Pediatric Ethanol Toxicity Workup

Updated: Mar 09, 2021
  • Author: Elizabeth Fernandez, MD; Chief Editor: Stephen L Thornton, MD  more...
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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 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.

Arterial blood gas levels

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.

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