approach to alcohol ingestions catherine mobley preissig, md pediatric critical care medicine april...

Approach to Alcohol Approach to Alcohol IngestionsIngestions

Catherine Mobley Preissig, MDCatherine Mobley Preissig, MD

Pediatric Critical Care Pediatric Critical Care MedicineMedicine

April 25, 2007April 25, 2007

““A couple of suggestions for the A couple of suggestions for the lecture. Our group really likes lecture. Our group really likes storiesstories.. So telling the story about the So telling the story about the guy that went blind with methanol guy that went blind with methanol in the 50’sin the 50’s would be good, finding out would be good, finding out triviatrivia like like which alcohols give you which alcohols give you erectile dysfunctionerectile dysfunction or make you or make you glow in the dark would goglow in the dark would go a long a long way…”way…”

KPKP

For Kalpesh: Causes of For Kalpesh: Causes of EDED EthanolEthanol High blood pressureHigh blood pressure High cholesterolHigh cholesterol Heart diseaseHeart disease DiabetesDiabetes Spinal injury/ surgerySpinal injury/ surgery StressStress SmokingSmoking Certain drugs (Ca-channel blockers, Certain drugs (Ca-channel blockers,

etc)etc)

EpidemiologyEpidemiology

Pediatric poisonings: 4 million Pediatric poisonings: 4 million cases/yrcases/yr

300,000 lead to hospitalization300,000 lead to hospitalization 30,000 lead to death30,000 lead to death 1 million in children < 6 yo1 million in children < 6 yo 2003 TESS database: 84,000 2003 TESS database: 84,000

were toxic alcohol exposureswere toxic alcohol exposures

Volatile alcoholsVolatile alcohols

EthanolEthanol

MethanolMethanol

IsopropanolIsopropanol

Ethylene glycolEthylene glycol

What do they have in What do they have in common?common?

Readily found in household Readily found in household productsproducts

Rapidly absorbed from GI tractRapidly absorbed from GI tract– Signs of intoxication within 30 Signs of intoxication within 30

minutes!minutes!

All taste pretty good!All taste pretty good!

Life-threatening symptoms caused Life-threatening symptoms caused by toxic breakdown productsby toxic breakdown products

Broken down by alchohol Broken down by alchohol dehydrogenasedehydrogenase

Have many symptoms in commonHave many symptoms in common– Very wide-rangingVery wide-ranging

When to suspectWhen to suspectalcohol ingestions???alcohol ingestions???

In any ingestion In any ingestion work-up!!!work-up!!!

Specifically…Specifically…

CNS depressionCNS depression

Nausea/ vomitingNausea/ vomiting

SeizuresSeizures

ComaComa

Hypotension, shockHypotension, shock

HypoglycemiaHypoglycemia

High anion gapHigh anion gap

High osmolal gap!!!High osmolal gap!!!

Anion gap review- yep Anion gap review- yep you know it!you know it!

Na – (Cl + HCO3)Na – (Cl + HCO3)

Should be 8-16Should be 8-16

MUDPILESMUDPILES

MethanolMethanol UremiaUremia DKADKA PbPb Iron, Inhalants, Isoniazid, IbuprofenIron, Inhalants, Isoniazid, Ibuprofen Lactic acidosisLactic acidosis Ethylene glycol, EthanolEthylene glycol, Ethanol Salicylates, SolventsSalicylates, Solvents

Osmolal gap reviewOsmolal gap review

Measured osmolality Measured osmolality – calculated – calculated osmolalityosmolality

Normal osmolality is 275-295Normal osmolality is 275-295

Gap should be <10Gap should be <10

If it’s higher, then something If it’s higher, then something else is there!else is there!

Measured Measured osmolality??osmolality??

That’s what the lab gives you!!That’s what the lab gives you!!

Calculated osmolality??Calculated osmolality??

2xNa + Glucose/18 + BUN/2.82xNa + Glucose/18 + BUN/2.8

For Example….For Example…. Lab reports serum osm = 315Lab reports serum osm = 315

You calculate based on Na, Gluc, You calculate based on Na, Gluc, BUN and get 280BUN and get 280

Gap is 315-280 = 35Gap is 315-280 = 35

Something else is contributing!!Something else is contributing!!– And you need to find it!!And you need to find it!!

Specific alcoholsSpecific alcohols

PreparationsPreparations

Clinical presentationClinical presentation

Work-up Work-up

TreatmentTreatment

DispositionDisposition

Ethanol Ethanol (yeh, the good stuff)(yeh, the good stuff)

Other preparationsOther preparations

Mouthwash preparationsMouthwash preparations– 20 oz can lead to death in toddler20 oz can lead to death in toddler

PerfumesPerfumes

Medicinal productsMedicinal products


HypoglycemiaHypoglycemia HypomagnesemiaHypomagnesemia AMS/ SeizuresAMS/ Seizures AtaxiaAtaxia HypothermiaHypothermia Loss of airway reflexesLoss of airway reflexes

Work-upWork-up

In addition to tox screen and ETOH In addition to tox screen and ETOH levels...levels...

Follow elecs, Mg, phos, LFTs, Follow elecs, Mg, phos, LFTs, glucoseglucose

Calculate AG (high)Calculate AG (high) Calculate osm gap (high)Calculate osm gap (high) Consider CT head if AMS in excess Consider CT head if AMS in excess

of ETOH levelof ETOH level

– Levels 100-150mg/dl = Levels 100-150mg/dl = intoxicationintoxication

– 50mg/dl symptoms in 50mg/dl symptoms in toddlerstoddlers

TreatmentTreatment ABCsABCs Supportive careSupportive care GlucoseGlucose ThiamineThiamine Correct dehydration/ Elec Correct dehydration/ Elec

disturbancesdisturbances Narcan/ Flumazenil controversialNarcan/ Flumazenil controversial Folate, Mg in chronics- Folate, Mg in chronics-

– adult world revisitedadult world revisited

Benzos for seizuresBenzos for seizures Keep em warmKeep em warm No place for gastric lavage or No place for gastric lavage or

charcoalcharcoal

DispositionDisposition Average observation for Average observation for

uncomplicated toxicity = 5 hoursuncomplicated toxicity = 5 hours Can delay identification of Can delay identification of

traumatic injury- be carefultraumatic injury- be careful Can be discharged when Can be discharged when

ambulatoryambulatory Rarely needs ICURarely needs ICU Defer to admission for social Defer to admission for social

reasonsreasons


Rubbing alcohol (70-90% Rubbing alcohol (70-90% concentration)concentration)

Industrial solventsIndustrial solvents Paints/ Paint thinnersPaints/ Paint thinners InksInks Hair tonicsHair tonics

Beware of:Beware of:– Parents sponge-bathing febrile child Parents sponge-bathing febrile child

with rubbing alcoholwith rubbing alcohol– Inhalation exposureInhalation exposure– Overzealous application to umbilical Overzealous application to umbilical

stumpstump


Fruity odorFruity odor CNS depression predominatesCNS depression predominates Seizures/ Absent reflexesSeizures/ Absent reflexes Acetone is culprit- 2.7x more Acetone is culprit- 2.7x more

depression than ETOHdepression than ETOH HypoventilationHypoventilation

HypotensionHypotension Noncardiogenic pulmonary Noncardiogenic pulmonary

edemaedema GastritisGastritis GI hemorrhageGI hemorrhage Hemorrhagic tracheobronchitisHemorrhagic tracheobronchitis

Work-upWork-up

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

TreatmentTreatment ABCsABCs FluidsFluids Keep em warmKeep em warm DextroseDextrose Supportive- similar to ETOH intoxSupportive- similar to ETOH intox Rarely need HD- but can if not Rarely need HD- but can if not

improvingimproving Lavage and charcoal not helpfulLavage and charcoal not helpful


Depends on depth of CNS Depends on depth of CNS depressiondepression

Observe mild intox for 3-4 hrsObserve mild intox for 3-4 hrs Can be discharged to appropriate Can be discharged to appropriate

place when ambulatoryplace when ambulatory Everyone else should be Everyone else should be

hospitalized 12-24 hrshospitalized 12-24 hrs PICU if unstable or GI complicationPICU if unstable or GI complication

MethanolMethanol


Windshield washer fluidWindshield washer fluid Carburetor cleanersCarburetor cleaners AntifreezeAntifreeze SternoSterno Paints and varnishesPaints and varnishes Fuel octane boostersFuel octane boosters Industrial solventsIndustrial solvents

Formate causes toxic effectsFormate causes toxic effects Responsible for increased AGResponsible for increased AG Formaldehyde rapidly Formaldehyde rapidly

metabolizedmetabolized Formate inhibits cytochrome aaFormate inhibits cytochrome aa33

anaerobic metabolismanaerobic metabolism


CNS disturbanceCNS disturbance Electrolyte disturbancesElectrolyte disturbances Hypoxic changes to cerebrum Hypoxic changes to cerebrum

and distal optic nerve and distal optic nerve vasculaturevasculature

Optic disk hyperemia and Optic disk hyperemia and blindnessblindness

Ethylene glycolEthylene glycol


Radiator antifreezeRadiator antifreeze Hydraulic brake fluidHydraulic brake fluid Condensers/ heat exchangersCondensers/ heat exchangers Foam stabilizersFoam stabilizers SolventsSolvents De-icing solutionsDe-icing solutions PaintsPaints LacquersLacquers CosmeticsCosmetics

Glycolate causes high AG, but Glycolate causes high AG, but isn’t toxicisn’t toxic

Glycolaldehyde and glyoxylate Glycolaldehyde and glyoxylate more toxicmore toxic

Glyoxylate Oxalate- tissue Glyoxylate Oxalate- tissue depositiondeposition


CNS- cerebral edema, loss of CNS- cerebral edema, loss of Purkinje cellsPurkinje cells

Lung- edema, interstitial Lung- edema, interstitial pneumonitis, hemorrhagic pneumonitis, hemorrhagic bronchopneumoniabronchopneumonia

Kidney- interstitial deposition, Kidney- interstitial deposition, proximal and distal tubular dilitationproximal and distal tubular dilitation

Other- liver, heart...Other- liver, heart...

AMS, seizures, herniation AMS, seizures, herniation syndromessyndromes

HypertensionHypertension Pulmonary edemaPulmonary edema Acute renal failure, Ca oxalate Acute renal failure, Ca oxalate

crystalluriacrystalluria

Work-up for Ethylene Work-up for Ethylene glycol and Methanolglycol and Methanol

Tox screen, ethylene glycol and Tox screen, ethylene glycol and methanol levels by gas methanol levels by gas chromatographychromatography

Elecs, LFTs, glucose, CaElecs, LFTs, glucose, Ca Calculate AG (high)Calculate AG (high) Calculate osm gap (high)Calculate osm gap (high)

UA shows Ca oxylate crystals in UA shows Ca oxylate crystals in ethylene glycol toxicityethylene glycol toxicity

Fun with Woods lampFun with Woods lamp Level of 20mg/dL for either Level of 20mg/dL for either

substance is toxic, even without substance is toxic, even without acidosisacidosis

Note on tox screensNote on tox screens

Toxic alcohol screen measures Toxic alcohol screen measures ETOH, isopropanol, and methanolETOH, isopropanol, and methanol

Must specifically request ethylene Must specifically request ethylene glycolglycol

Tests measure only parent Tests measure only parent alcoholsalcohols

So level <20mg/dL in face of So level <20mg/dL in face of increased AG indicates toxicityincreased AG indicates toxicity

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

TreatmentTreatment ABCsABCs Monitor for increased ICP, Monitor for increased ICP,

especially in ethylene glycolespecially in ethylene glycol Fluids, glucoseFluids, glucose Na Bicarb only in life-threatening Na Bicarb only in life-threatening

acidemiaacidemia Benzos for seizuresBenzos for seizures Calcium for symptomatic Calcium for symptomatic

hypocalcemiahypocalcemia

Ethanol: Load 0.8grams/kg 100% Ethanol: Load 0.8grams/kg 100% ETOHETOH– 130mg/kg/hr gtt of 100% ETOH 130mg/kg/hr gtt of 100% ETOH

diluted in 10% dextrosediluted in 10% dextrose Monitor hourly until steady state Monitor hourly until steady state

acheivedacheived Goal level 100-150mg/dLGoal level 100-150mg/dL

Alcohol Alcohol dehydrogenase dehydrogenase inhibitorsinhibitors Fomepizole: load with 15mg/kgFomepizole: load with 15mg/kg

– Maintainence: 10mg/kg q 12hrs x 4 Maintainence: 10mg/kg q 12hrs x 4 doses, then 15mg/kg q 12doses, then 15mg/kg q 12

Treat until levels <20 and Treat until levels <20 and acidosis resolvedacidosis resolved


Admit for unstable vital signsAdmit for unstable vital signs Levels >20Levels >20 AcidosisAcidosis Clinical manifestations of end-Clinical manifestations of end-

organ damageorgan damage Most require ICU managementMost require ICU management

So which alcohol So which alcohol is it???is it???

3 simple rules...3 simple rules...

Anion GapAnion Gap

KetosisKetosis

CalciumCalcium

Look at Anion GapLook at Anion Gap

3 of 4 have increased AG, so 3 of 4 have increased AG, so memorize the one that memorize the one that doesn’t!doesn’t!

Isopropanol!!Isopropanol!!Hallmark is normal AGHallmark is normal AG

Anion GapAnion Gap KetosisKetosis HypocalcemiHypocalcemiaa

EthanolEthanol

MethanolMethanol

IsopropylIsopropyl

AlcoholAlcohol

EthlyleneEthlylene

GlycolGlycol

Look at KetosisLook at Ketosis A little harder… 2 of 4 have it…A little harder… 2 of 4 have it…

Ethanol and Isopropanol:Ethanol and Isopropanol:

KetoticKetotic

Methanol and Ethylene Glycol:Methanol and Ethylene Glycol:

NonketoticNonketotic


EthanolEthanol

MethanolMethanol

IsopropylIsopropyl

AlcoholAlcohol

EthlyleneEthlylene

GlycolGlycol

One more trick… One more trick… CalciumCalcium

Hallmark of Ethylene Glycol:Hallmark of Ethylene Glycol:

Hypocalcemia!!Hypocalcemia!!


EthanolEthanol

MethanolMethanol

IsopropylIsopropyl

AlcoholAlcohol

EthlyleneEthlylene

GlycolGlycol

So…So…

High AG, nonketotic, High AG, nonketotic, hypocalcemic?hypocalcemic?

Ethylene GlycolEthylene Glycol

Normal AG, ketotic?Normal AG, ketotic?

High AG, nonketotic?High AG, nonketotic?

MethanolMethanol

I drank lots of beer?I drank lots of beer?

EthanolEthanol

Why do we care?Why do we care?

Because treatment Because treatment is different!!is different!!

Methanol and Ethylene GlycolMethanol and Ethylene Glycol

Fomepizole is antidote!!Fomepizole is antidote!!

So recognize it quickly!!!So recognize it quickly!!!

??Questions????Questions??

approach to alcohol ingestions catherine mobley preissig, md pediatric critical care medicine april...

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