PICU Doc On Call

Approach Toxic Alcohol Ingestion in the PICU


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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:

  1. Early: Dizziness, nausea, vomiting (0–6 hours)
  2. Latent: Asymptomatic (6–30 hours)
  3. 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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PICU Doc On CallBy Dr. Pradip Kamat, Dr. Rahul Damania

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