Ethylene glycol poisoning: mind the gap

The initial POC laboratory results showed a metabolic acidosis, elevated anion gap with a lactate >31mmol/L. This initially clouded our diagnostic picture. When the repeat lactate obtained from our main hospital laboratory was significantly lower, resulting in what is known as a ‘lactate gap’, EG moved to the top of our differential, and was verified by urine microscopy, confirming the presence of oxalate crystals.

EM@3AM: Ethylene Glycol Toxicity

Ethanol level should be obtained. If negative and patient appears intoxicated, think toxic alcohol. If ethanol level is positive, this can be protective against a toxic alcohol. Positive ethanol level does not rule out toxic alcohol.

Ethylene glycol & methanol poisoning

Beware of relying on the osmolal gap; a normal osmolal gap doesn't exclude toxic alcohol ingestion.

Methanol and Ethylene? Siri tells us all about it

We discuss a complex topic and make sure its under 17 minutes. Methanol, Ethylene glycol. How to catch it, how to diagnose it, and how to treat it! Siri makes a guest appearance.

#SimBlog: Ethylene Glycol Poisoning

The classical products to think about are de-icers/ antifreeze, screen washes and solvents. It is important to identify why they were consumed, it may be the patient wanted to harm themselves. In other cases it is because it is cheaper than buying alcohol. Also beware of accidental consumption by children. Fortunately some of these products are mixed with agents to make them hard to drink.

Back to Basics: Methanol and Ethylene Glycol Toxicity

Ethylene Glycol Poisoning = initial 12 hrs present as intoxication (nausea / vomit / slurred speech / ataxia / altered mental status), 12 to 24 hrs after ingestion predominately cardiopulmonary effects (tachycardia, tachypnea, hypertension, CHF, ARDS), 24+ hrs after ingestion predominately renal effects (flank pain, hematuria, oliguria / anuria, ATN, ARF)

CASE 5: Ethylene Glycol and Methanol

The entire point of the basic science correlate of this case is knowing that it is the metabolite of ethylene glycol and methanol that causes their toxic effects. Ethylene glycol is not directly toxic to the kidney. Ethylene glycol is metabolized to glycolic acid and oxalic acid. It is the metabolites that are dangerous to the kidney tubules by their direct cytotoxic effects.

Diagnostics: Toxic Alcohols

In ethylene glycol ingestion, the patient’s urine may appear fluorescent under Wood’s lamp. This is due to the presence of sodium fluorescein that is added to antifreeze to help assess for radiator leaks. The clinician may also use this method to assess the patient’s mouth, vomitus, or clothing for the presence of fluorescence. This finding, however, has poor sensitivity and specificity for ethylene glycol toxicity, and therefore should not be used to rule toxicity in or out ,

Ethylene Glycol Ingestion

Initiate alcohol dehydrogenase blockade. 15 mg/kg of fomepizole should be ordered. Administration of ethanol is also sufficient – 4-5 shots of hard liquor down a nasogastric tube. IV ethanol is not available. (Target serum ethanol level should be 100-150 mg/dL if fomepizole is not available).

Ethylene glycol poisoning: A diagnostic challenge in a patient with persistent seizures and a severe metabolic acidosis

Toxic alcohol ingestion is a common and lethal type of poisoning in Africa with many documented cases of mass poisoning. The diagnosis of toxic alcohol poisoning is challenging in our context as most laboratories do not do diagnostic assays.

Ethylene Glycol Toxicity in the Setting of Recurrent Ingestion: A Case Report and Literature Review

Ethylene glycol (EG) poisoning is a toxicologic emergency requiring high clinical suspicion and early diagnosis to prevent life-threatening complications. Direct EG quantification methods involve cumbersome and time-consuming laboratory tests of limited utility in the emergency setting. Accordingly, the osmolal gap is frequently employed as a surrogate screening method in cases of suspected toxic alcohol poisoning. However, the osmolal gap has several inherent limitations to be considered when used as a diagnostic tool for EG toxicity.

Paucis Verbis: Toxic alcohols – Ethylene glycol

The parent compounds for ethylene glycol and methanol are innocuous and the metabolites are toxic.

Pharmacology and Toxicology: Treatment of Poisons – Ethylene Glycol Intoxication

The estimated minimum lethal dose for adults is approximately 100 ml

Prompt Diagnosis of Ethylene Glycol Intoxication by an Unusual “Lactate Gap”: A Case Report

Ethylene glycol (EG) intoxication can lead to severe metabolic acidosis and acute kidney injury and can be lethal if diagnosis is delayed. Direct measurement of ethylene glycol is often not readily available. Prompt recognition and intervention may require recognition of indirect laboratory findings. Here, the author presents a case of EG intoxication whose diagnosis was based on an unusual “lactate gap.”

Tasty Morsels of EM 001

In ethylene glycol poisoning in lieu of getting a level (which will arrive 2 weeks after the funeral) you can measure the “lactate gap”. This is the difference between the lactate measured on two different instruments the ABG machine the fancy lab one Ethylene glycol metabolites interfere with the lactate assay and the gap between the two measurements gives an approximation for the level.

The Toxic Shelf: Ethylene Glycol - The Drink You Shouldn't Accept At A Party.

Fomepizole is the first line treatment, as it greatly slows the elimination of ethylene glycol and its conversion to the toxic metabolites, glycolic acid and oxalic acid, by inhibition of alcohol dehydrogenase.

Toxic Alcohols

Similarly, the toxic metabolites of ethylene glycol cause end-organ damage at levels greater than 20mg/dl. The most notable toxic metabolites are glycolic acid and oxalic acid.

Volatile Alcohol Ingestion: A Good Ole Boy Drinking Ethylene Gly, Singin This’ll Be How I Get AKI

Based on the history of ingestion and the patient’s family’s concern for self-harm, the above lab-work, as well as a volatile alcohol panel, was sent on the patient. While awaiting results of the alcohol panel, the clinicians calculated an increased osmolar and anion gaps (see below), leading them to conclude that the patient was currently poisoned with a toxic alcohol. He was therefore started on fomepizole and bicarb. However, the patient continued to display a refractory acidosis, and nephrology was consulted for immediate dialysis. This was initiated in the ED and the patient was admitted to the ICU for further care.