Alcohol Toxidrome

AGENTS

  • ethanol
  • methanol
  • ethylene glycol
  • isopropyl alcohol
  • others!

CLINICAL FEATURES

  • euphoria
  • disinhibition
  • stupour
  • respiratory depression
  • cardiovascular depression
  • coma
  • ocular toxicity = methanol
  • hypocalcemia + renal failure = ethylene glycol
  • haemorrhagic gastriyis = isopropyl alcohol

INVESTIGATIONS

  • ethanol level (> 400mg/dL -> coma and respiratory depression)
  • ethylene glycol level (severe lactic acidosis)
  • high osmolar gap then HAGMA
  • electrolyte abnormalities

SPECIFIC MANAGEMENT AND TRIGGERS FOR INTERVENTION

Ethanol

  • thiamine (50-100mg) then dextrose
  • hydration
  • supportive
  • replace electrolytes

Methanol

  • decreased production of toxic metabolites:

-> ethanol (competitive inhibitor to alcohol dehydrogenase)
-> 4-methylapyrazole (same as ethanol but easier to titrate and no sedative effects – not available in Australasia)
-> sodium bicarbonate (undissociated formic acid more toxic than the dissociated product – give if pH < 7.3) -> folinic acid: 50mg Q4hrly (decreases formate levels and decreases toxicity)

  • increase elimination:

-> haemodialysis: effectively and rapidly removed including toxic metabolites

Ethylene Glycol

  • 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
  • thamine 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

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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