Approach to Alcohol Ingestions

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Approach to Alcohol Ingestions

• Catherine Mobley Preissig, MD
• Pediatric Critical Care Medicine
• April 25, 2007

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• A couple of suggestions for the lecture.  Our
  group really likes stories.  So telling the story
  about the guy that went blind with methanol in
  the 50s would be good, finding out trivia like
  which alcohols give you erectile dysfunction or
  make you glow in the dark would go a long way
• KP

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For Kalpesh Causes of ED

• Ethanol
• High blood pressure
• High cholesterol
• Heart disease
• Diabetes
• Spinal injury/ surgery
• Stress
• Smoking
• Certain drugs (Ca-channel blockers, etc)

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Epidemiology

• Pediatric poisonings 4 million cases/yr
• 300,000 lead to hospitalization
• 30,000 lead to death
• 1 million in children lt 6 yo
• 2003 TESS database 84,000 were toxic alcohol
  exposures

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Volatile alcohols

• Ethanol
• Methanol
• Isopropanol
• Ethylene glycol

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What do they have in common?

• Readily found in household products
• Rapidly absorbed from GI tract
• Signs of intoxication within 30 minutes!
• All taste pretty good!

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• Life-threatening symptoms caused by toxic
  breakdown products
• Broken down by alchohol dehydrogenase
• Have many symptoms in common
• Very wide-ranging

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When to suspectalcohol ingestions???
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In any ingestion work-up!!!
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Specifically

• CNS depression
• Nausea/ vomiting
• Seizures
• Coma

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• Hypotension, shock
• Hypoglycemia
• High anion gap
• High osmolal gap!!!

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Anion gap review- yep you know it!

• Na (Cl HCO3)
• Should be 8-16
• MUDPILES

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• Methanol
• Uremia
• DKA
• Pb
• Iron, Inhalants, Isoniazid, Ibuprofen
• Lactic acidosis
• Ethylene glycol, Ethanol
• Salicylates, Solvents

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Osmolal gap review

• Measured osmolality calculated osmolality

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• Normal osmolality is 275-295
• Gap should be lt10
• If its higher, then something else is there!

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• Measured osmolality??
• Thats what the lab gives you!!

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• Calculated osmolality??
• 2xNa Glucose/18 BUN/2.8

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For Example.

• Lab reports serum osm 315
• You calculate based on Na, Gluc, BUN and get 280
• Gap is 315-280 35
• Something else is contributing!!
• And you need to find it!!

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Specific alcohols

• Preparations
• Clinical presentation
• Work-up
• Treatment
• Disposition

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• Ethanol (yeh, the good stuff)

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Other preparations

• Mouthwash preparations
• 20 oz can lead to death in toddler
• Perfumes
• Medicinal products

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Clinical presentation

• Hypoglycemia
• Hypomagnesemia
• AMS/ Seizures
• Ataxia
• Hypothermia
• Loss of airway reflexes

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Work-up

• In addition to tox screen and ETOH levels...
• Follow elecs, Mg, phos, LFTs, glucose
• Calculate AG (high)
• Calculate osm gap (high)
• Consider CT head if AMS in excess of ETOH level

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• Levels 100-150mg/dl intoxication
• 50mg/dl symptoms in toddlers

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Treatment

• ABCs
• Supportive care
• Glucose
• Thiamine
• Correct dehydration/ Elec disturbances
• Narcan/ Flumazenil controversial
• Folate, Mg in chronics-
• adult world revisited

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• Benzos for seizures
• Keep em warm
• No place for gastric lavage or charcoal

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Disposition

• Average observation for uncomplicated toxicity
  5 hours
• Can delay identification of traumatic injury- be
  careful
• Can be discharged when ambulatory
• Rarely needs ICU
• Defer to admission for social reasons

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• Isopropanol

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Preparations

• Rubbing alcohol (70-90 concentration)
• Industrial solvents
• Paints/ Paint thinners
• Inks
• Hair tonics

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• Beware of
• Parents sponge-bathing febrile child with rubbing
  alcohol
• Inhalation exposure
• Overzealous application to umbilical stump

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Clinical presentation

• Fruity odor
• CNS depression predominates
• Seizures/ Absent reflexes
• Acetone is culprit- 2.7x more depression than
  ETOH
• Hypoventilation

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• Hypotension
• Noncardiogenic pulmonary edema
• Gastritis
• GI hemorrhage
• Hemorrhagic tracheobronchitis

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Work-up

• Tox screen and ACETONE levels...
• Isopropanol levels unhelpful
• Follow elecs, LFTs, glucose
• Calculate AG- It will be normal
• Calculate osm gap (high)
• Urine ketones

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Treatment

• ABCs
• Fluids
• Keep em warm
• Dextrose
• Supportive- similar to ETOH intox
• Rarely need HD- but can if not improving
• Lavage and charcoal not helpful

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Disposition

• Depends on depth of CNS depression
• Observe mild intox for 3-4 hrs
• Can be discharged to appropriate place when
  ambulatory
• Everyone else should be hospitalized 12-24 hrs
• PICU if unstable or GI complication

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• Methanol

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Preparations

• Windshield washer fluid
• Carburetor cleaners
• Antifreeze
• Sterno
• Paints and varnishes
• Fuel octane boosters
• Industrial solvents

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• Formate causes toxic effects
• Responsible for increased AG
• Formaldehyde rapidly metabolized
• Formate inhibits cytochrome aa3 ?anaerobic
  metabolism

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Clinical presentation

• CNS disturbance
• Electrolyte disturbances
• Hypoxic changes to cerebrum and distal optic
  nerve vasculature?
• Optic disk hyperemia and blindness

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• Ethylene glycol

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Preparations

• Radiator antifreeze
• Hydraulic brake fluid
• Condensers/ heat exchangers
• Foam stabilizers
• Solvents
• De-icing solutions
• Paints
• Lacquers
• Cosmetics

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• Glycolate causes high AG, but isnt toxic
• Glycolaldehyde and glyoxylate more toxic
• Glyoxylate Oxalate- tissue deposition

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Clinical presentation

• CNS- cerebral edema, loss of Purkinje cells
• Lung- edema, interstitial pneumonitis,
  hemorrhagic bronchopneumonia
• Kidney- interstitial deposition, proximal and
  distal tubular dilitation
• Other- liver, heart...

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• AMS, seizures, herniation syndromes
• Hypertension
• Pulmonary edema
• Acute renal failure, Ca oxalate crystalluria

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Work-up for Ethylene glycol and Methanol

• Tox screen, ethylene glycol and methanol levels
  by gas chromatography
• Elecs, LFTs, glucose, Ca
• Calculate AG (high)
• Calculate osm gap (high)

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• UA shows Ca oxylate crystals in ethylene glycol
  toxicity
• Fun with Woods lamp
• Level of 20mg/dL for either substance is toxic,
  even without acidosis

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Note on tox screens

• Toxic alcohol screen measures ETOH, isopropanol,
  and methanol
• Must specifically request ethylene glycol
• Tests measure only parent alcohols
• So level lt20mg/dL in face of increased AG
  indicates toxicity

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• Propylene glycol, glycerol, and
  beta-hydroxybutyrate cause false-positive
  ethylene glycol

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Treatment

• ABCs
• Monitor for increased ICP, especially in ethylene
  glycol
• Fluids, glucose
• Na Bicarb only in life-threatening acidemia
• Benzos for seizures
• Calcium for symptomatic hypocalcemia

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• Ethanol Load 0.8grams/kg 100 ETOH
• 130mg/kg/hr gtt of 100 ETOH diluted in 10
  dextrose
• Monitor hourly until steady state acheived
• Goal level 100-150mg/dL

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Alcohol dehydrogenase inhibitors

• Fomepizole load with 15mg/kg
• Maintainence 10mg/kg q 12hrs x 4 doses, then
  15mg/kg q 12
• Treat until levels lt20 and acidosis resolved

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Disposition

• Admit for unstable vital signs
• Levels gt20
• Acidosis
• Clinical manifestations of end-organ damage
• Most require ICU management

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So which alcohol is it???
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3 simple rules...

• Anion Gap
• Ketosis
• Calcium

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Look at Anion Gap

• 3 of 4 have increased AG, so memorize the one
  that doesnt!
• Isopropanol!!
• Hallmark is normal AG

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Look at Ketosis

• A little harder 2 of 4 have it
• Ethanol and Isopropanol
• Ketotic
• Methanol and Ethylene Glycol
• Nonketotic

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One more trick Calcium

• Hallmark of Ethylene Glycol
• Hypocalcemia!!

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So

• High AG, nonketotic, hypocalcemic?

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Ethylene Glycol
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• Normal AG, ketotic?

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Isopropanol
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• High AG, nonketotic?

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Methanol
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• I drank lots of beer?

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Ethanol
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Why do we care?
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Because treatment is different!!

• Methanol and Ethylene Glycol
• Fomepizole is antidote!!
• So recognize it quickly!!!

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• ??Questions??