Rosen & Barkin's 5-Minute Emergency Medicine Consult (259 page)

• Fomepizole is class C in pregnancy.
  
• Ethanol is not recommended in pregnancy. Class D/X
  

Ethanol can cause serious CNS depression and hypoglycemia when administered to children.

• Activated charcoal: 1 g/kg PO
  
• Dextrose: D
  ₅₀
  W 1 ampule: 50 mL or 25 g (peds: D
  ₂₅
  W 2–4 mL/kg) IV
  
• Ethanol:
  
  • PO: 50% ethanol solution (100-proof liquor) via nasogastric tube:
    
    • Loading dose: 1.5 mL/kg
      
    • Maintenance dose: 0.2–0.4 mL/kg/h
      
    • Maintenance dose during hemodialysis: 0.4–0.7 mL/kg/h
      
  • IV: 10% ethanol in D
    ₅
    W:
    
    • Loading dose: 8 mL/kg over 30–60 min
      
    • Maintenance infusion: 1–2 mL/kg/h
      
    • Maintenance infusion during hemodialysis: 2–4 mL/kg/h
      
• Fomepizole:
  
  • Loading dose: 15 mg/kg slow infusion over 30 min
    
  • Maintenance dose: 10 mg/kg q12h for 4 doses, then 15 mg/kg q12h until ethylene glycol serum concentration are reduced to <25mg/dL
    
  • Dosing related to hemodialysis:
    
    • Do not administer dose at beginning of dialysis if last dose was <6 hr previously.
      
    • Administer next dose if last dose was >6 hr previously.
      
    • Dose q4h during dialysis.
      
    • If time between last dose and end of dialysis was <1 hr from last dose, do not administer new dose.
      
    • If time between last dose and end of dialysis was 1–3 hr from last dose, administer 1/2 of next scheduled dose.
      
    • If time between last dose and end of dialysis was >3 hr from last dose, administer next scheduled dose.
      
• Magnesium: 25–50 mg/kg IV 1 dose up to 2 g
  
• Naloxone: 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  
• Pyridoxine: 100 mg/d for 2 days
  
• Sodium bicarbonate: 1–2 mEq/kg in D
  ₅
  W IV
  
• Thiamine: 100 mg (peds: 50 mg) IV or IM per day for 2 days
  

FOLLOW-UP

• All patients with significant ethylene glycol ingestion, even if initially asymptomatic
  
• ICU admission for seriously ill patients, metabolic acidosis, and renal failure
  
• Transfer to another facility if hemodialysis or fomepizole is indicated but not readily available.
  

Asymptomatic patient with isolated ethylene glycol ingestion, if serum ethylene glycol serum concentration is undetectable and no metabolic acidosis

Psychiatric referral for suicidal patients.

• An osmol gap <10 mmol/L does not rule out an ethylene glycol exposure.
  
• Administer fomepizole immediately and confirm exposure with a serum concentration for patients with an elevated anion gap and ethylene glycol exposure in the differential diagnosis.
  
• If you cannot confirm an ethylene glycol exposure, or do not have hemodialysis capabilities 24/7, or no antidote, transfer the patient to a facility which has all of the above capabilities.
  
• Not all patients will have an elevated osmol and anion gap. Early presenters will have an osmol gap only, and late presenters may have an anion gap only.
  
• Do not use the absence of urine crystals or fluorescence of the urine to rule out an ethylene glycol exposure.
  

• Leikin J, Paloucek F. Ethylene glycol. Fomepizole. Alcohol. In: Leikin JB, Paloucek F, eds.
  Leikin and Paloucek’s Poisoning and Toxicology Handbook
  . 4th ed. Boca Raton, FL: Lexi-Comp; 2008;989: 294–295, 794–795.
  
• Levine M, Curry SC, Ruha AM, et al. Ethylene glycol elimination kinetics and outcomes in patients managed without hemodialysis.
  Ann Emerg Med
  . 2012;59:527–531.
  

CODES

982.8 Toxic effect of other nonpetroleum-based solvents

BASICS

Inflammation and/or infection of the pinna

• Mechanism:
  
  • Cartilage of the external ear is easily damaged due to:
    
    • Lack of overlying subcutaneous tissue
      
    • Relative avascularity
      
    • Exposed position
      
  • Chondritis:
    
    • Most commonly a secondary complication of otic trauma and burns
      
    • Onset is often insidious and may be delayed until apparent healing has occurred.
      
• Improper management may cause disfiguration of the pinna secondary to cartilage avascular necrosis:
  
  • Ranges from being a shriveled, cauliflower-like ear to complete loss of the external ear and possible stenosis of the auditory meatus.
    
• Causes:
  
  • Common causes of chondritis include:
    
    • Chemical or thermal burns
      
    • Frostbite
      
    • Hematoma formation
      
    • Trauma
      
    • Human/insect bites
      
    • Deep abrasions
      
    • External otitis
      
    • High piercing of the ear lobe especially with poor technique, hygiene, and aftercare.
      
  • Bacteria involved:
    
    • Pseudomonas aeruginosa
      
    • Staphylococcus
      
    • Proteus
      

DIAGNOSIS

• Initially a dull pain that increases in severity
  
• Fever
  
• Chills
  

• Ear trauma
  
• Ear piercing
  

• Pinna:
  
  • Painful
    
  • Exquisite tenderness
    
  • Erythematous
    
  • Warmth
    
  • Loss of contours caused by edema often with sparing of the lobule.
    
• Increase of the auriculocephalic angle
  
• Fluctuant areas develop with eventual breakdown and suppuration.
  

Clinical diagnosis:

• Typical physical findings in combination with aforementioned causes
  

Only if systemic signs of infection:

• CBC
  
• Blood cultures
  
• Local cultures for chondritis and abscess drainage
  

• Allergic reaction
  
• Mastoiditis
  
• Dermatitis
  
• Hematoma
  

TREATMENT

General postinjury preventive measures:

• Prevention of chondritis is of utmost importance:
  
  • Difficult management and disfiguring potential
    
• Avoid pressure to the injured ear.
  
• Minimize active débridement of eschars and crusts.
  
• Gentle washing twice daily with antibacterial soap and water followed by complete drying and application of topical antibiotics
  
• Keep hair away from the ear.
  
• Oral antibiotics for minor cases of early ear-lobe inflammation
  
• Parenteral antibiotics and early surgical drainage for patients with chondritis
  

• Ciprofloxacin: 500 mg PO BID (adult)
  
• Cephalexin: 500 mg (peds: 50 mg/kg/d) PO QID
  
• Dicloxacillin: 500 mg (peds: 25 mg/kg/d) PO QID
  
• IV antibiotics for severe infection
  
• Apply topical antibiotics when there is a break in skin barrier.
  

FOLLOW-UP