Ep 106 Toxic Alcohols – Minding the Gaps

We see patients with toxic alcohol poisoning most commonly in three clinical scenarios. One, which is usually relatively straightforward, after an intentional suicide attempt where they tell you exactly what they took; the next scenario is a bit more challenging - when they come in agitated and won’t give you a history and the third – also very challenging - the inebriated patient found down. Alcohol is everywhere, and inevitably inebriated people show up at your ED with a myriad of medical and psychiatric problems – we’re all familiar with these patients. Or they are simply very drunk. And most of them just need to sober up and can be sent home. But, it’s our job as ED professionals, not only to identify traumatic, medical and psychiatric catastrophes in these patients but also to identify and manage the relatively rare but potentially life and sight threatening toxicologic diagnoses in the inebriated or agitated patient. And that isn’t so easy - especially when it comes to toxic alcohols. So, in this Episode #106 Toxic Alcohols – Minding the Gaps - Recognition and Emergency Management, we’ve got the mighty return of two of my favorite brilliant Toronto based toxicologists –Margaret Thompson, the medical director of the Ontario Poison Control Centre, and the blossoming toxicology educator extraordinaire Emily Austin to help give you the knowledge of toxic alcohol poisoning recognition, clinical and lab clues, limitations of the osmolar gap, goals of management, time sensitive treatments and more... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Anton Helman January, 2018 Cite this podcast as: Helman, A, Thompson, M, Austin, E. Toxic Alcohols - Minding the Gaps. Emergency Medicine Cases. January, 2018. https://emergencymedicinecases.com/toxic-alcohols/. Accessed [date]. Alcohols can be divided into two broad groups based on presentation, pathophysiology and management: The toxic alcohols are methanol and ethylene glycol, which can both cause a scary anion gap metabolic acidosis in the first group and ethanol and isopropyl alcohol which aren’t quite as scary and generally don’t cause a big anion gap metabolic acidosis in the second group. Methanol is commonly found in windshield-wiper fluid and de-icing products, as well as paint removers, shoe dyes embalming fluid, and surprisingly a number of Windex products. Learn more about methanol poisoning in Killer Coma Cases- The Intoxicated Patient Ethylene glycol is typically found in radiator antifreeze, degreasing agents, foam stabilizers and metal cleaners. Diethylene glycol is also found in some anti-freeze products, and has caused outbreaks of renal failure after being inadvertently being substituted for sucrose. Isopropanol is found in rubbing alcohol, hand sanitizer gels and other antiseptic preparations. Practical Pearl: Call your local poison control center and request a product identification for products that you are unsure of the the contents. Put simply, methanol and ethylene glycol get metabolized into acids which lead to optic neuritis (methanol) ATN/ARF (ethylene glycol) requiring specific treatments, while isopropyl alcohol gets metabolized into acetone which generally requires supportive treatment only. Recognition of toxic alcohol poisoning: Clinical clues While most toxic alcohol ingestions are recognized either on history or the finding of an anion gap metabolic acidosis, there are sometimes clinical clues that, if recognized, can lead to early initiation of time sensitive treatments. Early signs of both methanol and ethylene glycol toxi...