasma cholinesterase is a useful indicator of exposure to organophosphorus compounds or carbamates, and a normal plasma cholinesterase activity effectively excludes acute poisoning by these compounds. The diagnosis can sometimes be assisted by detection of a poison or metabolite in a body fluid, but the simplest method available is relatively insensitive. Measurement of serum osmolality The normal osmolality of plasma (280-295mOsm/Kg) is largely accounted by sodium, urea &glucose. However, large increases in plasma osmolality may follow the absorption of osmotically active poisons (especially methanol, ethanol, or propan-2-ol) in relatively large amounts. Together with the standard chemistry panel, serum osmolality allows identification of an osmolal gap, which may indicate intoxication with ethanol or other alcohols. Hematological tests Hematocrit (Erythrocyte volume fraction) Acute or acute-on-chronic over dosage with iron salts, acetylsalicylic acid, indomethacin, and other non-steroidal anti- inflammatory drugs may cause gastrointestinal bleeding leading to anemia. Anaemia may also result from chronic exposure to toxins that interfere with haem synthesis, such as lead. Leukocyte count Increases in the leukocyte (white blood cell) count often occur in acute poisoning, for example, in response to an acute metabolic acidosis, resulting from ingestion of ethylene glycol or methanol, or secondary to hypostatic pneumonia following prolonged coma. Blood clotting The prothrombin time and other measures of blood clotting are likely to be abnormal in acute poisoning with rodenticides such as Coumarin anticoagulants. Carboxyhemoglobin Measurement of blood carboxyhemoglobin can be used to assess the severity of acute carbon monoxide poisoning. However, carboxyhemoglobin is dissociated rapidly once the victim is removed from the contaminated atmosphere, especially if oxygen is administered, and the sample should therefore be 39 Toxicology obtained as soon as possible after admission. Even then, blood carboxyhemoglobin concentrations tend to correlate poorly with clinical features of toxicity. Mention the steps that are necessary to undertake analytic toxicological investigations. Describe specimen collection, transportation, storage, characteristics & physical examination used in clinical toxicology laboratory. Describe apparatus, reference compounds & reagents used in clinical toxicology laboratory. Understand the common toxicology laboratory techniques Introduction Methods for particular toxicologic tests or panels are a well established part of routine laboratory tests, and information about them is available on request. In order to interpret toxicology results properly, the laboratory technician should have a rudimentary familiarity with the analytic methods employed. The choice depends on the size and budget of the institution, the types of victims served the proximity to more elaborate toxicology facilities, and other factors. Selection of test methods Selection of test methods can be generally classified as either screening or confirmatory. Screening methods Screening is the testing or examining of a poisoned person for a chemical agent causing toxicity.

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Its upper surface is covered by the mucous membrane of the such as mylohyoid and geniohyoid and closed by the masseter 300 mg seroquel treatment zinc toxicity, tem- mouth and its numerous ducts open onto a ridge in the floor of the poralis and medial pterygoid discount seroquel 50 mg with amex medicine hat jobs. The upper part of the neck and the submandibular region 145 66 The mouth buy 200mg seroquel mastercard medicine 6mp medication, palate and nose Fungiform papillae Filiform papillae Vallate papillae Foramen caecum Palatoglossal fold Lingual lymphatic Fig. The nerve supply of the pharynx Muscles The pharyngeal plexus is a plexus of nerves formed by: • Levator palati: elevates the palate. This provides the motor supply to the muscles palate so that it moves towards the back wall of the oropharynx where except for the tensor palati which is supplied by the mandibular divi- it meets a part of the superior constrictor which contracts strongly sion of the trigeminal. The mouth and nasal cavi- • The glossopharyngeal nerve, which provides the sensory supply to ties are thus separated so that food does not regurgitate into the nose the pharynx. They raise two ridges, the palatoglossal and palatopharyngeal nasopalatine nerves from the maxillary division of the trigeminal arches, that are also called the anterior and posterior pillars of the (Fig. Posterior one third by the glossopharyngeal • The tonsil: a mass of lymphatic tissue lying in the tonsillar fossa nerve. A small part of the tongue near the epiglottis is supplied by the which, like the rest of the lymphatic system, reaches its maximum size internal laryngeal branch of the vagus nerve. Lateral to the tonsil is its fibrous capsule and the superior Since the anterior part of the tongue develops from a pair of lingual constrictor. It is supplied by the tonsillar branch of the facial artery swellings, the nerves and blood vessels of each side of the tongue do not but the bleeding that occurs after tonsillectomy is usually from the cross the midline (although some lymphatics do) so that a midline inci- paratonsillar vein. If the motor supply is cut off on been mentioned and there is also a lingual tonsil lying in the back of one side, the tongue will diverge to the affected side when protruded the tongue. The permanent teeth comprise two The boundaries of the nasal cavity include the: incisors, a canine, two premolars and three molars. The first milk teeth • Nasal septum: perpendicular plate of the ethmoid, vomer and a large to erupt are usually the lower central incisors at about 6 months and the plate of cartilage. The tongue is divided developmentally and anatomically into an an- • Roof: nasal bones, cribriform plate of the ethmoid, body of the terior two-thirds and a posterior one third, separated by the sulcus sphenoid. The spaces beneath the conchae are the meatuses and the region In front of the sulcus is a row of vallate papillae. The paranasal sinuses • The maxillary sinus: inside the body of the maxilla, it opens into the Muscles (Fig. Since the opening is in the upper part of the sinus it does • Intrinsic muscles: run in three directions, longitudinally, trans- not drain easily. Genioglossus is especially important as it is inserted along the whole • The sphenoidal sinus: inside the body of the sphenoid. Drains into the inferior • Sensory: anterior two-thirds by the lingual nerve; taste fibres travel meatus. The mouth, palate and nose 147 67 The face and scalp Frontal belly of occipitofrontalis Temporalis Orbicularis oculi Zygomaticus major Zygomaticus minor Levator labii superioris (elevator of the upper lip) Buccinator Levator anguli oris (elevator of the angle of the mouth) Orbicularis oris Outline of parotid (salivary) gland Masseter Depressor anguli oris (depressor of the angle of the mouth) Depressor labii inferioris (depressor of the lower lip) Fig. They are all sup- has an orbital part which surrounds the eye as a sphincter and closes the plied by the mandibular division of the trigeminal (p. They have only one attachment to bone, or sometimes no attach- to keep the cheeks in contact with the gums so that food does not collect ment at all, the other end of the muscle being inserted into skin or in this region. It • The facial nerve: having left the stylomastoid foramen, the facial extends deeply to come into contact with the pharynx and posteriorly it nerve enters the parotid and divides into frontal, zygomatic, buccal, is moulded around the mastoid process and sternomastoid. The whole gland is enclosed in dense fascia so mandibular branch lies below the mandible for part of its course so that that swelling of the gland, as in mumps for instance, is very painful. Lesions of the facial nerve, for example superficial to deep: the facial nerve, the retromandibular vein (the by tumours of the parotid, cause unilateral drooping of the face with beginning of the external jugular) and the external carotid artery, with loss of the normal skin creases, and it can be shown up by asking the its maxillary and superficial temporal branches. The face and scalp 149 Supraorbital artery and nerve Temporal branch Supratrochlear artery Zygomatic branch Facial artery Superficial Infraorbital nerve temporal artery Facial vein Parotid duct Labial branches Lesser occipital nerve Buccal branch Greater auricular nerve Mental nerve Posterior auricular vein Marginal mandibular branch Retromandibular vein Cervical branch Fig. It has a fibres of the palpebral part of the orbicularis oculi, some loose areolar tortuous course, passes close to the corner of the mouth and then along- tissue and skin. Partly embedded in the deep surface of the tarsal plates side the nose to end near the medial angle of the eye. It anastomoses are the tarsal (Meibomian) glands which open onto the edge of the eye- freely across the midline and with other arteries on the face. This is a possible route for infection to travel the superior fornix of the conjunctiva and thence across the eye to the from the face to the sinus. From here the tears pass into the lacrimal puncta, two minute openings in the upper and lower eyelids, and thence The eye into the lacrimal sac lying in a groove in the lacrimal bone. This drains • The conjunctiva: covers the surface of the eye and is reflected onto the tears into the nasolacrimal duct which opens into the inferior mea- the inner surface of the eyelids, the angle of reflection forming the tus of the nose. The conjunctiva over the surface of the eye is thin so that a conjunctival haemorrhage is bright red as the blood remains fully oxygenated. Small veins that pass through the skull and unite the veins of the scalp • Loose areolar tissue: this forms a plane of cleavage in head injuries with the intracranial veins. The face and scalp 151 68 The cranial cavity Cerebral veins Falx cerebri Tentorium cerebelli Endothelium of superior sagittal sinus Diaphragma sellae Emissary vein Fibrous dura Serous dura Fig. The cere- also forms two large sheetsathe falx cerebri and the tentorium cere- brospinal fluid is produced in the choroid plexuses of the lateral, 3rd belli (see below). The subarachnoid space contains the cerebrospinal between the arachnoid and pia and serves to protect the brain and spinal fluid. It tapers to a point anteriorly but pos- which forms a roof over the pituitary fossa and the pituitary gland. Veins from the cerebral hemispheres drain into the superior The cavernous sinus lies on either side of the pituitary fossa and the sagittal sinus or into diverticula from it, the lacunae laterales. Like the other venous sinuses, it is formed by a the underlying arachnoid sends small outgrowths through the serous layer of serous dura lined by endothelium. These are the arachnoid villi and they are dura from the posterior cranial fossa projects forwards into the side of the site of absorption of cerebrospinal fluid into the bloodstream. The cranial cavity 153 69 The orbit and eyeball Frontal Superior oblique Lacrimal Optic nerve Trochlear Central artery of retina Oculomotor Ophthalmic artery Abducent Oculomotor Nasociliary Fibrous ring Inferior oblique Fig. The most important branch of the ophthalmic artery is the central and 6th cranial nerves and the three branches of the ophthalmic division artery of the retina which enters the optic nerve and is the only blood of the trigeminal nerve. The outermost is a tough superior and inferior ophthalmic veins drain it, passing through the fibrous layer, the sclera. Anteriorly, the • The superior orbital fissure: this slit-like opening is divided into sclera is replaced by the transparent cornea, which is devoid of vessels two parts by the fibrous ring that forms the origin of the main muscles or lymphatics and can therefore be transplanted. Behind the cornea, the choroid is replaced by • Above the ringafrontal, lacrimal and trochlear nerves. These, when they contract, • The inferior orbital fissure: transmits the maxillary nerve and some relax the lens capsule and allow the lens to expand; thus they are used in small veins. The lens the levator palpebrae superioris which is inserted into the upper eyelid lies behind the pupil and is enclosed in a delicate capsule. The ciliary body secretes the aqueous humour into the posterior • The medial rectusaturns the eyeball medially.

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Hyperphosphatemia cheap seroquel 50 mg with mastercard 68w medications, or abnormally increased levels of phosphates in the blood buy discount seroquel 200mg 3 medications that affect urinary elimination, occurs if there is decreased renal function or in cases of acute lymphocytic leukemia purchase 50mg seroquel visa symptoms 2015 flu. Regulation of Sodium and Potassium Sodium is reabsorbed from the renal filtrate, and potassium is excreted into the filtrate in the renal collecting tubule. Aldosterone Recall that aldosterone increases the excretion of potassium and the reabsorption of sodium in the distal tubule. Aldosterone is released if blood levels of potassium increase, if blood levels of sodium severely decrease, or if blood pressure decreases. Its net effect is to conserve and increase water levels in the plasma by reducing the excretion of sodium, and thus water, from the kidneys. This action increases the glomerular filtration rate, resulting in more material filtered out of the glomerular capillaries and into Bowman’s capsule. In the distal convoluted tubules and collecting ducts of the kidneys, aldosterone stimulates the synthesis and activation of the sodium-potassium pump (Figure 26. Aldosterone’s effect on potassium is the reverse of that of sodium; under its influence, excess potassium is pumped into the renal filtrate for excretion from the body. The hormone activates osteoclasts to break down bone matrix and release inorganic calcium-phosphate salts. The hormone increases the activity of osteoblasts, which remove calcium from the blood and incorporate calcium into the bony matrix. A variety of buffering systems permits blood and other bodily fluids to maintain a narrow pH range, even in the face of perturbations. A buffer is a chemical system that prevents a radical change in fluid pH by dampening the change in hydrogen ion concentrations in the case of excess acid or base. Most commonly, the substance that absorbs the ions is either a weak acid, which takes up hydroxyl ions, or a weak base, which takes up hydrogen ions. Buffer Systems in the Body The buffer systems in the human body are extremely efficient, and different systems work at different rates. The renal system can also adjust blood pH through the excretion of + hydrogen ions (H ) and the conservation of bicarbonate, but this process takes hours to days to have an effect. The buffer systems functioning in blood plasma include plasma proteins, phosphate, and bicarbonate and carbonic acid buffers. The kidneys help control acid-base balance by excreting hydrogen ions and generating bicarbonate that helps maintain blood plasma pH within a normal range. Proteins are made up of amino acids, which contain positively charged amino groups and negatively charged carboxyl groups. The charged regions of these molecules can bind hydrogen and hydroxyl ions, and thus function as buffers. Buffering by proteins accounts for two-thirds of the buffering power of the blood and most of the buffering within cells. Hemoglobin as a Buffer Hemoglobin is the principal protein inside of red blood cells and accounts for one-third of the mass of the cell. Bicarbonate ions and carbonic acid are present in the blood in a 20:1 ratio if the blood pH is within the normal range. With 20 times more bicarbonate than carbonic acid, this capture system is most efficient at buffering changes that would make the blood more acidic. This is useful because most of the body’s metabolic wastes, such as lactic acid and ketones, are acids. In red blood cells,2 carbonic anhydrase forces the dissociation of the acid, rendering the blood less acidic. The level of bicarbonate in the blood is controlled through the renal system, where2 bicarbonate ions in the renal filtrate are conserved and passed back into the blood. Respiratory Regulation of Acid-Base Balance The respiratory system contributes to the balance of acids and bases in the body by regulating the blood levels of carbonic acid (Figure 26. Reduced breathing (hypoventilation) due to drugs such as morphine, barbiturates, or ethanol (or even just holding one’s breath) can also result in hypercapnia. A decrease of blood bicarbonate can result2 from the inhibition of carbonic anhydrase by certain diuretics or from excessive bicarbonate loss due to diarrhea. Blood bicarbonate levels are also typically lower in people who have Addison’s disease (chronic adrenal insufficiency), in which aldosterone levels are reduced, and in people who have renal damage, such as chronic nephritis. Finally, low bicarbonate blood levels can result from elevated levels of ketones (common in unmanaged diabetes mellitus), which bind bicarbonate in the filtrate and prevent its conservation. The hydrogen ion is secreted into the filtrate, where it can become part of new water molecules and be reabsorbed as such, or removed in the urine. It is also possible that salts in the filtrate, such as sulfates, phosphates, or ammonia, will capture hydrogen ions. In such cases,2 bicarbonate ions are not conserved from the filtrate to the blood, which will also contribute to a pH imbalance and acidosis. If more potassium is present than normal, potassium, rather than the hydrogen ions, will be exchanged, and increased potassium enters the filtrate. If there is less potassium, more hydrogen ions enter the filtrate to be exchanged with sodium and more bicarbonate is conserved. If chloride is lost, the body uses bicarbonate This OpenStax book is available for free at http://cnx. Acid-Base Balance: Ketoacidosis Diabetic acidosis, or ketoacidosis, occurs most frequently in people with poorly controlled diabetes mellitus. When certain tissues in the body cannot get adequate amounts of glucose, they depend on the breakdown of fatty acids for energy. When acetyl groups break off the fatty acid chains, the acetyl groups then non-enzymatically combine to form ketone bodies, acetoacetic acid, beta-hydroxybutyric acid, and acetone, all of which increase the acidity of the blood. Ketoacidosis can be severe and, if not detected and treated properly, can lead to diabetic coma, which can be fatal. Treatment for diabetic coma is ingestion or injection of sugar; its prevention is the proper daily administration of insulin. Among people with type 2 diabetes, those of Hispanic and African-American descent are more likely to go into ketoacidosis than those of other ethnic backgrounds, although the reason for this is unknown. Acidosis has several symptoms, including headache and confusion, and the individual can become lethargic and easily fatigued (Figure 26. Some symptoms of alkalosis include cognitive impairment (which can progress to unconsciousness), tingling or numbness in the extremities, muscle twitching and spasm, and nausea and vomiting. Metabolic Acidosis: Primary Bicarbonate Deficiency Metabolic acidosis occurs when the blood is too acidic (pH below 7. The most common cause of metabolic acidosis is the presence of organic acids or excessive ketones in the blood. The first three of the eight causes of metabolic acidosis listed are medical (or unusual physiological) conditions. Metabolic acidosis can also arise from diabetic ketoacidosis, wherein an excess of ketones is present in the blood. Other causes of metabolic acidosis are a decrease in the excretion of hydrogen ions, which inhibits the This OpenStax book is available for free at http://cnx.