Approach Toxic Alcohol Ingestion in the PICU

Dec 15, 2024

This discussion dives into the urgent management of toxic alcohol ingestion in infants. A critical case involving a 7-month-old highlights symptoms like lethargy and CNS depression following accidental ethanol consumption. The podcast covers the challenges posed by methanol and ethylene glycol poisoning, emphasizing early recognition and treatment. Notably, Fomipazole is spotlighted as a key treatment, along with the role of hemodialysis in severe cases. Overall, it underscores the vital importance of timely interventions in pediatric critical care.

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Intro

00:00 • 2min

Management of Toxic Alcohol Ingestion in Pediatrics

02:26 • 10min

Understanding Methanol and Ethylene Glycol Poisoning

11:58 • 4min

Understanding Osmolar Gap in Toxic Alcohol Ingestion

15:55 • 2min

Management of Toxic Alcohol Ingestion with Fomipazole

17:41 • 2min

Managing Toxic Alcohol Ingestion

19:39 • 10min

Welcome and Episode Introduction

Hosts: Dr. Pradip Kamat (Children’s Healthcare of Atlanta/Emory University) and Dr. Rahul Damania (Cleveland Clinic Children’s Hospital)
Mission: A podcast dedicated to current and aspiring pediatric intensivists, exploring intriguing PICU cases and acute care pediatric management
Focus of the Episode: Managing toxic alcohol ingestion in the PICU with emphasis on ethanol, methanol, ethylene glycol, propylene glycol, and isopropyl alcohol

Case Presentation

Patient Details: A 7-month-old male presented with accidental ethanol ingestion after his formula was mixed with vodka
Key Symptoms: Lethargy, uncoordinated movements, decreased activity, and ethanol odor
Initial Labs & Findings:
EtOH level: 420 mg/dL.
Glucose: 50 mg/dL.
Normal CXR and EKG.
PICU Presentation: Tachycardic, normotensive, lethargic, with signs of CNS depression
Initial Management: Dextrose infusion, glucose monitoring, neurological observation, and ruling out complications

Key Learning Points from the Case

Toxic alcohol ingestion in pediatrics requires rapid stabilization and targeted interventions
Hypoglycemia and CNS depression are common features of ethanol toxicity in infants
Management prioritizes glucose correction, airway support, and close neurological monitoring

Deep Dive: Toxic Alcohols in the PICU

1. Ethanol

Typical Presentation in Infants/Toddlers: Hypotonia, ataxia, coma, hypoglycemia, hypotension, and hypothermia
Diagnostic Workup:
Focus on CNS and metabolic effects
Labs: Glucose, electrolytes, bicarbonate, anion gap, ketones, toxicology screen
Imaging (head CT) if indicated
Management: Stabilization, IV dextrose for hypoglycemia, NPO status until alert, and consultation with poison control and social work

2. Methanol

Sources: Windshield fluids, cleaning agents, moonshine

Clinical Stages:

Early: Dizziness, nausea, vomiting (0–6 hours)
Latent: Asymptomatic (6–30 hours)
Late: Vision disturbances, seizures, respiratory failure (6–72 hours)

Key Symptoms: “Snowstorm blindness” from retinal toxicity
Management: Fomepizole, correction of metabolic acidosis, and hemodialysis in severe cases

3. Ethylene Glycol

Sources: Antifreeze, brake fluids, household cleaners
Pathophysiology: Metabolism to glycolic acid (acidosis) and oxalic acid (renal failure due to calcium oxalate crystals)
Red Flags: Hypocalcemia, renal failure, QT prolongation
Management: Fomepizole, supportive care, and hemodialysis for severe toxicity

4. Propylene Glycol

Sources: Medications like lorazepam and pentobarbital
Presentation: High anion gap metabolic acidosis at high doses, with renal and liver dysfunction
Management: Discontinue offending agent, supportive care, and hemodialysis if severe

5. Isopropyl Alcohol

Sources: Disinfectants, hand sanitizers
Presentation: CNS depression, GI irritation, fruity acetone breath, but no metabolic acidosis
Management: Supportive care; fomepizole and ethanol are ineffective

Key Laboratory Insights

Osmolar Gap Formula:
Measured Osmolality - Calculated Osmolality
A high osmolar gap indicates unmeasured osmoles like toxic alcohols.
Lactate Gap in Ethylene Glycol: Discrepancy between bedside and lab lactate levels due to glycolate interference

Management Pearls

Ethanol and Ethylene Glycol: Fomepizole as first-line treatment; hemodialysis for severe cases
Methanol: Similar approach with additional focus on preventing blindness
Propylene Glycol: Monitor lactate and renal function, discontinue offending medications
Isopropyl Alcohol: Supportive care, no acidosis present

Mnemonics for Toxic Alcohols

MEGA GAP:

Methanol and Ethylene Glycol: Anion Gap Acidosis with elevated Osmolar Gap
Isopropyl Alcohol: Isolated Osmolar Gap (no acidosis)
Propylene Glycol: Mimics ethylene glycol with HAGMA at high doses

Takeaway Messages

Early recognition of toxic alcohol ingestion is critical for successful management
Differentiate between toxic alcohols using anion gap, osmolar gap, and clinical presentation
Engage poison control and social work early in the process

Conclusion

Pediatric toxic alcohol ingestions are rare but potentially life-threatening
Fomepizole is a cornerstone therapy for methanol and ethylene glycol toxicity
Supportive care remains essential across all toxic alcohol ingestions

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