Transcript Slide 1
Approach to Alcohol Ingestions Catherine Mobley Preissig, MD Pediatric Critical Care Medicine April 25, 2007 “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 go a long way…” KP 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) 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 Volatile alcohols Ethanol Methanol Isopropanol Ethylene glycol 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! Life-threatening symptoms caused by toxic breakdown products Broken down by alchohol dehydrogenase Have many symptoms in common – Very wide-ranging When to suspect alcohol ingestions??? In any ingestion work-up!!! Specifically… CNS depression Nausea/ vomiting Seizures Coma Hypotension, shock Hypoglycemia High anion gap High osmolal gap!!! Anion gap review- yep you know it! Na – (Cl + HCO3) Should be 8-16 MUDPILES Methanol Uremia DKA Pb Iron, Inhalants, Isoniazid, Ibuprofen Lactic acidosis Ethylene glycol, Ethanol Salicylates, Solvents Osmolal gap review Measured osmolality – calculated osmolality Normal osmolality is 275-295 Gap should be <10 If it’s higher, then something else is there! Measured osmolality?? That’s what the lab gives you!! Calculated osmolality?? 2xNa + Glucose/18 + BUN/2.8 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!! Specific alcohols Preparations Clinical presentation Work-up Treatment Disposition Ethanol (yeh, the good stuff) Other preparations Mouthwash preparations – 20 oz can lead to death in toddler Perfumes Medicinal products Clinical presentation Hypoglycemia Hypomagnesemia AMS/ Seizures Ataxia Hypothermia Loss of airway reflexes 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 – Levels 100-150mg/dl = intoxication – 50mg/dl symptoms in toddlers Treatment ABCs Supportive care Glucose Thiamine Correct dehydration/ Elec disturbances Narcan/ Flumazenil controversial Folate, Mg in chronics– adult world revisited Benzos for seizures Keep em warm No place for gastric lavage or charcoal 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 Isopropanol Preparations Rubbing alcohol (70-90% concentration) Industrial solvents Paints/ Paint thinners Inks Hair tonics Beware of: – Parents sponge-bathing febrile child with rubbing alcohol – Inhalation exposure – Overzealous application to umbilical stump Clinical presentation Fruity odor CNS depression predominates Seizures/ Absent reflexes Acetone is culprit- 2.7x more depression than ETOH Hypoventilation Hypotension Noncardiogenic pulmonary edema Gastritis GI hemorrhage Hemorrhagic tracheobronchitis 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 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 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 Methanol Preparations Windshield washer fluid Carburetor cleaners Antifreeze Sterno Paints and varnishes Fuel octane boosters Industrial solvents Formate causes toxic effects Responsible for increased AG Formaldehyde rapidly metabolized Formate inhibits cytochrome aa3 anaerobic metabolism Clinical presentation CNS disturbance Electrolyte disturbances Hypoxic changes to cerebrum and distal optic nerve vasculature Optic disk hyperemia and blindness Ethylene glycol Preparations Radiator antifreeze Hydraulic brake fluid Condensers/ heat exchangers Foam stabilizers Solvents De-icing solutions Paints Lacquers Cosmetics Glycolate causes high AG, but isn’t toxic Glycolaldehyde and glyoxylate more toxic Glyoxylate Oxalate- tissue deposition 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... AMS, seizures, herniation syndromes Hypertension Pulmonary edema Acute renal failure, Ca oxalate crystalluria 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) 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 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 Propylene glycol, glycerol, and betahydroxybutyrate cause false-positive ethylene glycol Treatment ABCs Monitor for increased ICP, especially in ethylene glycol Fluids, glucose Na Bicarb only in life-threatening acidemia Benzos for seizures Calcium for symptomatic hypocalcemia Ethanol: Load 0.8grams/kg 100% ETOH – 130mg/kg/hr gtt of 100% ETOH diluted in 10% dextrose Monitor hourly until steady state acheived Goal level 100-150mg/dL Alcohol dehydrogenase inhibitors Fomepizole: load with 15mg/kg – Maintainence: 10mg/kg q 12hrs x 4 doses, then 15mg/kg q 12 Treat until levels <20 and acidosis resolved Disposition Admit for unstable vital signs Levels >20 Acidosis Clinical manifestations of end-organ damage Most require ICU management So which alcohol is it??? 3 simple rules... Anion Gap Ketosis Calcium Look at Anion Gap 3 of 4 have increased AG, so memorize the one that doesn’t! Isopropanol!! Hallmark is normal AG Anion Gap Ethanol Methanol Isopropyl Alcohol Ethlylene Glycol Ketosis Hypocalcemia Look at Ketosis A little harder… 2 of 4 have it… Ethanol and Isopropanol: Ketotic Methanol and Ethylene Glycol: Nonketotic Anion Gap Ethanol Methanol Isopropyl Alcohol Ethlylene Glycol Ketosis Hypocalcemia One more trick… Calcium Hallmark of Ethylene Glycol: Hypocalcemia!! Anion Gap Ethanol Methanol Isopropyl Alcohol Ethlylene Glycol Ketosis Hypocalcemia So… High AG, nonketotic, hypocalcemic? Ethylene Glycol Normal AG, ketotic? Isopropanol High AG, nonketotic? Methanol I drank lots of beer? Ethanol Why do we care? Because treatment is different!! Methanol and Ethylene Glycol Fomepizole is antidote!! So recognize it quickly!!! ??Questions??