Ethylene Glycol Toxicity
OVERVIEW
- >1 mL/kg or a mouthful in a child is potentially lethal
- ethylene glycol itself is relatively non-toxic -> metabolites extremely toxic (glycolate)
- rate limiting step = alcohol dehydrogenase activity
- accumulation of glycolate -> direct cellular toxicity
CLINICAL FEATURES
- drunk: automotive antifreeze, solvent, polish, paints, cosmetics, brake fluid, car wash fluid.
- 30 minutes -> 12 hours post ingestion:excitement, confusion, disorientation -> ataxia, lethargy, stupor, coma, nausea/vomiting, myoclonus, seizures, cranial nerve deficits: nystagmus, ophthalmoplegia, facial palsy, dysarthria, dysphagia
- 12 – 24 hours: progressive cardiorespiratory failure
- 24 – 72 hours: renal failure from ATN
INVESTIGATIONS
- ethylene glycol level (rarely useful acutely due to delays in obtaining result)
- severe metabolic acidosis (high anion gap) from glycolic acid accumulation
- very high lactate (artefactual as there is high cross reactivity between lactate and glycolate in laboratory analysis) -> high lactate with oxidase method, less high with lactate dehydrogenase method
- high osmolar gap
- calcium oxalate crystalluria (oxalate produced by ethylene glycol metabolism chelates Ca2+ -> formation of crystals) + hypocalcaemia
- fluorescence of urine on exposure to UV light (automotive antifreeze solutions have this to identify cooling system leaks)
MANAGEMENT
- goal = blockade of alcohol dehydrogenase -> so ethylene glycol isn’t converted to glycolate
- decrease absorption: no techniques really effective
- decrease production of toxic metabolites: ethanol or 4-methylpyrazole (not available in Australiasia)
-> ethanol dose (IV): 10% solution in D5W as a 40% solution, loading dose 7.5mL/kg -> 1-2mL/kg/hr
-> ethanol dose (PO): quarter the above dose
-> dose in CRRT: double IV dose
-> maintain ethanol level @ 25-40mmol/L
- haemodialysis
- thiamine 100mg IV Q6 hrly – theoretical benefit to increase elimination
- pyridoxine (vitamin B6) 50mg IV Q6hrly – theoretical benefit to increase elimination
- don’t replace Ca2+ unless low enough to cause manifestations
References and Links
CCC Toxicology Series
General
Approach to acute poisoning, ECGs in Tox, Evidenced-based Tox, Toxicology literature summaries, Does anti-venom work?
Toxins / Overdose
Amphetamines, Barbituates, Benzylpiperazine, Beta Blockers, Calcium Channel Blocker, Carbamazepine, Carbon Monoxide, Ciguatera, Citrate, Clenbuterol, Cocaine, Corrosive ingestion, Cyanide, Digoxin, Ethanol, Ethylene Glycol, Iron, Isoniazid, Lithium, Local anaesthetic, Methanol, Monoamine oxidase inhibitor (MAOI), Mushrooms (non-hallucinogenic), Opioids, Organophosphate, Paracetamol, Paraquat, Plants, Polonium, Salicylate, Scombroid, Sodium channel blockers, Sodium valproate, Theophylline, Toxic alcohols, Tricyclic antidepressants (TCA)
Envenomation
Marine, Snakebite, Spider, Tick paralysis
Syndromes
Alcohol withdrawal, Anticholinergic syndrome, Cholinergic syndrome, Drug withdrawals in ICU, Hyperthermia associated toxidromes, Malignant hyperthermia (MH), Neuroleptic malignant syndrome (NMS), Opioid withdrawal, Propofol Infusion Syndrome (PrIS) Sedative toxidrome, Serotonin syndrome, Sympatholytic toxidrome, Sympathomimetic toxidrome
Decontamination
Activated Charcoal, Gastric lavage, GI Decontamination
Enhanced Elimination
Enhanced elimination, Hyperbaric therapy for CO
Antidotes
Antidote summary, Digibind, Glucagon, Flumazenil, HIET – High dose euglycaemic therapy, Intralipid, Methylene Blue, N-Acetylcysteine (NAC), Naloxone
Miscellaneous
Cocaine chest pain, Digoxin and stone heart theory, Hyperbaric oxygen, Hypoxaemia in tox, Liver failure in tox, Liver transplant for paracetamol, Methaemoglobinaemia, Urine drug screen
- Tox Conundrum – Ethylene glycol inebriation
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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