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PHM 702- Toxicology > Toxic Alcohol Poisoning > Flashcards

Toxic Alcohol Poisoning Flashcards

1
Q

What are toxic alcohols?

A

Alcohol not intended for ingestion

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2
Q

Examples of toxic alcohols

A

Methanol-containing consumer products (like windshield washer fluid), ethylene glycol (car antifreeze), isopropanol (rubbing alcohol)

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3
Q

Clinical manifestations of toxic alcohol poisoning are usually seen where?

A

CNS

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4
Q

Inebriation with a toxic alcohol poisoning is dependent on what?

A

Dose and molecular weight

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5
Q

What happens if a patient doesn’t LOOK inebriated

A

Just because they don’t look like it, doesn’t meant they didn’t ingest anything

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6
Q

Other clinical manifestation of toxic alcohol poisoning (not CNS effects)

A

Metabolic acidosis

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7
Q

How is metabolic acidosis caused in toxic alcohol poisoning?

A

The toxic alcohols are metabolized to toxic organic acids which causes a high anion gap metabolic acidosis

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8
Q

Methanol is metabolized to what?

A

Formic acid

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9
Q

Ethylene glycol is metabolized to what?

A

Glycolic acid

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10
Q

Isopropanol is metabolized to what?

A

Acetone; it causes ketosis without acidosis

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11
Q

Toxic alcohol-specific clinical manifestations: methanol

A

Retinal toxicity: blurry vision to complete blindness, can be asymmetric

Neurotoxicity: basal ganglia lesions bilaterally which can lead to Parkinsonism

AKI

Pancreatitis

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12
Q

Toxic alcohol-specific clinical manifestations: ethylene glycol

A

Nephrotoxicity

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13
Q

How can ethylene glycol cause nephrotoxicity?

A

Oxalic acid + calcium = calcium oxalate monohydrate crystals → deposit in renal tubules → precipitation can cause hypocalcemia

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14
Q

What to monitor in ethylene glycol toxicity

A

Calcium levels

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15
Q

Toxic alcohol-specific clinical manifestations: isopropanol

A

Hemorrhagic gastritis

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16
Q

Toxic alcohol poisoning diagnostic tests: serum concentrations to look for/order

A

Methanol, formate, ethylene glycol, isopropanol

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17
Q

Caveat about the toxic alcohol serum concentrations

A

The results may not come back in a timely manner, so you have to base the diagnosis on clinical history and other lab values that have been obtained

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18
Q

What levels can be helpful if it’s been a while since the patient ingested the toxic alcohol?

A

Formate

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19
Q

How to handle toxic alcohol samples

A

The sample tubes should be airtight to prevent evaporation (isopropanol and methanol specifically)

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20
Q

Toxic concentration of methanol and ethylene glycol

A

> 25mg/dl

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21
Q

What other values should you obtain for toxic alcohol poisoning testing?

A

Electrolytes, calcium, BUN, Cr, UA, VBG or ABG, lactate, measured serum osmolality and serum ethanol concentration

22
Q

If you have a high anion gap metabolic acidosis for an unknown reason, what can you suspect?

A

Toxic alcohol ingestion

23
Q

Normal osmol gap range

A

-14 to +10 mOsm/L

24
Q

Extremely elevated osmol gap level

A

> 50mOsm/L

25
What is needed to assess the severity of the osmol gap?
Baseline osmol gap; a current gap may be within normal range but abnormal for the patient compared to their baseline
26
Serum ethanol concentrations can do what?
Prevent metabolism to the organic acid, can be considered protective
27
What levels are elevated with methanol and ethylene glycol poisoning?
Lactate
28
That chart of the osmol and anion gap: what is the relationship between it?
After ingestion, alcohols in the serum RAISE THE OSMOL GAP, but the ANION GAP remains NORMAL because metabolism to the organic acid hasn't occurred yet. As toxic alcohols are metabolized, the ANION GAP RISES and the OSMOL GAP FALLS.
29
Methanol and ethylene glycol treatment: resuscitation
Fluids and vasopressors
30
Methanol and ethylene glycol treatment: inhibition of ADH
IV 10% ethanol, fomepizole
31
Downsides of IV ethanol 10% infusion for ADH inhibition
Serum concentrations have to be constantly monitored with a goal level of 100mg/dl Lots of side effects
32
Side effects of 10% ethanol infusion
hypotension, respiratory depression, CNS depression and inebriation, flushing, hypoglycemia, hyponatremia, pancreatitis, gastritis
33
Fomepizole initial bolus dose
15mg/kg IV piggyback over 30 minutes
34
Fomepizole maintenance dose
10mg/kg IV piggyback q12h x4 doses, then increase dose to 15mg/kg IV piggyback q12h
35
Why do you increase the fomepizole dose after 48 hours?
It induces its own metabolism
36
How long do you continue fomepizole treatment for?
Until serum toxic alcohol concentrations are <20mg/dl and patient is asymptomatic with normal serum pH
37
ADEs of fomepizole
hypotension, bradycardia
38
Methanol and ethylene glycol treatment: renal replacement therapy; which one is better. hemodialysis or RRT?
hemodialysis > RRT
39
When to use renal replacement therapy in toxic alcohol poisoning
Depends on the severity and impact of metabolites
40
Dose adjustments for renal replacement therapy are needed in what disease state?
AKI; use intermittent hemodialysis or CRRT
41
Methanol and ethylene glycol treatment: adjunctive therapy for methanol toxicity
folic acid methylprednisolone continuous infusion of sodium bicarb
42
Methanol and ethylene glycol treatment: role of folic acid in methanol toxicity
enhances formate elimination
43
Methanol and ethylene glycol treatment: methylprednisolone dose
1gm IV q24h x3 days
44
Methanol and ethylene glycol treatment: role of methylprednisolone in methanol toxicity
Improve amount of vision loss experienced
45
Methanol and ethylene glycol treatment: role of sodium bicarb in methanol toxicity
shifts formic acid to formate and causes ion trapping in the ruine
46
Goal serum pH of sodium bicarb infusion in methanol toxicity
>7.2
47
Methanol and ethylene glycol treatment: adjunctive therapy for ethylene glycol toxicity
thiamine pyridoxine sodium bicarb IV infusion
48
Methanol and ethylene glycol treatment: role of thiamine in ethylene glycol toxicity
promotes conversation of ethylene glycol to ketoadipate
49
Methanol and ethylene glycol treatment: role of pyridoxine in ethylene glycol toxicity
promotes conversion of glycine to hippuric acid
50
Methanol and ethylene glycol treatment: when to consider a sodium bicarb continuous IV infusion in patients with ethylene glycol toxicity
if their pH is <7.15

PHM 702- Toxicology (12 decks)

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