▪️Imp: methanol/ethylene glycol toxicity
▪️Cond: urgency
▪️Diet: NPO
▪️Act: CBR and bed sides up
▪️CVS
▪️CM and POM
▪️oxygen therapy if sat<90%
* Secure airway as necessary in severely intoxicated patients
▪️IV line fix
▪️IV fluid therapy if needed
* Treat hypotension with intravenous crystalloid, followed by standard vasopressors as necessary
▪️ECG stat
▪️BS glucometer stat
▪️CBC, BUN, Cr, Na, K, Cl, BS, LFTs, VBG, Ca(to rule out ethylene-glycol associated hypocalcemia), pregnancy test, U/A(for oxalate crystals)
* calculate AG, serum osmolality
▪️Check Serum ethanol, methanol, ethylene glycol, and isopropyl alcohol concentrations.
*also check serum Acetaminophen and salicylate levels( to rule out these common co-ingestions)
▪️Amp fomepizole 15 mg/kg IV loading dose, followed by 10 mg/kg every 12 hours for 4 doses then 15 mg/kg every 12 hours as needed.(preferred antidote)
▪️Ethanol (10% IV solution) 10 mL/kg IV loading dose, followed by 1 mL/kg/hour titrated to serum ethanol concentration of 100 mg/dL.
▫️If fomepizole is unavailable.
▫️For patients requiring hemodialysis, ADH inhibitor (ie, fomepizole, ethanol) dose adjustments are required, eg, increasing the rate of ethanol infusion by about 50 percent during hemodialysis or possibly by adding ethanol directly to the dialysate.
▫️اتانول باعث هایپوگلیسمی میشه پس قند بیمار رو هم چک کنیم.
▪️check serum ethanol concentrations q1-2h initially, following any change in dose or infusion rate, during and after hemodialysis, and q 2-4h
otherwise.
▪️ Sodium bicarbonate 1 to 2 mEq/kg IV bolus followed by continuous infusion (eg, 133 mEq sodium bicarbonate in 1 L D5W administered at 150 to 250 mL/hour).
* For patients with moderate to severe metabolic acidosis (eg, blood pH <7.25, anion gap >24),
▪️Folic acid 50 mg IV every 6 hours.
*For patients with known or suspected methanol poisoning
▪️thiamine 100 mg IV once daily
* For patients with known or suspected ethylene glycol poisoning
▪️pyridoxine 100 mg IV once daily.
* For patients with known or suspected ethylene glycol poisoning
‼️If toxic alcohol poisoning is possible or suspected but the exact alcohol is unknown, especially in the presence of a metabolic acidosis, it is reasonable to empirically administer all three cofactors.(Folic acid + thiamine + pyridoxine)
▪️Consider ICU and intubation if needed
🔹Appendix :
▪️Indications for antidote with fomepizole or ethanol
▫️Documented serum methanol or ethylene glycol concentration >20 mg/dL (equivalent to methanol 6.2 mmol/L or ethylene glycol 3.2 mmol/L)
or
▫️Documented recent history of ingesting toxic amounts of methanol or ethylene glycol and serum osmol gap >10
or
▫️Strong clinical suspicion of methanol or ethylene glycol poisoning and at least two of the following:
•Arterial pH <7.3
•Serum bicarbonate <20 meq/L (mmol/L)
•Osmol gap >10
•Urinary oxalate crystals present
▪️طرز ساخت محلول ۱۰ درصد اتانول برای وریدی: ( 900cc DW5% + 100cc ethanol 96%)
Loading dose: 10ml/kg IV over 60 minutes.
Maintenance dose: 1ml/kg/hr IV.
▫️طرز ساخت محلول ۲۰درصد اتانول برای خوراکی: (400cc DW5% + 100c ethanol 96%)
Loading dose: 5ml/kg oral over 60 minutes.
Maintenance dose: 0.5ml/kg/hr oral.
▪️Hemodialysis is indicated in severe toxicity, which we define as follows:
▫️Elevated moderate-severe anion gap metabolic acidosis (eg, pH <7.25, anion gap >24), regardless of toxic alcohol concentration
▫️Serum methanol concentration greater >50 mg/dL (15.6 mmol/L)
▫️Serum ethylene glycol concentration >50 mg/dL (8.1 mmol/L) and presence of metabolic acidosis
▫️Evidence of end-organ damage attributable to the toxic alcohol (eg, visual changes following methanol, kidney failure following ethylene glycol)
▪️GI decontamination – In a patient known to have ingested a large amount of methanol or ethylene glycol who presents within 60 minutes of the ingestion, we recommend gastric aspiration via fexible NG tubing.
▫️ activated charcoal, gastric lavage, and syrup of ipecac have no routine role in the management of toxic alcohol exposures.
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