• Approach Toxic Alcohol Ingestion in the PICU

  • Dec 15 2024
  • Length: 30 mins
  • Podcast

Approach Toxic Alcohol Ingestion in the PICU

  • Summary

  • 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...
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