eMedicine Specialties > Emergency Medicine > Toxicology

Toxicity, Alcohols: Follow-up

Author: Michael D Levine, MD, Physician, Department of Medical Toxicology, Banner Good Samaritan Medical Center
Coauthor(s): Tobias D Barker, MD, Attending Physician, Department of Emergency Medicine; Director, Harvard Medical School Dubai Center Simulation Center
Contributor Information and Disclosures

Updated: Nov 11, 2009

Follow-up

Further Inpatient Care

  • Patients with significant ingestions of toxic alcohols require hospital admission in a closely monitored setting such as the intensive care unit.  
  • Patients who are chronic alcoholics may be at risk of alcohol withdrawal if admitted to the hospital.

Transfer

  • Patients with ethanol intoxication can be observed until they are no longer clinically intoxicated and then discharged. 
  • Patients with isopropanol ingestion may require observation in the hospital. 
  • Patients with known or suspected methanol or ethylene glycol intoxication should be monitored closely, probably in an intensive care unit.

Complications

  • Ethanol ingestion complications
    • Hypoglycemia is common.14 The etiology is multifactorial but largely related to decreased glycogen stores and malnutrition in children and chronic alcoholics, as well as ethanol’s inhibition of glycogenolysis.
    • Patients with acute intoxication may exhibit "holiday heart," in which dysrhythmias, especially atrial fibrillation, occur following a heavy drinking episode.
    • Ethanol lowers the threshold for developing atrial fibrillation. Cirrhosis, esophageal varices, and erosive gastritis are common in patients who use ethanol on a frequent basis.
  • Ingestion of isopropanol is associated with hemorrhagic gastritis.
  • Ingestion of methanol is associated with blindness, acidosis, coma, cardiovascular collapse, and death.
  • Ingestion of ethylene glycol is associated with renal failure, acidosis, coma, cardiovascular collapse, and death.10

Miscellaneous

Medicolegal Pitfalls

  • Patients with alcohol intoxication should be evaluated for coexisting injuries. A common error is to assume that a patient with altered mental status is simply intoxicated without adequate consideration of other possible causes of an altered mental status.  
  • Hypoglycemia should always be sought, particularly in the setting of an altered mental status because it can occur both as a result of intoxication with alcohol and as a result of treatment with ethanol after toxic alcohol ingestion. At-risk populations include children, chronic alcoholics, and others whose glycogen stores are depleted such as malnourished patients.  
  • Additional pitfalls include assuming that intoxication is due to simply ethanol without adequate consideration of the possible presence of a toxic alcohol, either exclusively or as a coingestant.
  • Patients who have accidentally ingested a mouthful of methanol or ethylene glycol can ingest enough to be at risk of developing significant toxicity.
  • As noted in earlier sections, exclusive use of the osmolar gap to rule out intoxication with a toxic alcohol is fraught with pitfalls and guidance from a toxicologist or poison center is recommended (see Lab Studies). 
  • Another pitfall is to assume that the absence of an anion gap rules out the possibility of toxic alcohol poisoning. As noted above, this is especially true early in the course when a patient appears inebriated without other symptoms and before significant metabolism has occurred so that an anion gap has not yet developed (see Lab Studies). 
  • Not considering the use of hemodialysis, particularly in the presence of metabolic abnormalities, is another potential pitfall. Consultation with a nephrologist and/or toxicologist may be of assistance. 
  • Failure to initiate treatment while awaiting laboratory tests to confirm the presence of a toxic alcohol is another common source of medical error.
 


More on Toxicity, Alcohols

Overview: Toxicity, Alcohols
Differential Diagnoses & Workup: Toxicity, Alcohols
Treatment & Medication: Toxicity, Alcohols
Follow-up: Toxicity, Alcohols
References
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References

  1. Hornfeldt CS. A report of acute ethanol poisoning in a child: mouthwash versus cologne, perfume and after-shave. J Toxicol Clin Toxicol. 1992;30(1):115-21. [Medline].

  2. ATSDR. Methanol toxicity. Agency for Toxic Substances and Disease Registry. Am Fam Physician. Jan 1993;47(1):163-71. [Medline].

  3. Aufderheide TP, White SM, Brady WJ, et al. Inhalational and percutaneous methanol toxicity in two firefighters. Ann Emerg Med. Dec 1993;22(12):1916-8. [Medline].

  4. Barceloux DG, Krenzelok EP, Olson K, et al. American Academy of Clinical Toxicology Practice Guidelines on the Treatment of Ethylene Glycol Poisoning. Ad Hoc Committee. J Toxicol Clin Toxicol. 1999;37(5):537-60. [Medline].

  5. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, Heard SE. 2007 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). Dec 2008;46(10):927-1057. [Medline].

  6. Barceloux DG, Bond GR, Krenzelok EP, et al. American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning. J Toxicol Clin Toxicol. 2002;40(4):415-46. [Medline].

  7. Krahn J, Khajuria A. Osmolality gaps: diagnostic accuracy and long-term variability. Clin Chem. Apr 2006;52(4):737-9. [Medline].

  8. Brent J. Fomepizole for ethylene glycol and methanol poisoning. N Engl J Med. May 21 2009;360(21):2216-23. [Medline].

  9. Kraut JA, Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management. Clin J Am Soc Nephrol. Jan 2008;3(1):208-25. [Medline].

  10. Brent J, McMartin K, Phillips S, et al. Fomepizole for the treatment of ethylene glycol poisoning. Methylpyrazole for Toxic Alcohols Study Group. N Engl J Med. Mar 18 1999;340(11):832-8. [Medline].

  11. Brent J, McMartin K, Phillips S, et al. Fomepizole for the treatment of methanol poisoning. N Engl J Med. Feb 8 2001;344(6):424-9. [Medline].

  12. Burns MJ, Graudins A, Aaron CK, et al. Treatment of methanol poisoning with intravenous 4-methylpyrazole. Ann Emerg Med. Dec 1997;30(6):829-32. [Medline].

  13. Megarbane B, Borron SW, Baud FJ. Current recommendations for treatment of severe toxic alcohol poisonings. Intensive Care Med. Feb 2005;31(2):189-95. [Medline].

  14. Lepik KJ, Levy AR, Sobolev BG, Purssell RA, DeWitt CR, Erhardt GD. Adverse drug events associated with the antidotes for methanol and ethylene glycol poisoning: a comparison of ethanol and fomepizole. Ann Emerg Med. Apr 2009;53(4):439-450.e10. [Medline].

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Further Reading

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Keywords

alcohol toxicity, alcohol poisoning, alcohol ingestion, ethanol poisoning, ethanol toxicity, methanol poisoning, methanol toxicity, isopropanol toxicity, isopropanol poisoning, ethyl alcohol toxicity, ethyl alcohol poisoning, ethyl alcohol, methyl alcohol toxicity, methyl alcohol poisoning, isopropyl alcohol toxicity, isopropyl alcohol poisoning, alcohol metabolism, acute alcohol intoxication

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Contributor Information and Disclosures

Author

Michael D Levine, MD, Physician, Department of Medical Toxicology, Banner Good Samaritan Medical Center
Michael D Levine, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, Emergency Medicine Residents Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Tobias D Barker, MD, Attending Physician, Department of Emergency Medicine; Director, Harvard Medical School Dubai Center Simulation Center
Tobias D Barker, MD is a member of the following medical societies: American College of Emergency Physicians, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey Glenn Bowman, MD, MS, Consulting Staff, Highfield MRI, Columbus, Ohio
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & St. Joseph's Hospitals
John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Michael J Burns, MD, Instructor, Department of Emergency Medicine, Harvard University Medical School, Beth Israel Deaconess Medical Center
Michael J Burns, MD is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD, Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital
Disclosure: Nothing to disclose.

 
 
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