TOXIC ALCOHOL INGESTION

Question 1

Clinical Features

Answer 1

Early toxicity: CNS sedation and inebriation

Late toxicity: metabolic acidosis with elevated anion gap; compensatory tachypnea/hyperpnea; coma in severe cases

Question 2

Clinical Feature specific to Methanol bs Ethylene Glycol

Answer 2

ocular toxicity (methanol)

renal failure (ethylene glycol)

Question 3

Diagnostic Testing

Answer 3

Arterial or venous blood gas (to determine extent of acidosis)

Basic chemistry (to determine anion gap and renal function)

Serum osmolality (to help determine diagnosis)

Serum ethanol concentration (to help determine osmolal gap)

Serum calcium concentration (to rule out ethylene-glycol associated hypocalcemia)

Serum methanol, ethylene glycol, and isopropanol concentrations (to establish diagnosis)

Urinalysis (for oxalate crystals)

Question 4

Management

Answer 4

Secure airway as necessary

Treat hypotension: IV crystalloid, vasopressors as necessary

fomepizole, 15 mg/kg IV loading dose, followed by 10 mg/kg q 12 h × 4 doses.

sodium bicarbonate, 1 to 2 meq/kg bolus followed by infusion of 132 meq NaHCO3 in 1 L D5W to run at 200 to 250 mL/hour for patients with pH below 7.3

For patients with known or suspected methanol poisoning, administer folic acid, 50 mg IV every six hours

For patients with known or suspected ethylene glycol poisoning, administer thiamine, 100 mg IV, and administer pyridoxine, 50 mg IV

Question 5

Alternative to fomepizole

Answer 5

If fomepizole is unavailable or patient has a known allergy: ethanol, 10 mL/kg of a 10% ethanol solution, followed by 1 mL/kg of 10% ethanol solution infused per hour. Titrate to serum ethanol concentration of 100 mg/dL

Question 6

Indications for hemdyalisis

Answer 6

Metabolic acidosis, regardless of drug level
Elevated serum methanol or ethylene glycol levels (more than 50 mg/dL; or methanol 15.6 mmol/L, ethylene glycol 8.1 mmol/L), unless arterial pH is above 7.3
Evidence of end-organ damage (eg, visual changes, renal failure)