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<< Toxic Alcohol Ingestion: Prompt Recognition and Management in the Emergency Department (Critical Care Topic and Pharmacology CME)

Risk Management Pitfalls In Management Of Toxic Alcohol Ingestion

  1. “The patient was found unconscious at home next to an empty container of windshield-washer fluid. I began fomepizole therapy and admitted him. I don’t know why he started to posture.” 
    Patients who are found unconscious or who present with significant intoxication may need a head CT scan to evaluate for underlying traumatic injury. Patients intoxicated with a toxic alcohol who receive antidotal therapy will remain intoxicated for a prolonged period of time due to ADH blockade, and emergency clinicians should have a low threshold to assess for traumatic intracranial abnormality early, given that the patient’s neurological examination is compromised by the presence of intoxication.
     
  2. “The patient had a normal anion gap, so I knew he couldn’t have ingested a toxic alcohol.”
    Failure to understand the reciprocal relationship between the osmol gap and the anion gap in toxic alcohol poisoning may lead to a misdiagnosis. Patients with toxic alcohol exposure may have a normal or elevated osmol gap early after the ingestion. However, after just a few hours, the parent toxic alcohol compound will be metabolized to toxic metabolites that cause an anion gap acidosis, and any elevation in the osmol gap may resolve. Early assessment of a patient with exposure to a toxic alcohol may reveal normal osmol and anion gaps, and this may be misleading if the emergency clinician uses these results alone to rule out a toxic alcohol exposure.

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