Ethylene Glycol Toxicity

Begin fomepizole immediately if ethylene glycol ingestion is suspected from a credible history together with anion-gap metabolic acidosis, increased osmolar gap, urinary oxalate crystals, or a documented ethylene glycol concentration greater than 20 mg/dL. Do not wait for clinical deterioration or for a send-out concentration: untreated metabolism produces glycolic and oxalic acids and can progress to seizures, coma, acute tubular necrosis, and death. dailymed nlm nih+1dailymed nlm nih[PDF] FOMEPIZOLE - DailyMeddailymed nlm nihANTIZOL® (fomepizole) Injection

Obtain initial venous or arterial blood gas, basic metabolic panel, measured serum osmolality, glucose, BUN, ethanol concentration, urinalysis with microscopy, and a serum ethylene glycol concentration where available. Repeat acid-base and electrolyte measurements frequently during treatment; a falling parent-compound concentration does not establish safety if the anion gap or acidosis is worsening from accumulating metabolites. dailymed nlm nih+1dailymed nlm nih[PDF] FOMEPIZOLE - DailyMedCDCEthylene Glycol and Propylene Glycol Toxicity: What Laboratory Tests Can Help in Evaluating Patients Exposed to Ethylene Glycol? | Environmental Medicine | ATSDR

Admit patients receiving fomepizole, ethanol, or hemodialysis to an ICU-level setting. Give crystalloid for clinically important volume depletion from vomiting or osmotic diuresis, and correct severe acidemia while preparing antidote therapy and dialysis when indicated. CDC+1CDCEthylene Glycol | Medical Management Guidelines | Toxic Substance Portal | ATSDRacep[PDF] Pediatric Ethylene Glycol Ingestion - Patient Name; Age

Calculate the osmolar gap using measured osmolality minus calculated osmolality: 2 × sodium + BUN/2.8 + glucose/18 + ethanol/4.6 when ethanol is present. A normal osmolar gap is approximately -14 to +10 mOsm/L by this method. An increased osmolar gap supports unmeasured parent alcohol, whereas an elevated anion gap identifies accumulating acidic metabolites. CDCCDCEthylene Glycol and Propylene Glycol Toxicity: What Laboratory Tests Can Help in Evaluating Patients Exposed to Ethylene Glycol? | Environmental Medicine | ATSDR

The strongest bedside laboratory pattern is high-anion-gap metabolic acidosis with an elevated osmolar gap and urinary calcium oxalate or hippurate crystals. Calcium oxalate crystals may be dumbbell-, envelope-, or needle-shaped; needle forms are reported most commonly. Urine microscopy is supportive rather than exclusionary: renal damage can occur without crystal deposition or detectable crystalluria. CDCCDCEthylene Glycol and Propylene Glycol Toxicity: What Laboratory Tests Can Help in Evaluating Patients Exposed to Ethylene Glycol? | Environmental Medicine | ATSDR

Interpret gaps in the clinical time course. Early after ingestion, parent ethylene glycol can raise the osmolar gap before major acidosis develops. Later, ethylene glycol may have fallen as glycolate and oxalate rise, producing marked anion-gap acidosis with a less conspicuous osmolar gap. Therefore, neither a declining ethylene glycol concentration nor a single gap calculation should override worsening acidemia or kidney injury. dailymed nlm nih+1dailymed nlm nih[PDF] FOMEPIZOLE - DailyMedNatureToxic Alcohol Poisoning and Metabolic Acidosis | Toxicology | Pharmacology and Pharmaceutical Sciences | Health sciences | Topics | Nature Index

A normal anion gap does not categorically exclude ethylene glycol toxicity. Rarely, concurrent bromide intoxication may artifactually lower the calculated anion gap and conceal the expected organic acidosis; retain diagnostic concern when the exposure history, osmolar gap, coma, or crystalluria is compelling. annemergmedannemergmedEthylene glycol poisoning with a normal anion gap due to occult bromide intoxication - Annals of Emergency Medicine

Use fomepizole as the preferred alcohol dehydrogenase inhibitor when available. It competitively inhibits alcohol dehydrogenase, preventing formation of toxic metabolites from ethylene glycol; compared with ethanol, it has predictable pharmacokinetics, simpler administration, and avoids ethanol-related inebriation. NEJM+1NEJMFomepizole for Ethylene Glycol and Methanol Poisoning | New England Journal of MedicineCDCEthylene Glycol | Medical Management Guidelines | Toxic Substance Portal | ATSDR

Give fomepizole 15 mg/kg IV as a loading dose, followed 12 hours later by 10 mg/kg IV every 12 hours for four doses. After 48 hours, increase to 15 mg/kg IV every 12 hours because fomepizole metabolism increases with continued treatment. The pivotal prospective ethylene glycol study continued therapy until the plasma ethylene glycol concentration was below 20 mg/dL. NEJM+1NEJMFomepizole for the Treatment of Ethylene Glycol Poisoning | New England Journal of MedicineCDCEthylene Glycol | Medical Management Guidelines | Toxic Substance Portal | ATSDR

If fomepizole is unavailable, ethanol can provide alcohol dehydrogenase blockade while fomepizole is obtained or the patient is transferred. Ethanol requires frequent concentration monitoring and dose adjustment and has clinically consequential adverse effects, including central nervous system depression, hypoglycemia, hypothermia, and agitation. acep+1acep[PDF] Pediatric Ethylene Glycol Ingestion - Patient Name; AgeWHO[PDF] the national protocol for treatment of substance use disorders in ...

Continue serial blood gas or acid-base assessment, serum electrolytes, renal function, and ethylene glycol concentrations during antidote therapy. Escalate to hemodialysis when acidosis becomes significant or worsens, renal failure develops, or the measured ethylene glycol concentration is at least 50 mg/dL. dailymed nlm nih+1dailymed nlm nih[PDF] FOMEPIZOLE - DailyMeddailymed nlm nihANTIZOL® (fomepizole) Injection

Consider hemodialysis in addition to fomepizole for renal failure, significant or worsening metabolic acidosis, or a measured ethylene glycol concentration of at least 50 mg/dL. These criteria reflect the need to remove both the parent alcohol and metabolites while correcting life-threatening metabolic abnormalities. dailymed nlm nih+1dailymed nlm nih[PDF] FOMEPIZOLE - DailyMeddailymed nlm nihANTIZOL® (fomepizole) Injection

Do not delay dialysis for a repeat ethylene glycol concentration when acidemia remains refractory to correction, kidney injury is evolving, or end-organ injury such as hypotension or shock accompanies the poisoning. A practical endpoint is correction of acidosis together with closure of the osmolar gap or reduction of ethylene glycol concentration below 20 mg/dL. acepacep[PDF] Pediatric Ethylene Glycol Ingestion - Patient Name; Age

Continue frequent electrolyte and acid-base monitoring during and after dialysis because the procedure corrects metabolic abnormalities, while delayed kidney injury can become apparent over 24 to 72 hours. Persistent or new renal failure after clearance of ethylene glycol warrants ongoing renal replacement assessment. dailymed nlm nih+1dailymed nlm nih[PDF] FOMEPIZOLE - DailyMedCDCEthylene Glycol | Medical Management Guidelines | Toxic Substance Portal | ATSDR

Follow ethylene glycol concentrations and acid-base status at frequent intervals throughout treatment. Use the serial anion gap and blood gas, rather than a single concentration alone, to detect continuing toxic metabolite burden; ethylene glycol concentrations diminish as metabolism proceeds and may be misleadingly low in delayed presentation. dailymed nlm nih+1dailymed nlm nih[PDF] FOMEPIZOLE - DailyMeddailymed nlm nihANTIZOL® (fomepizole) Injection

Trend serum creatinine and urine output for at least the period in which delayed renal effects are expected, because renal injury typically develops 24 to 72 hours after poisoning. Acute renal failure requires hemodialysis. CDCCDCEthylene Glycol | Medical Management Guidelines | Toxic Substance Portal | ATSDR

Patients requiring fomepizole, ethanol infusion, or hemodialysis require ICU admission. A patient with a significant ingestion history but no or mild symptoms still requires blood and urine testing and prompt treatment decisions rather than discharge based on an initially benign examination. CDCCDCEthylene Glycol | Medical Management Guidelines | Toxic Substance Portal | ATSDR