Pediatric Ethanol Toxicity Workup

Updated: Feb 27, 2017
  • Author: Elizabeth Fernandez, MD; Chief Editor: Timothy E Corden, MD  more...
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Workup

Laboratory Studies

See the list below:

  • 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

See the list below:

  • 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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