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Toxic Alcohol Ingestion: Prompt Recognition And Management In The Emergency Department (Critical Care Topic)

September 2016

Abstract

Identifying patients with potential toxic alcohol exposure and initiating appropriate management is critical to avoid significant patient morbidity. Sources of toxic alcohol exposure include ethylene glycol, methanol, diethylene glycol, propylene glycol, and isopropanol. Treatment considerations include the antidotes fomepizole and ethanol, and hemodialysis for removal of the parent compound and its toxic metabolites. Additional interventions include adjunctive therapies that may improve acidosis and enhance clearance of the toxic alcohol or metabolites. This issue reviews common sources of alcohol exposure, basic mechanisms of toxicity, physical examination and laboratory findings that may guide rapid assessment and management, and indications for treatment.

Key words: ethylene glycol, methanol, diethylene glycol, propylene glycol, isopropyl alcohol, isopropanol, fomepizole, ethanol, toxic alcohol, metabolites, anion gap, osmol gap, hemodialysis

Points:

  • Testing for toxic alcohols is not readily available in hospital laboratories. While neither sensitive nor specific, an elevated osmol gap or unexplained elevated anion gap metabolic acidosis should prompt consideration of a toxic alcohol exposure.
  • Often, patients with toxic alcohol ingestion have chronic nutritional deficiencies, and vitamin supplementation should be considered. In ethylene glycol ingestion, thiamine, pyridoxine, and magnesium sulfate can be used to promote conversion to nontoxic metabolites. In methanol ingestion, folic acid can facilitate the conversion of formic acid to water and carbon dioxide.

Pearl:

  • In acute ethylene glycol or methanol ingestion, the relationship between the osmol gap and anion gap is reciprocal.
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