Approach to Alcohol Ingestions

1. Approach to Alcohol Ingestions Catherine Mobley Preissig, MD Pediatric Critical Care Medicine April 25, 2007

2. “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 50’s would be good, finding out trivia like which alcohols give you erectile dysfunction or make you glow in the dark would goa long way…” • KP

3. 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)

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

5. Volatile alcohols • Ethanol • Methanol • Isopropanol • Ethylene glycol

6. 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!

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

8. When to suspectalcohol ingestions???

9. In any ingestion work-up!!!

10. Specifically… • CNS depression • Nausea/ vomiting • Seizures • Coma

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

12. Anion gap review- yep you know it! • Na – (Cl + HCO3) • Should be 8-16 • MUDPILES

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

14. Osmolal gap review Measured osmolality – calculated osmolality

15. Normal osmolality is 275-295 • Gap should be <10 • If it’s higher, then something else is there!

16. Measured osmolality?? That’s what the lab gives you!!

17. Calculated osmolality?? 2xNa + Glucose/18 + BUN/2.8

18. 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!!

19. Specific alcohols • Preparations • Clinical presentation • Work-up • Treatment • Disposition

20. Ethanol (yeh, the good stuff)

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

23. Clinical presentation • Hypoglycemia • Hypomagnesemia • AMS/ Seizures • Ataxia • Hypothermia • Loss of airway reflexes

24. 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

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

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

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

28. 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

29. Isopropanol

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

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

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

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

34. 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

35. 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

36. 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

37. Methanol

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

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

41. Clinical presentation • CNS disturbance • Electrolyte disturbances • Hypoxic changes to cerebrum and distal optic nerve vasculature • Optic disk hyperemia and blindness

42. Ethylene glycol

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

45. Glycolate causes high AG, but isn’t toxic • Glycolaldehyde and glyoxylate more toxic • Glyoxylate Oxalate- tissue deposition

46. 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...

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

48. 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)

49. 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

50. Note on tox screens • Toxic alcohol screen measures ETOH, isopropanol, and methanol • Must specifically request ethylene glycol • Tests measure only parent alcohols • So level <20mg/dL in face of increased AG indicates toxicity