What is included in emergency department (ED) care of alcohol toxicity?

Updated: Jan 05, 2021
  • Author: Michael D Levine, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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As with all emergency patients, initial treatment should focus on the airway, breathing, and circulation. Gastric decontamination is rarely necessary for any of the alcohols. An exception to this may be a patient who presents immediately after ingestion of a toxic alcohol in whom one might reasonably expect to be able to recover a significant amount of the toxin via aspiration through a nasogastric tube.

Treatment of ethanol and isopropanol intoxication is largely supportive. [24] Because of the hemorrhagic gastritis that can follow isopropanol ingestion, H2 blockade or proton-pump inhibitors may be helpful. Hemodialysis, while effective, is rarely indicated, and should only be used in the setting of profound hemodynamic compromise. [5]

Once either methanol or ethylene glycol intoxication are suspected, treatment should be initiated without delay. Fortunately, since both alcohols are metabolized by alcohol dehydrogenase, the treatment is the same, and differentiating which of the two toxic alcohols is responsible is not necessary before implementing treatment. [24]

The primary antidotal treatment of methanol or ethylene glycol involves blocking alcohol dehydrogenase. This enzyme can be inhibited by either ethanol or fomepizole. [25, 26, 27] Toxic alcohol levels are frequently not immediately available. Thus, ideally, if methanol or ethylene glycol poisoning is suspected, the patient should receive a loading dose of fomepizole while the levels are being obtained. Because the next dose of fomepizole is not due for an additional 12 hours, this strategy allows 12 hours for the blood to be processed at a reference laboratory before additional treatment is needed.

Inhibition of alcohol dehydrogenase with ethanol may be substituted for treatment with fomepizole (see below), though studies have highlighted the greater safety of fomepizole as a treatment, when available. [11] In some patients, treatment with fomepizole alone may represent definitive treatment and can prevent the need for hemodialysis. [28]

In addition to blocking alcohol dehydrogenase, significant metabolic acidosis should be treated with sodium bicarbonate infusions. If methanol is suspected, folinic acid should be administered at a dose of 1 mg/kg, with a maximal dose of 50 mg. It should be repeated every 4 hours. If folinic acid is not immediately available, folic acid can be substituted at the same dose.

If ethylene glycol overdose is suspected, the patient should also receive 100 mg of intravenous thiamine every 6 hours and 50 mg of pyridoxine every 6 hours. The purpose of the thiamine and pyridoxine is to shunt metabolism of glyoxylic acid away from oxalate and favor the formation of less toxic metabolites.

In methanol overdose, sodium bicarbonate should be administered liberally, with the goal being to completely reverse the acidosis. Experimental studies suggest that formate is excreted in the kidneys at a much higher rate when the patient is not acidotic. In addition, when the patient is not acidotic, formic acid dissociates to formate at lower rates so that less formate crosses the blood-brain barrier. Thus, in methanol intoxication, correcting the acidosis actually speeds up elimination of the toxic compound and decreases toxicity.

If ethanol is used as an antidote, the recommended target serum concentration is 100-150 mg/dL. Because ethanol inhibits gluconeogenesis, hypoglycemia is common in patients on an ethanol infusion. [29] Hypoglycemia is particularly prevalent in pediatric patients on such drips. Thus, serum glucose levels must be checked frequently, at least every 2 hours. In addition, because it is difficult to attain a steady serum concentration of ethanol, the ethanol level also must be checked frequently, and titrations made.

A 5% or 10% ethanol solution can be made in the pharmacy. If giving ethanol, administer a loading dose of 600 mg/kg, followed by a drip of 66-154 mg/kg/h, with chronic alcoholics requiring doses at the higher end of the scale. Ethanol can be given either intravenously or orally.

In addition to hypoglycemia, additional adverse effects from ethanol infusion include inebriation, CNS depression, pancreatitis, and local phlebitis. Because of the phlebitis that occurs with ethanol infusions, some advocate that ethanol should only be administered via a central venous line.

Ethanol infusions are not only labor intensive, but once the costs of the frequent blood glucose and serum ethanol level assays are accounted for, ethanol antidotal therapy is frequently more expensive than fomepizole. Ethanol has also been associated with more frequent adverse reactions than fomepizole. [30] Thus, because of the lower overall cost and the ease of administration and safety considerations, fomepizole has become the preferred antidote for methanol or ethylene glycol poisoning. [31]

Fomepizole should be administered as a loading dose of 15 mg/kg. Subsequent doses should be at 10 mg/kg every 12 hours for 4 doses. Because fomepizole actually induces its own metabolism after 48 hours of treatment, if additional doses are needed, the dose should be increased to 15 mg/kg. Fomepizole needs to be re-dosed during hemodialysis. The package insert or local poison center can help with the re-dosing strategy. Fomepizole should be continued until the serum ethylene glycol or methanol concentrations are less than 20 mg/dL.

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