Rosen & Barkin's 5-Minute Emergency Medicine Consult (406 page)

• Accidental ingestions common in <6-yr olds.
  
• Rubbing alcohol sponge baths may cause inhalational toxicity.
  

• History of ingestion
  
• Odor of isopropanol or acetone on patient’s breath
  

• Electrolytes, BUN, creatinine (Cr), glucose:
  
  • Hypoglycemia occurs.
    
  • Does
    not
    produce significant acidosis unless accompanied by end-organ hypoperfusion.
    
  • Acetone can produce false elevation of serum Cr:
    
    • When acetone level >40 mg/dL, Cr values rise at ∼1 mg Cr/100 mg/dL acetone.
      
    • Cr returns to baseline following acetone metabolism.
      
• CBC:
  
  • Decreased hematocrit with significant hemorrhagic gastritis
    
• Arterial blood gas:
  
  • Acidosis rare unless owing to hypoperfusion or coingestant.
    
• Urinalysis:
  
  • Ketones present.
    
• Serum ketones are present.
  
• Isopropanol level:
  
  • Coma with level >150 mg/dL
    
• Serum osmolarity:
  
  • Osmolar gap: Difference between measured and calculated osmolarity
    
  • Calculated osmolarity = 2 Na
    ⁺
    BUN/2.8 + glucose/18 + ethanol/4.6.
    
  • Osmolar gap is present if measured minus calculated osmolality is >10.
    
  • Gap increases by 1 mOsm/kg for each 5.9 mg/dL of isopropanol and 5.5 mg/dL of acetone.
    

• CXR: For aspiration pneumonia with altered mental status and vomiting
  
• CT head: Concomitant head injury occurs.
  

• For CNS depression and elevated osmolar gap includes:
  
  • Ethanol
    
  • Ethylene glycol
    
  • Methanol
    
  • Glycerol
    
  • Mannitol
    

Prone to hypoglycemia following exposure

TREATMENT

Search for and transport all bottles and medications that may have been ingested by the patient when an overdose is suspected.

• ABCs:
  
  • Maintain airway and assist in ventilation if necessary.
    
• Hypotension:
  
  • Treat initially with 0.9% NS IV fluid bolus.
    
  • Initiate dopamine or norepinephrine infusion if hypotension persists.
    
  • Packed RBCs with significant hemorrhagic gastritis
    
• Place NG tube and irrigate for patients with hematemesis.
  
• Naloxone, thiamine, dextrose (or Accu-Chek) if altered mental status
  

• Primarily supportive therapy—no specific antidote
  
• Irrigate skin/eyes for dermal or ocular exposure.
  
• Consider activated charcoal:
  
  • For coingestants
    
  • Large doses can absorb significant amounts of isopropanol.
    
• Do
  not
  treat with ethanol infusion or 4-methylpyrazole.
  
• Hemodialysis:
  
  • Effectively removes isopropanol and acetone.
    
  • Most managed with supportive care alone.
    
  • Indications:
    
    • Hemodynamic instability despite fluid replacement and use of pressors
      
    • Levels >400 mg/dL (associated with severe hypotension and prolonged coma)
      

• Activated charcoal slurry: 1–2 g/kg up to 90 g PO
  
• Dextrose: D50W 1 amp: 50 mL or 25 g (peds: D25W 2–4 mL/kg) IV
  
• Dopamine: 2–20 mg/kg/min IV
  
• Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  
• Thiamine (vitamin B
  ₁
  ): 100 mg (peds: 50 mg) IV or IM
  

FOLLOW-UP

Moderate to severe isopropanol toxicity (altered mental status, hypotension)

• Observe asymptomatic patients following ingestion for 2–4 hr before discharge.
  
• Mild intoxication that resolves over 4–6 hr
  

GI referral for endoscopy for patients with recurrent hematemesis.

Alcohol detox or psychiatry referral for patients with intentional ingestion

• Supportive care is the primary treatment.
  
• Do
  not
  treat with ethanol infusion or 4-methylpyrazole.
  

• Emadi A, Coberly L. Intoxication of a hospitalized patient with an isopropanol-based hand sanitizer.
  N Engl J Med
  . 2007;356:530–531.
  
• Kraut JA, Kurtz I. Toxic alcohol ingestions: Clinical features, diagnosis, and management.
  Clin J Am Soc Nephrol
  . 2008;3:208–225.
  
• Smith JC, Quan D. Chapter 179: Alcohols.
  Tintinalli’s Emergency Medicine: A Comprehensive Study Guide
  . 7th ed. McGraw-Hill; 2011.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Alcohol Poisoning
  
• Ethylene Glycol Poisoning
  
• Methanol Poisoning
  

CODES

• 976.0 Poisoning by local anti-infectives and anti-inflammatory drugs
  
• 980.2 Toxic effect of isopropyl alcohol
  
• 982.8 Toxic effect of other nonpetroleum-based solvents
  

BASICS

Yellow pigmentation of tissues and body fluids due to hyperbilirubinemia, usually present at levels of >2.5 mg/dL

• Unconjugated (indirect) hyperbilirubinemia: Unconjugated bilirubin is the direct breakdown product of heme, is water insoluble, and is measured as indirect bilirubin:
  
  • Hemolytic:
    
    • Excessive production of unconjugated bilirubin
      
  • Hepatic:
    
    • Decreased hepatobiliary excretion of bilirubin by:
      
      • Defective uptake (drugs, Crigler–Najjar syndrome)
        
      • Defective conjugation (Gilbert syndrome drugs)
        
      • Defective excretion of bilirubin by the liver cell (drugs, Dubin–Johnson syndrome)
        
• Conjugated (direct) hyperbilirubinemia:
  
  • Conjugated bilirubin is water soluble and measured as direct bilirubin.
    
  • In conjugated hyperbilirubinemia, bilirubin is returned to the bloodstream after conjugation in the liver instead of draining into the bile ducts.
    
  • Hepatocellular dysfunction:
    
    • Hepatitis
      
    • Cirrhosis
      
    • Tumor invasion
      
    • Toxic injury
      
  • Intrahepatic (nonobstructive) cholestasis
    
  • Extrahepatic (obstructive) cholestasis
    

DIAGNOSIS

• Cholestasis:
  
  • Pruritus
    
  • Pale stools
    
  • Dark urine
    
• Malignancy:
  
  • Anorexia
    
  • Weight loss
    
  • Malaise
    
• Abdominal pain