Toxic Alcohol Ingestion Medical Slides

Present the temporal evolution: Early ingestion (0-6 hours) — parent alcohol present, elevated osmol gap (>10 mOsm/kg), normal anion gap, minimal symptoms. As metabolism proceeds — osmol gap falls (parent compound metabolized), anion gap rises (toxic metabolites accumulate), symptoms worsen. Late presentation — normal osmol gap but elevated anion gap metabolic acidosis with end-organ damage. Key teaching point: a normal osmol gap does NOT exclude toxic alcohol ingestion — it may indicate late presentation where the parent compound is already metabolized. Calculated osmolality = 2(Na) + glucose/18 + BUN/2.8 + EtOH/4.6.

Present the fomepizole (Antizol) protocol: loading dose 15 mg/kg IV, then 10 mg/kg every 12 hours for 4 doses, then 15 mg/kg every 12 hours thereafter (auto-induction of its own metabolism increases clearance). During hemodialysis: dose every 4 hours (dialyzed out). Continue until toxic alcohol level <20 mg/dL and patient clinically improving with normal pH. Fomepizole is preferred over ethanol infusion: predictable dosing, no CNS depression, no hypoglycemia, easier to manage. Ethanol infusion (target level 100-150 mg/dL) is used only when fomepizole is unavailable. Emphasize: give fomepizole empirically if clinical suspicion is high — do not wait for levels.

Present the EXTRIP workgroup (2015) recommendations: Methanol — strongly recommend HD for: visual impairment, pH ≤7.15, serum methanol >70 mg/dL, or deterioration despite treatment. Consider HD for: serum methanol >60 mg/dL without other criteria, impaired kidney function. Ethylene glycol — strongly recommend HD for: pH ≤7.15, serum EG >50 mg/dL with impaired kidney function, or deterioration despite treatment. HD removes both parent compound and toxic metabolites, corrects acidosis, and shortens treatment duration. Continue fomepizole during HD (redose Q4H). Dialyze until toxic alcohol level undetectable and acidosis resolved.