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Toxicity, Ethanol: Differential Diagnoses & Workup

Author: Elizabeth Brothers, MD, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center
Coauthor(s): Christopher I Doty, MD, FACEP, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Contributor Information and Disclosures

Updated: Oct 14, 2009

Differential Diagnoses

Attention Deficit Hyperactivity Disorder
Hypoglycemia
Child Abuse & Neglect: Reactive Attachment Disorder
Hyponatremia
Cognitive Deficits
Respiratory Distress Syndrome
Conduct Disorder
Respiratory Failure
Dehydration
Toxicity, Carbon Monoxide
Diabetic Ketoacidosis
Toxicity, Oral Hypoglycemic Agents
Gastroenteritis
Head Trauma
Hyperammonemia

Other Problems to Be Considered

Isopropyl alcohol poisoning
Methanol poisoning
Toxicity, Ethylene Glycol
Alcoholic ketoacidosis
Occult trauma
Opiate intoxication
Toxicity, Benzodiazepine
Toxicity, Barbiturate
Sepsis

Workup

Laboratory Studies

  • Serum glucose level: A bedside glucose finger stick is a quick and inexpensive method of assessing hypoglycemia. Hypoglycemia in a common in young children with ethanol intoxication.
  • Electrolyte levels: The anion gap measurement should be determined. Acute ethanol intoxication usually does not cause significant anion gap metabolic acidosis. The presence of a large anion gap or severe acidosis should suggest the ingestion of another substance, such as methanol or ethylene glycol. However, patients with multiple-trauma can also have marked metabolic acidosis, and ethanol intoxication predisposes patients to trauma.
  • Ethanol level
    • The serum ethanol concentration determined to obtain a starting level. Ethanol is metabolized at a fixed rate in an individual; however, alcohol metabolism rates widely vary, and predicting an individual's metabolism rate is impossible. If ethanol levels are obtained at two different times, one can reliably predict what a patient's ethanol level would be at a given point in the future. However, one cannot predict whether the patient would be "intoxicated" without knowing the patient's tolerance to ethanol.
    • A blood alcohol concentration (BAC) that could make one person apneic may be a level at which another individual would suffer withdrawal. Also, a pharmacodynamic property, called the Mellanby effect, is observed when neurological impairment is greater at a given BAC when the BAC is increasing than the impairment observed at the same BAC when the BAC isdecreasing.
    • Most hospitals use ethanol assays that function by enzymatic methods that utilize ADH. These assays detect ethanol only and do not have false-positive results when other toxic alcohols are present. Therefore, these assays cannot detect other toxic alcohols, and ingestion or co-ingestion of toxic alcohols or isopropanol may go unrecognized.
    • If ingestion of toxic alcohols is suspected, a specific assay for those alcohols or gas chromatography should be obtained.
    • Clinical findings and ethanol concentrations may be categorized as follows (these are rough estimates only and have not been validated in children):
      • Intoxication or inebriation - 100-150 mg/dL
      • Loss of muscle coordination - 150-200 mg/dL
      • Decreased level of consciousness - 200-300 mg/dL
      • Death - 300-500 mg/dL
    • The effects widely vary based on the patient's BAC.
  • Human chorionic gonadotropin level: Urine pregnancy tests should be performed in all women of childbearing age.
  • Serum salicylate and acetaminophen levels: In intentional suicidal ingestions, the presence of other toxic substances must be determined, especially if the patient presents late or if he or she has ingested a substance that has a significant risk of morbidity (eg, acetaminophen, salicylate).
  • Urine drug levels: Older patients may have ingested recreational drugs such as cocaine, marijuana, benzodiazepines, amphetamines, and opiates.
  • ABG level
    • A determination of the pH is important when polysubstance ingestion or ketoacidosis is suspected. The partial pressure of carbon dioxide (pCO2) can be helpful in assessing respiratory depression.
    • The pH also can help in ruling out the co-ingestion of methanol and ethylene glycol, because significant academia is associated with those ingestions. However, reports in the literature have documented that the co-ingestion of ethanol and methanol does not cause significant acidosis.
  • Serum calcium and magnesium levels: High concentrations of ethanol and its chronic use can deplete these cations.
  • Serum osmolality: The osmolar gap can provide information about the ethanol concentration in the blood.
    • The osmolar gap is calculated using the following equation: gap = measured osmolality - (2 X [Na concentration]) + (glucose concentration/18) + (BUN concentration/2.8).
    • An osmolar gap of 22-25 mOsm/kg results for every 100 mg/dL of ethanol in the serum. A normal osmolar gap is 2 ± 6 mOsm/kg; 95% of the population have osmolar gaps between –14 and +10 mOsm/kg.
    • The predicted concentration of ethanol is calculated using the following equation: Ethanol concentration = (osmolar gap - 10) X 4.6. This equation may provide a gross estimate of the predicted level but varies based on the baseline osmolar gap.
  • Methanol levels: These results can be helpful if an ingestion of combined substances is suspected. A positive methanol level can alert the physician to a co-ingestion.

Imaging Studies

  • Head CT scanning is warranted in patients with a change of mental status, focal neurologic findings, or scalp bruises or lacerations and in patients in whom trauma cannot be excluded. C-spine precautions should also be used if trauma is a suspected comorbidity until the neck is thoroughly investigated.
  • If trauma is suspected, perform appropriate radiography.

More on Toxicity, Ethanol

Overview: Toxicity, Ethanol
Differential Diagnoses & Workup: Toxicity, Ethanol
Treatment & Medication: Toxicity, Ethanol
Follow-up: Toxicity, Ethanol
Multimedia: Toxicity, Ethanol
References
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Further Reading

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Keywords

ethanol, ethanol toxicity, alcohol intoxication, ethanol intoxication, drunkenness, inebriation, ethyl alcohol intoxication, alcohol overdose, ethanol poisoning, alcohol poisoning, drinking, psychoactive drug, hypoglycemia, alcohol abuse, hypoglycemia, hypoglycemic seizures, trauma risk, over-the-counter medication, alcoholism, respiratory depression, hypoxia, urticaria, hypothermia, myocardial depression, diuresis, acute pancreatitis, lactic acidosis, congestive heart failure, pulmonary edema, arrhythmia, cardiovascular collapse, sudden death, cardiomyopathy, obesity

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Contributor Information and Disclosures

Author

Elizabeth Brothers, MD, Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center
Elizabeth Brothers, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, FACEP, FAAEM, Assistant Professor of Emergency Medicine, Residency Program Director, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center
Christopher I Doty, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Halim Hennes, MD, MS, Pediatric Emergency Medicine Research Director, Professor, Departments of Pediatrics and Emergency Medicine, Medical College of Wisconsin
Halim Hennes, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Jeffrey R Tucker, MD, Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut and Connecticut Children's Medical Center
Jeffrey R Tucker, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Pediatrics, and Massachusetts Medical Society
Disclosure: Merck Salary Employment

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD, Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin
Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society
Disclosure: Nothing to disclose.

 
 
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