Morning Report: 4/21/2015

Thanks to Dr. Rolston-Cregler for today’s Morning Report!

Ethylene Glycol Toxicity

The Basics

• Toxic Alcohol with the chemical structure C2H6O2
• Main ingredient in antifreeze
• Sweet taste often attracts children and animals

Clinical Presentation

• Altered mental status
• Dyspnea may be a manifestation of underlying metabolic acidosis

Laboratory Findings

• Early findings include an osmolar gap
• Followed by a high anion gap metabolic acidosis

Calculation of Levels

Most laboratory assays are send outs and not helpful in a timeframe that will benefit the patient

Osmolar Gap = calculated osmolality – serum osmolality

If no other alcohol ingestions, level can be estimated by multiplying osmolar gap X 6.2

(Molecular weight of 62 g/mol)

Metabolism Pathway

http://www.cjem-online.ca/sites/cjem-online.ca/files/image/034-f2.gif

Interventions

Fomepizole or 4MP – competitively inhibits alcohol dehydrogenase

• slows the reduction of toxic metabolites
• inhibits deposition of oxalic acid in tissues
• 15 mg/kg over 30 minutes

Ethanol

• can be given oral or parenteral
• loading dose followed by continuous infusion to maintain a level of 100 mg/dL
  • loading dose of 10 ml/kg in 10% ethanol solution of D5W given over 60 minutes should raise serum concentration by 100 mg/dL
  • maintenance infusion of the same solution should start at 1 ml/kg/hr and be titrated to the desired concentration, Q1-2 hour recheck of levels
• can be difficult to titrate
• frequent fingersticks due to potential hypoglycemia

Thiamine & Pyridoxine: administration of co-factors can shunt reactions away from the major pathway and result in the production of less oxalic acid, the main toxic metabolite of glycolic acid pathway

Dialysis

• used to treat metabolic acidosis and to prevent renal insufficiency
• once oxalate has begun to deposit in tissues must be used in conjunction with fomepizole to remove parent compound as well as metabolites

Threshold for Therapy

– Arterial pH less than 7.3

– Serum bicarbonate level less than 20 mg/dL

– Osmol gap greater than 10 mOsm/L

– Oxalate crystals in the urine

– Ethylene glycol level > 20

References:

• http://en.wikipedia.org/wiki/Fomepizole
• http://reference.medscape.com/drug/antizol-fomepizole-343713
• http://lifeinthefastlane.com/toxicology-conundrum-035/
• http://reference.medscape.com/drug/antizol-fomepizole-343713
• http://emedicine.medscape.com/article/812411-workup
• http://www.uptodate.com.newproxy.downstate.edu/contents/methanol-and-ethylene-glycol-poisoning?source=machineLearning&search=ethylene+glycol+toxicity&selectedTitle=1~20&sectionRank=2&anchor=H16#H16

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital

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