Ethanol Toxicity Workup

  • Author: Elizabeth Brothers, MD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Oct 17, 2011
 

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 is decreasing.
    • 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.
Next

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, obtain appropriate radiography.
Previous
Proceed to Treatment & Management
 
 
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 and Emergency Medicine Residents Association

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.

Specialty Editor Board

Halim Hennes, MD, MS  Division Director, Pediatric Emergency Medicine, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School; Director of Emergency Services, Children's Medical Center

Halim Hennes, MD, MS is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Jeffrey R Tucker, MD  Assistant Professor, Department of Pediatrics, Division of Emergency Medicine, University of Connecticut School of Medicine, Connecticut Children's Medical Center

Disclosure: Merck Salary Employment

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.

Additional Contributors

The authors gratefully acknowledge the previous coauthors, Dr. Sage Wiener and Dr. Binita Shah for their contributions to the development and writing of this article.

References

  1. Harris RA, Trudell JR, Mihic SJ. Ethanol's molecular targets. Sci Signal. Jul 15 2008;1(28):re7. [Medline].

  2. Eaton DK, Kann L, Kinchen S, Shanklin S, Ross J, Hawkins J, et al. Youth risk behavior surveillance - United States, 2009. MMWR Surveill Summ. Jun 4 2010;59(5):1-142. [Medline].

  3. Meropol SB, Moscati RM, Lillis KA, et al. Alcohol-related injuries among adolescents in the emergency department. Ann Emerg Med. Aug 1995;26(2):180-6. [Medline].

  4. Miller JW, Naimi TS, Brewer RD, Jones SE. Binge drinking and associated health risk behaviors among high school students. Pediatrics. Jan 2007;119(1):76-85. [Medline].

  5. Swahn MH, Bossarte RM, Sullivent EE 3rd. Age of alcohol use initiation, suicidal behavior, and peer and dating violence victimization and perpetration among high-risk, seventh-grade adolescents. Pediatrics. Feb 2008;121(2):297-305. [Medline].

  6. Elphinstone PE, Kobza Black A, Greaves MW. Alcohol-induced urticaria. J R Soc Med. Apr 1985;78(4):340-1. [Medline].

  7. [Guideline] Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. Apr 6 2004;140(7):554-6. [Medline]. [Full Text].

  8. Brown SA, McGue M, Maggs J, et al. A developmental perspective on alcohol and youths 16 to 20 years of age. Pediatrics. Apr 2008;121 Suppl 4:S290-310. [Medline].

  9. Maio RF, Shope JT, Blow FC, Gregor MA, Zakrajsek JS, Weber JE. A randomized controlled trial of an emergency department-based interactive computer program to prevent alcohol misuse among injured adolescents. Ann Emerg Med. Apr 2005;45(4):420-9. [Medline].

  10. Spirito A, Sindelar-Manning H, Colby SM, Barnett NP, Lewander W, Rohsenow DJ. Individual and family motivational interventions for alcohol-positive adolescents treated in an emergency department: results of a randomized clinical trial. Arch Pediatr Adolesc Med. Mar 2011;165(3):269-74. [Medline].

  11. Mennella JA, Beauchamp GK. The transfer of alcohol to human milk. Effects on flavor and the infant's behavior. N Engl J Med. Oct 3 1991;325(14):981-5. [Medline].

  12. Baer JS, Barr HM, Bookstein FL, et al. Prenatal alcohol exposure and family history of alcoholism in the etiology of adolescent alcohol problems. J Stud Alcohol. Sep 1998;59(5):533-43. [Medline].

  13. Bates BA, Shannon MW, Woolf AD. Ethanol-related visits by adolescents to a pediatric emergency department. Pediatr Emerg Care. Apr 1995;11(2):89-92. [Medline].

  14. Beech DJ, Mercadel R. Correlation of alcohol intoxication with life-threatening assaults. J Natl Med Assoc. Dec 1998;90(12):761-4. [Medline].

  15. Caballeria J. Current concepts in alcohol metabolism. Ann Hepatol. Apr-Jun 2003;2(2):60-8. [Medline].

  16. Ceballos NA. Tobacco use, alcohol dependence, and cognitive performance. J Gen Psychol. Oct 2006;133(4):375-88. [Medline].

  17. Chabali R. Diagnostic use of anion and osmolal gaps in pediatric emergency medicine. Pediatr Emerg Care. Jun 1997;13(3):204-10. [Medline].

  18. Church AS, Witting MD. Laboratory testing in ethanol, methanol, ethylene glycol, and isopropanol toxicities. J Emerg Med. Sep-Oct 1997;15(5):687-92. [Medline].

  19. Eckardt MJ, File SE, Gessa GL, et al. Effects of moderate alcohol consumption on the central nervous system. Alcohol Clin Exp Res. Aug 1998;22(5):998-1040. [Medline].

  20. Ernst AA, Jones K, Nick TG, Sanchez J. Ethanol ingestion and related hypoglycemia in a pediatric and adolescent emergency department population. Acad Emerg Med. Jan 1996;3(1):46-9. [Medline].

  21. Gemma S, Vichi S, Testai E. Individual susceptibility and alcohol effects:biochemical and genetic aspects. Ann Ist Super Sanita. 2006;42(1):8-16. [Medline].

  22. Hernandez OH, Vogel-Sprott M, Ke-Aznar VI. Alcohol impairs the cognitive component of reaction time to an omitted stimulus: a replication and an extension. J Stud Alcohol Drugs. Mar 2007;68(2):276-81. [Medline].

  23. Hussain SZ, Rawal J, Henry JA. Gastric evacuation for acute ethanol intoxication in a three year old. J Accid Emerg Med. Jan 1998;15(1):54-62. [Medline].

  24. Kotwica M, Jarosz A, Kolacinski Z, Rogaczewska A. Sources of poisoning exposures in children during 1990-1995. An analysis of the National Poison Information Centre files. Int J Occup Med Environ Health. 1997;10(2):177-86. [Medline].

  25. Laitinen K, Lamberg-Allardt C, Tunninen R, et al. Transient hypoparathyroidism during acute alcohol intoxication. N Engl J Med. Mar 14 1991;324(11):721-7. [Medline].

  26. Lamminpaa A. Alcohol intoxication in childhood and adolescence. Alcohol Alcohol. Jan 1995;30(1):5-12. [Medline].

  27. Lamminpaa A, Vilska J, Korri UM, Riihimaki V. Alcohol intoxication in hospitalized young teenagers. Acta Paediatr. Sep 1993;82(9):783-8. [Medline].

  28. Lang RM, Borow KM, Neumann A, Feldman T. Adverse cardiac effects of acute alcohol ingestion in young adults. Ann Intern Med. Jun 1985;102(6):742-7. [Medline].

  29. Li J, Mills T, Erato R. Intravenous saline has no effect on blood ethanol clearance. J Emerg Med. Jan-Feb 1999;17(1):1-5. [Medline].

  30. Litovitz T. The alcohols: ethanol, methanol, isopropanol, ethylene glycol. Pediatr Clin North Am. Apr 1986;33(2):311-23. [Medline].

  31. Litt I. Alcohols. In: Behrman RE, Kliegman R, Jenson HB, eds. Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders; 2000:Chapter 113.1.

  32. Lopez GP, Yealy DM, Krenzelok EP. Survival of a child despite unusually high blood ethanol levels. Am J Emerg Med. May 1989;7(3):283-5. [Medline].

  33. McKinnon SA, O'rourke KM, Thompson SE, Berumen JH. Alcohol use and abuse by adolescents: the impact of living in a border community. J Adolesc Health. Jan 2004;34(1):88-93. [Medline].

  34. O'Connor AD, Rusyniak DE, Bruno A. Cerebrovascular and cardiovascular complications of alcohol and sympathomimetic drug abuse. Med Clin North Am. Nov 2005;89(6):1343-58. [Medline].

  35. Ostrea EM Jr. Testing for exposure to illicit drugs and other agents in the neonate: a review of laboratory methods and the role of meconium analysis. Curr Probl Pediatr. Feb 1999;29(2):37-56. [Medline].

  36. Ragan FA Jr, Samuels MS, Hite SA. Ethanol ingestion in children. A five-year review. JAMA. Dec 21 1979;242(25):2787-8. [Medline].

  37. Rogers GC. Ethanol. In: Handbook of Common Poisonings in Children. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics, Committee on Injury and Poison Prevention; 1994.

  38. Rosett HL. A clinical perspective of the Fetal Alcohol Syndrome. Alcohol Clin Exp Res. Apr 1980;4(2):119-22. [Medline].

  39. Tovey C, Rana PS, Anderson DJ. Alcohol intoxication in a toddler. J Accid Emerg Med. Jan 1998;15(1):69-70. [Medline].

  40. Yip L. Ethanol. In: Goldfrank LR, Flomenbaum NE, Lewin NA, Weisman RS, Howland MA, Hoffman RS, eds. Goldfrank's Toxicologic Emergencies. 9th ed. McGraw-Hill Professional Publishing; 2011:[Full Text].

 
Previous
Next
 
The pathway of ethanol metabolism. Disulfiram reduces the rate of oxidation of acetaldehyde by competing with the cofactor nicotinamide adenine dinucleotide (NAD) for binding sites on aldehyde dehydrogenase (ALDH).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.