Agency for Toxic Substances and Disease Registry
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Learning Objectives |
Upon completion of this section, you should be able to
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Introduction |
Treatment should not be delayed pending results of ethylene glycol serum levels if the patient’s condition or history suggests such poisoning. Treatment advice can be obtained from a regional poison control center or medical toxicologist. |
First Steps |
Initial management of suspected poisoning
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Prevent Absorption |
When the ingestion is recent, take steps to prevent ethylene glycol absorption.
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Specific Treatment |
Specific treatment for ethylene glycol poisoning includes
This treatment strategy is effective in most cases, but renal failure and death can occur if treatment is delayed. |
Table 3. Intravenous administration of ethanol in ethylene glycol and methanol poisoning. | ||
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Dose | Level† | Milliliters (mL) of 10% ethanol‡ |
Loading | 600 to 800 mg/kg | 7.6 to 10/kg |
Maintenance | ||
Chronic alcoholic | 154 mg/kg/hr | 1.95 kg/hr |
Social drinker | 110 mg/kg/hr | 1.39 kg/hr |
Nondrinker | 66 mg/kg/hr | 0.83 kg/hr |
During hemodialysis§ | ||
Chronic alcoholic | 304 mg/kg/hr | 3.95 kg/hr |
Social drinker | 256 mg/kg/hr | 3.29 kg/hr |
Nondrinker | 216 mg/kg/hr | 2.70 kg/hr |
*The goal of ethanol therapy is to maintain the blood ethanol level between 100 and 150 mg/dL. †mg/kg: milligrams per kilogram; mg/kg/hr: milligrams per kilogram per hour. ‡In 5% dextrose in distilled water (D5W) per kilogram body weight. §Assuming no ethanol is added to dialysis bath.Adapted from Hall 1992. |
Monitor the Patient |
Prolonged administration of ethanol can cause hypoglycemia, particularly in children; therefore, blood glucose should be monitored closely throughout treatment. The hypoglycemia that develops in adults is often overlooked because the impairment of mental status is attributed to the ethanol. |
Calculate the Dose |
To prepare 1 L of 10% ethanol in 5% dextrose in distilled water (D5W) for intravenous infusion, perform either of the following steps
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Monitor the Dose |
Monitor blood ethanol and serum glucose levels at the end of the loading dose and hourly until the maintenance dose is adjusted. Both should then be monitored 2-3 times daily, along with blood glucose. More frequent monitoring is required during dialysis. Most ethylene glycol (93.75%) is eliminated over 4 half-lives (prolonged to 17 hours with therapy). Therefore, most ethylene glycol should be out of the body within 68 hours (2.83 days). Ethanol therapy should be continued for 3 days if ethylene glycol levels are not available, or until the following conditions are met (Burkhart and Kulig 1990):
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Fomepizole Treatment Guidelines |
Fomepizole (Antizol) was approved by the FDA in December 1997 for use as an ADH antagonist in treatment of ethylene glycol poisoning. The following criteria (Barceloux, Krenzelok et al. 1999) were developed by the American Academy of Clinical Toxicology for using fomepizole rather than ethanol:
The manufacturer recommends a loading dose of 15 mg/kg infused intravenously over 30 minutes, followed by doses of 10 mg /kg every 12 hours for 4 doses, then 15 mg/kg every 12 hours until ethylene glycol levels are below 20 mg/dl (Meditext 2004). The dosage must be adjusted during dialysis. |
Advantages of Fomepizole Treatment |
This therapy may obviate the need for hemodialysis in the absence of both renal insufficiency and significant metabolic acidosis (Harry, Turcant et al. 1994; Harry, Jobard et al. 1998; Borron, Megarbane et al. 1999; Watson 2000; Brent 2001; Battistella 2002; Druteika, Zed et al. 2002). In addition, in comparison with ethanol, fomepizole
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Disadvantages of Ethanol Treatment |
The disadvantages of ethanol are that it
Although ethanol costs much less, the savings may be offset by additional costs for
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Hemodialysis |
Hemodialysis should be considered under these conditions (Ford M 1991; Hall AH 1992):
However, the decision to add hemodialysis in the treatment of ethylene glycol poisoning on the basis of plasma ethylene glycol concentrations is still debatable (Battistella 2002). A recent study suggested glycolic acid >8 mmol/L as a criterion for the initiation of hemodialysis in ethylene glycol ingestion (Porter, Rutter et al. 2001). Hemodialysis should be continued until
At that level, ethanol or fomepizole therapy can also be discontinued. In contrast, a recent report described successful clinical management of pediatric ethylene glycol poisoning cases without hemodialysis (Caravati, Heileson et al. 2004). |
Vitamin Treatment |
Thiamine and pyridoxine are two water-soluble B-complex vitamins that act as metabolic cofactors in the metabolism of ethylene glycol. They
Both should be administered intravenously [in dosages of 100 mg daily until intoxication is resolved (Davis, Bramwell et al. 1997; Jacobsen and McMartin 1997)] to patients who have ethylene glycol toxicity. Alcoholics who are nutritionally deprived may need more thiamine. If the vitamins are administered before dialysis, the dose should be repeated after dialysis because they are highly water-soluble and are likely to be removed by the procedure. Magnesium may help prevent deposition of calcium oxalate in the urine (Meditext 2004). |
Key Points |
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Progress Check |