S61(2) - Toxic Alcohol

Question 1

Na = 141
Cl = 110
BUN = 19
glucose = 145
K = 3.6
Bicarb = 20
SCr - 1.6

calculate anion gap?

Answer 1

141-110-20 = 11

Question 2

Na - Cl - bicarb = anion gap

Answer 2

true

Question 3

2(Na+) + BUN/2.8 + Glucose/18 = olsmalality

Answer 3

true

Question 4

2(Na+) + BUN/2.8 + Glucose/18 + EtOH/4.6 = = calculated osmolality

Answer 4

true

Question 5

Osmolar gap = measured – calculated

Answer 5

true

Question 6

A consensus guideline recommends that children with more than an observed lick, sip or taste ingestion or an adult with known accidental ingestion of more than a “swallow” (10 to 30 mL) should be referred immediately to a healthcare facility

Answer 6

true

Toxic ingestion: ~100mL

Question 7

Toxic product of ethylene glycol is oxalic acid

Answer 7

true

Question 8

oxalic acid can binds calcium to form calcium oxylate and forms crystals.

Deposits in lungs, heart, kidneys
Can cause cranial nerve damage
Co-ingestion of alcohol can delay damage

Answer 8

true

Question 9

Ethylene toxicity phases:

Phase 1

Answer 9

30 mins-12 hours

CNS effects: N/V, inebriation, sz

Question 10

Ethylene toxicity phases:

Phase 2

Answer 10

12-24 hour

Metabolic: cardiopulmonary compromise, Anion Gap acidosis

Question 11

Ethylene toxicity phases:

Phase 3

Answer 11

2-3 days

Renal: calcium oxalate, Acute Tubular Necrosis, hematuria/proteinuria

Question 12

Early management of ethylene toxicity:

Consider nasogastric aspiration (if less than 1 hour)
Activated charcoal NOT effective
Sodium bicarbonate only if life threatening acidosis

suction of contents

Answer 12

true

Question 13

Ethylene glycol toxicity antedote:
Ethanol
Fomepizole

Answer 13

true

Alcohol dehydrogenase inhibition

Question 14

Ethylene glycol toxicity Shunting therapy

Thiamine, magnesium, pyridoxine

Answer 14

true

Question 15

“Shunting Therapy” utilizes:
A. 50mg of vitamins B1 and B6 IV q 6 hours
B. 100mg of vitamins B1 and B6 PO q 12 hours
C. 50mg of folic acid SQ injection
D. 100mg of vitamins B1 and B6 IV q 6 hours

Answer 15

A. 50mg of vitamins B1 and B6 IV q 6 hours

Question 16

Antidotal Therapy
Indications
1.) Ethylene glycol level > 20 mg/dL
2.)History of ingesting ethylene glycol with osmol gap > 10 mOsm/kg
3.) Clinical suspicion of ethylene glycol poisoning + two of the following:
- pH < 7.3 (acidosis)
- Bicarbonate < 20 mEq/L (acidosis)
- Osmolar gap > 10 mOsm/kg 
- Urinary oxalate crystals

Answer 16

True

Continued until ethylene glycol < 20 mg/dL AND acidosis is resolved

Question 17

Ethanol administration Caution for the following:

Phlebitis (central line preferred)
Hypoglycemia
Altered mentation

Answer 17

true

Question 18

Fomepizole (FDA approved)
Alcohol dehydrogenase inhibitor
8000x higher affinity than ethanol

Answer 18

true

Dose MUST be adjusted if HD initiated

Question 19

Ethylene glycol
Found in
antifreeze (95%), brake fluid, and solvents in industry
also adulterated spirits

Answer 19

true

Question 20

What urgent treatment can we use, if any?

Answer 20

Hemodialysis
ethylene glycol > 100 mg/dL
refractory acidosis
renal failure

Question 21

ethylene glycol

Answer 21

anion gap present
osmolar gap present

normal anion gap = <12
normal osmolar gam 10-20