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PHM 702- Toxicology > Toxic Alcohol Poisoning > Flashcards

Toxic Alcohol Poisoning Flashcards

1
Q

What are toxic alcohols?

A

Alcohol not intended for ingestion

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2
Q

Examples of toxic alcohols

A

Methanol-containing consumer products (like windshield washer fluid), ethylene glycol (car antifreeze), isopropanol (rubbing alcohol)

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3
Q

Clinical manifestations of toxic alcohol poisoning are usually seen where?

A

CNS

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4
Q

Inebriation with a toxic alcohol poisoning is dependent on what?

A

Dose and molecular weight

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5
Q

What happens if a patient doesn’t LOOK inebriated

A

Just because they don’t look like it, doesn’t meant they didn’t ingest anything

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6
Q

Other clinical manifestation of toxic alcohol poisoning (not CNS effects)

A

Metabolic acidosis

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7
Q

How is metabolic acidosis caused in toxic alcohol poisoning?

A

The toxic alcohols are metabolized to toxic organic acids which causes a high anion gap metabolic acidosis

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8
Q

Methanol is metabolized to what?

A

Formic acid

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9
Q

Ethylene glycol is metabolized to what?

A

Glycolic acid

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10
Q

Isopropanol is metabolized to what?

A

Acetone; it causes ketosis without acidosis

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11
Q

Toxic alcohol-specific clinical manifestations: methanol

A

Retinal toxicity: blurry vision to complete blindness, can be asymmetric

Neurotoxicity: basal ganglia lesions bilaterally which can lead to Parkinsonism

AKI

Pancreatitis

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12
Q

Toxic alcohol-specific clinical manifestations: ethylene glycol

A

Nephrotoxicity

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13
Q

How can ethylene glycol cause nephrotoxicity?

A

Oxalic acid + calcium = calcium oxalate monohydrate crystals → deposit in renal tubules → precipitation can cause hypocalcemia

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14
Q

What to monitor in ethylene glycol toxicity

A

Calcium levels

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15
Q

Toxic alcohol-specific clinical manifestations: isopropanol

A

Hemorrhagic gastritis

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16
Q

Toxic alcohol poisoning diagnostic tests: serum concentrations to look for/order

A

Methanol, formate, ethylene glycol, isopropanol

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17
Q

Caveat about the toxic alcohol serum concentrations

A

The results may not come back in a timely manner, so you have to base the diagnosis on clinical history and other lab values that have been obtained

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18
Q

What levels can be helpful if it’s been a while since the patient ingested the toxic alcohol?

A

Formate

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19
Q

How to handle toxic alcohol samples

A

The sample tubes should be airtight to prevent evaporation (isopropanol and methanol specifically)

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20
Q

Toxic concentration of methanol and ethylene glycol

A

> 25mg/dl

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21
Q

What other values should you obtain for toxic alcohol poisoning testing?

A

Electrolytes, calcium, BUN, Cr, UA, VBG or ABG, lactate, measured serum osmolality and serum ethanol concentration

22
Q

If you have a high anion gap metabolic acidosis for an unknown reason, what can you suspect?

A

Toxic alcohol ingestion

23
Q

Normal osmol gap range

A

-14 to +10 mOsm/L

24
Q

Extremely elevated osmol gap level

A

> 50mOsm/L

25
Q

What is needed to assess the severity of the osmol gap?

A

Baseline osmol gap; a current gap may be within normal range but abnormal for the patient compared to their baseline

26
Q

Serum ethanol concentrations can do what?

A

Prevent metabolism to the organic acid, can be considered protective

27
Q

What levels are elevated with methanol and ethylene glycol poisoning?

A

Lactate

28
Q

That chart of the osmol and anion gap: what is the relationship between it?

A

After ingestion, alcohols in the serum RAISE THE OSMOL GAP, but the ANION GAP remains NORMAL because metabolism to the organic acid hasn’t occurred yet. As toxic alcohols are metabolized, the ANION GAP RISES and the OSMOL GAP FALLS.

29
Q

Methanol and ethylene glycol treatment: resuscitation

A

Fluids and vasopressors

30
Q

Methanol and ethylene glycol treatment: inhibition of ADH

A

IV 10% ethanol, fomepizole

31
Q

Downsides of IV ethanol 10% infusion for ADH inhibition

A

Serum concentrations have to be constantly monitored with a goal level of 100mg/dl

Lots of side effects

32
Q

Side effects of 10% ethanol infusion

A

hypotension, respiratory depression, CNS depression and inebriation, flushing, hypoglycemia, hyponatremia, pancreatitis, gastritis

33
Q

Fomepizole initial bolus dose

A

15mg/kg IV piggyback over 30 minutes

34
Q

Fomepizole maintenance dose

A

10mg/kg IV piggyback q12h x4 doses, then increase dose to 15mg/kg IV piggyback q12h

35
Q

Why do you increase the fomepizole dose after 48 hours?

A

It induces its own metabolism

36
Q

How long do you continue fomepizole treatment for?

A

Until serum toxic alcohol concentrations are <20mg/dl and patient is asymptomatic with normal serum pH

37
Q

ADEs of fomepizole

A

hypotension, bradycardia

38
Q

Methanol and ethylene glycol treatment: renal replacement therapy; which one is better. hemodialysis or RRT?

A

hemodialysis > RRT

39
Q

When to use renal replacement therapy in toxic alcohol poisoning

A

Depends on the severity and impact of metabolites

40
Q

Dose adjustments for renal replacement therapy are needed in what disease state?

A

AKI; use intermittent hemodialysis or CRRT

41
Q

Methanol and ethylene glycol treatment: adjunctive therapy for methanol toxicity

A

folic acid
methylprednisolone
continuous infusion of sodium bicarb

42
Q

Methanol and ethylene glycol treatment: role of folic acid in methanol toxicity

A

enhances formate elimination

43
Q

Methanol and ethylene glycol treatment: methylprednisolone dose

A

1gm IV q24h x3 days

44
Q

Methanol and ethylene glycol treatment: role of methylprednisolone in methanol toxicity

A

Improve amount of vision loss experienced

45
Q

Methanol and ethylene glycol treatment: role of sodium bicarb in methanol toxicity

A

shifts formic acid to formate and causes ion trapping in the ruine

46
Q

Goal serum pH of sodium bicarb infusion in methanol toxicity

A

> 7.2

47
Q

Methanol and ethylene glycol treatment: adjunctive therapy for ethylene glycol toxicity

A

thiamine
pyridoxine
sodium bicarb IV infusion

48
Q

Methanol and ethylene glycol treatment: role of thiamine in ethylene glycol toxicity

A

promotes conversation of ethylene glycol to ketoadipate

49
Q

Methanol and ethylene glycol treatment: role of pyridoxine in ethylene glycol toxicity

A

promotes conversion of glycine to hippuric acid

50
Q

Methanol and ethylene glycol treatment: when to consider a sodium bicarb continuous IV infusion in patients with ethylene glycol toxicity

A

if their pH is <7.15

PHM 702- Toxicology (12 decks)

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