These include recommendations on prehospital, emergency department, and critical care treatment. June 2009. [Medline]. 2018 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 36th Annual Report. headache, dizziness, or a feeling of intoxication. care, hemodialysis, and administration of a metabolic Urine fluorescence using a Wood's lamp to detect the antifreeze additive sodium fluorescein: a qualitative adjunctive test in suspected ethylene glycol ingestions. recognizing, evaluating, and treating illnesses resulting from exposure to hazardous substances. Ascertain as much specific information regarding the identity of the ingested substance as possible. In patients exposed to ethylene glycol, 100mg thiamine and 100mg pyridoxine can be administered IV daily to stimulate the conversion of glycolic acid and glyoxylic acid to non-toxic alpha-hydroxy-beta-ketoadipate and glycine, respectively. Any patient receiving intravenous ethanol therapy requires ICU monitoring. [Guideline] Barceloux DG, Krenzelok EP, Olson K, Watson W. American Academy of Clinical Toxicology Practice Guidelines on the Treatment of Ethylene Glycol Poisoning. Administer crystalloids at 250-500 mL/h IV initially to enhance renal clearance of the toxin and to limit deposition of oxalates in the renal cortices. Timely treatment is effective and consists of supportive 48:979-1178. The alcohol dehydrogenase inhibitor 4-methylpyrazole (4-MP) is a new antidote of ethylene glycol (EG) intoxication. Its metabolites are toxic and cause profound metabolic [Medline]. [13], Fomepizole (Antizol) is a convenient antidotal therapy for treatment of ethylene glycol or methanol intoxication. Weigh the benefits, risks, and costs of each therapeutic intervention at the treating institution. Procedures, 2002 Treatment with fomepizole without hemodialysis in massive ethylene glycol ingestion has been rarely reported in the literature; however, published literature and practice guidelines recommend considering dialysis for ethylene glycol levels >50 mg/dL. E… John G Benitez, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, American College of Preventive Medicine, Undersea and Hyperbaric Medical Society, Wilderness Medical Society, American College of Occupational and Environmental MedicineDisclosure: Nothing to disclose. 27(4):395-401. A review of 121 ethylene glycol poisoning cases found that patients who did not receive an antidote (ethanol and/or fomepizole) until more than 6 hours had passed had higher odds of dying or having prolonged renal insufficiency (odds ratio 3.34). Courtesy of John D Schaldenbrand, MD, Department of Pathology, St Joseph Mercy Health System, Ann Arbor, MI. Administration of either intravenous ethanol or fomepizole, both of which competitively inhibit ethylene glycol metabolism by alcohol dehydrogenase and can prevent the production and accumulation of the toxic metabolites, can be used as an antidote. American Journal of Kidney Diseases. An integrated perspective on the developmental toxicity of ethylene glycol. Lung DD, Kearney TE, Brasiel JA, Olson KR. Usual Adult Dose for Ethylene Glycol Poisoning A regional poison control center (1-800-222-1222) should be contacted for indications and dosing. Soghoian S, Sinert R, Wiener SW, Hoffman RS. We studied the efficacy of fomepizole, a new inhibitor of alcohol dehydrogenase, in the treatment of ethylene glycol poisoning. This is performed with either fomepizole (4-MP) or ethyl alcohol. Please confirm that you would like to log out of Medscape. Rapid recognition and early treatment, including alcohol dehydrogenase (ADH) inhibition, are crucial. John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System PharmacistsDisclosure: Nothing to disclose. [Medline]. Persons exposed to ethylene glycol liquid or vapor do Sage W Wiener, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American College of Medical Toxicology, Society for Academic Emergency MedicineDisclosure: Nothing to disclose. Incorporation of therapeutic interventions in physiologically based pharmacokinetic modeling of human clinical case reports of accidental or intentional overdosing with ethylene glycol. cramps. Pyridoxine and thiamine are cofactors in ethylene glycol metabolism that promote production of nontoxic metabolites, and are safe adjuncts with no significant disadvantages.They may be administered parenterally. Ipecac-induced Measure levels of electrolytes, calcium, and magnesium, especially in patients with alcoholism because alcohol is a cofactor in oxalate metabolism. Once any of these manifestations occurs, antidotal therapy alone (used to block alcohol dehydrogenase with ethanol or fomepizole) is insufficient to treat the poisoning. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvODE0NzAxLXRyZWF0bWVudA==. Serum bicarbonate level less than 20 mg/dL, Ethylene glycol serum concentration >50 mg/dL. Hodgman M, Marraffa JM, Wojcik S, Grant W. Serum Calcium Concentration in Ethylene Glycol Poisoning. [Guideline] Barceloux DG, Krenzelok EP, Olson K, Watson W. American Academy of Clinical Toxicology Practice Guidelines on the Treatment of Ethylene Glycol Poisoning. [Medline]. [Full Text]. Treatment of ethylene glycol poisoning with intravenous 4-methylpyrazole. Other potential adverse effects include hyponatremia, sclerosis of veins, and intoxication (which can be particularly distressing in pediatric patients). Available at https://www.atsdr.cdc.gov/mmg/mmg.asp?id=82&tid=21. Barceloux DG, Krenzelok EP, Olson K, Watson W. J Toxicol Clin Toxicol. Clin J Am Soc Nephrol. Diseases & Conditions, 2002 Toxic Alcohol Ingestions: Clinical Features, Diagnosis, and Management. If fomepizole is not used, oral or parenteral ethanol loading is less commonly used as a temporizing measure while awaiting test results. If dialysis is considered, consult a nephrologist as early as possible to allow timely treatment of patients with toxic metabolite accumulation. If started before onset of acidosis, fomepizole may be used as the sole treatment for ethylene glycol ingestion in some cases. [14] Fomepizole is administered with a loading dose and twice-daily intravenous dosing. Baud FJ, Galliot M, Astier A, et al. ___________;__________. or by inhalation. Ethylene glycol toxicity presenting with non-anion gap metabolic acidosis. Divakar Jammalamadaka and Sina Raissi. Obtain a ethylene glycol serum concentration if you have access to this at your institution or locally. renal failure, and possibly death. 2008. Krasowski MD. Overly aggressive ethanol administration has reportedly caused cases of apnea that required intubation and mechanical ventilation, so serum ethanol concentrations must be checked regularly and the infusion rate adjusted to prevent over- or undertreatment. The availability of timely results of laboratory tests can be a problem. If Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT Associate Clinical Professor, Department of Surgery/Emergency Medicine and Toxicology, University of Texas School of Medicine at San Antonio; Medical and Managing Director, South Texas Poison Center requiring hemodialysis. (See supplemental page for metabolic pathway figures for ethylene glycol and methanol). LeBlanc C, Murphy N. Should I stay or should I go? 339:276-281. Carefully calculate the loading dose and administration of ethanol antidote to prevent excessive administration. District, Hospital, ITU, Ward . Miguel C Fernandez, MD, FAAEM, FACEP, FACMT, FACCT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine, Texas Medical Association, American College of Occupational and Environmental MedicineDisclosure: Nothing to disclose. Airway management is a priority because of the risk of aspiration. Alcohol dehydrogenase–blocking therapy must be accompanied by dialysis to remove the metabolites in these cases. 1990 Jun. Avoid giving calcium to patients with ethylene glycol intoxication, as this may exacerbate the precipitation of calcium oxalate in tissues. Ethylene glycol is only mildly irritating to skin and Ethyl alcohol has traditionally been used for antidotal treatment, but it has largely been supplanted by fomepizole in the United States. Ingestion of ethylene glycol produces CNS depression Ethylene glycol is a clear, odorless, slightly viscous liquid with a sweet taste. 53:1091-1097. 325574-overview Ethylene glycol is a very useful industrial compound because of its low freezing point and high boiling point. Diseases & Conditions, 2002 Baud FJ, Galliot M, Astier A, et al. 3:208-225. The most important initial treatment for ethylene glycol poisoning is stabilizing the person. Odor does not provide any warning of hazardous concentrations. [Medline]. [Medline]. There are three main goals associated with the treatment of ethylene glycol toxicity: 1) Decrease the amount of ethylene glycol that is absorbed, 2) Flush the unabsorbed ethylene glycol out of the animal’s system, and 3) Prevent absorbed ethylene glycol from being metabolized (Grauer). N Engl J Med 1988; 319:97. 4-MP Treatment was performed 7 hours after EG ingestion. The prehospital (EMS) personnel often can provide important details regarding the identity of the chemical(s) involved and the clinical characteristics of the patient. [Medline]. Medical Management Guidelines for Ethylene Glycol. Fomepizole is used to treat and prevent toxicity from ethylene glycol poisoning. Hemodialysis is used to treat metabolic acidosis or to prevent renal insufficiency. care, hemodialysis, and administration of a specific Breath or serum ethanol level – as part of the risk assessment, ethanol delays the clinical effects of ethylene glycol and also to calculate how much ethanol will be required as a temporary antidote. Infuse the loading dose and the maintenance dose over the first hour of therapy. When administering ethanol, determine glucose levels by fingerstick collection at regular intervals and confirm with laboratory analysis, as hypoglycemia is occasionally associated with ethanol therapy. 2020 Jan-Dec. 7:2374289519900330. Winter ML, Ellis MD, Snodgrass WR. Email: Contact CDC-INFO. J Med Toxicol. Emergency medical services should do the following: Rapidly evaluate patients who present with signs, symptoms, or history of toxic alcohol ingestion; determine serum osmolal gap. [17] a patient with an initial ethylene glycol level of 700 mg/dL was treated aggressively with fomepizole and was able to avoid dialysis. 1999 Mar 18. Treatment for ethylene glycol poisoning typically includes basic supportive care, alcohol dehydrogenase inhibition, and hemodialysis. Methanol and ethylene glycol poisonings cause scores of fatal intoxications annually, and even relatively small ingestions of these alcohols can produce significant toxicity. Fomepizole is equally efficacious for the treatment of methanol intoxication but does not cause any alteration in mental status, hypoglycemia, or respiratory depression. chemical by contacting: ____________ or _____________, or by Administer bicarbonate to correct severe acidosis (pH level ≤7.2); this of course should be done in conjunction with addressing the underlying cause of the acidosis. Early and Late Presentations of Ethylene Glycol Poisoning. Ad Hoc Committee. Acad Pathol. Jeffrey Kraut and Ira Kurtz. If possible, obtain the bottle or container that held the ingested substance. [1]. [Medline]. [Full Text]. J Toxicol Clin Toxicol. 85(1):491-501. 2013 Dec 26. Foley catheterization may be considered for patients with altered mental status, to monitor urinary output and to allow serial examination of urine for crystals or fluorescence. Toxins reviewed: Baclofen, Ethylene glycol, Methotrexate, Isoniazid, Calcium Channel Blockers, Beta-Blockers, Dabigatran, Gabapentin/Pregabalin, Quinine/Chloroquine, Amatoxins Blood Purification in Toxicology: Reviewing the Evidence and Providing Recommendations Provide the Emergency Department with the name and the Ingestion is the most important exposure route. Traditionally, gastric lavage or nasogastric aspiration of gastric contents are the most common methods employed in ethylene glycol poisoning. [Full Text]. Second, the patient has a definite history of recent ethylene glycol ingestion (especially if the osmolal gap is 10 mOsm/L or more, though patients with potentially toxic ethylene glycol ingestions may have an apparently normal osmolar gap; see Workup/Laboratory Studies). Guidelines on the medical management of ethylene glycol poisoning are available from the Agency for Toxic Substances and Disease Registry. 2019 Dec. 57 (12):1220-1413. Haemodialysis is the treatment of choice for severe salicylate poisoning and should be considered when the plasma-salicylate concentration exceeds 700 mg/litre (5.1 mmol/litre) or in the presence of severe metabolic acidosis. Fomepizole for the treatment of ethylene glycol poisoning. number of your primary care physician so that the ED can John G Benitez, MD, MPH Associate Professor, Department of Medicine, Medical Toxicology, Vanderbilt University Medical Center; Managing Director, Tennessee Poison Center [12] : However these criteria may be too conservative; if there is clinical concern or if laboratory testing will take an extended amount of time to return it is advisable to initiate therapy earlier. Antidotal therapy is inadequate by itself in these circumstances, and dialysis should be performed as soon as possible. [Medline]. The American Academy of Clinical Toxicology recommends fomepizole as the preferred treatment in such cases. Oxalate crystals. acidosis, cerebral edema, cardiovascular collapse, acute Toxicol Sci. Educational Case: Ethylene Glycol Poisoning. This website also contains material copyrighted by 3rd parties. not pose significant risks of secondary contamination to Ethylene Glycol, Methanol, and Isopropyl Alcohol Intoxication. Stephen M.S. Corley RA, McMartin KE. Reprod Toxicol. The telephone number for certified poison centers anywhere in the United States and Puerto Rico is 1-800-222-1222. can cause acidosis, hyperventilation, and renal failure Epidemics of acute renal failure in children (diethylene glycol toxicity). [Full Text]. J … : toxic alcohol case in the emergency department. 2002 Tests under study to detect methanol or its metabolite formate might facilitate the diagnosis of this poisoning. Daniel C Keyes, MD, MPH Associate Chair, Academic Affairs, Department of Emergency Medicine, St Joseph Mercy Hospital; Clinical Faculty, Emergency Medicine Residency, University of Michigan Medical School; Clinical Associate Professor, Department of Surgery, Division of Emergency Medicine and Toxicology, University of Texas Southwestern School of Medicine Ethylene glycol is a clear, odorless, slightly viscous liquid. In one case report, Treatment of ethylene glycol poisoning with intravenous 4-methylpyrazole. 2009 Jan. 55(1):46-9. Ethylene glycol is a CNS depressant, similar to ethanol. In centers where fomepizole is available, patients who present early and are without acidosis clinically well can be treated with fomepizole and hemodialysis on a regular floor. Abid A Kagalwalla, MD Resident Physician, Department of Emergency Medicine, St Joseph Mercy Hospital, University of Michigan Health System, Abid A Kagalwalla, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine. Fomepizole is a comparatively newer agent with specific indication for ethylene glycol poisoning and has been approved by the US Food and Drug Administration [ 1. Considerations in emergency department (ED) care include the following: Many patients with ethylene glycol ingestions are extremely obtunded and are at high risk of aspiration; endotracheal intubation may need to be considered. It is combustible and has a low vapor pressure. The patient's actual drinking habits determine the appropriate dose. Venous bicarbonate can be used instead of an arterial blood gas in the asymptomatic patient. Buchanan JA, Alhelail M, Cetaruk EW, Schaeffer TH, Palmer RB, Kulig K, et al. J Intensive Care Med. Interviewing persons present at the site of the ingestion may be helpful in this regard. Dermal absorption is negligible and does not contribute significantly to systemic toxicity. Brent J, McMartin K, Phillips S, Burkhart KK, Donovan JW, Wells M, et al. If you log out, you will be required to enter your username and password the next time you visit. Title . John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals December 2010. Fomepizole received US Food and Drug Administration (FDA) approval for use in ethylene glycol intoxication in December 1997, and it appears to have largely supplanted ethanol as the antidote of choice in toxic alcohol exposures in the US. As ethylene glycol is rapidly absorbed, gastric decontamination is unlikely to be of benefit unless it is performed within 60 minutes of ingestion. Persons exposed to ethylene glycol do not pose a significant risk of secondary contamination to response personnel outside the Hot Zone. [Medline]. 1999; 37(5):537-60. [Guideline] Agency for Toxic Substances and Disease Registry. Share cases and questions with Physicians on Medscape consult. [Medline]. Wallace KL, Suchard JR, Curry SC, Reagan C. Diagnostic use of physicians' detection of urine fluorescence in a simulated ingestion of sodium fluorescein-containing antifreeze. Ad Hoc Committee. [ncbi.nlm.nih.gov] Treatment Current practice guidelines for initiating treatment of ethylene glycol poisoning have been published by the American Academy of Clinical Toxicology (AACT) 4 and are listed in Table 3. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Giffin SL. N Engl J Med. 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