Isopropyl Alcohol (part 2) – Management

18 May

(check out the previous post for some initial isopropyl alcohol tidbits)

WHAT TO ORDER, WHAT TO LOOK FOR:

Tests to obtain — The following tests should be obtained in all poisoned patients:

  • POC glucose
  • Acetaminophen and salicylate levels, to rule out these common co-ingestions
  • Electrocardiogram (ECG), to rule out conduction system poisoning by drugs that affect the QRS or QTc intervals
  • Pregnancy test in women of childbearing age
  • Serum isopropyl alcohol and acetone levels (or serum osmolality, if direct serum drug levels are unavailable). 
  • Basic electrolytes, with calculation of anion gap
  • BUN and creatinine
  • Serum and urine ketones
  • Arterial or venous blood gas

 

Elevated Osmolar Gap. The absence of a high anion gap metabolic acidosis four to six hours post-ingestion enables the clinician to distinguish from other alcohols.

 

Serum concentrations of at least 100 mg/dL (17 mmol/L) are necessary to cause a decreased level of consciousness. 

Both isopropyl alcohol and acetone will raise the osmolal gap.

The plasma osmolal gap cannot distinguish among isopropyl alcohol, methanol, and ethylene glycol poisoning, and so cannot be used to exclude ingestion of these more toxic alcohols.

 Calculated Sosm   =   (2 x serum [Na])  +  [glucose]/18  + [BUN]/2.8

 

MANAGEMENT – ABC’s, then…

Decontamination — There is no role for gastrointestinal (GI) decontamination in most cases of isolated isopropyl alcohol intoxication. Its rapid absorption after oral ingestion and its low toxicity make such interventions unnecessary.

 

Alcohol dehydrogenase (ADH) inhibition — Since acetone (the primary metabolite) is less toxic than isopropyl alcohol (the parent alcohol), there is no indication for ADH inhibition with fomepizole or ethanol following isopropyl alcohol exposure

 

Disposition – Symptoms from isopropyl alcohol manifest quickly. Therefore, patients with unintentional ingestions can be discharged after two hours if they remain asymptomatic and isopropyl alcohol is known to be the only substance involved.

 

Submitted by Christina Brown.

 

References: uptodate.com; Trullas JC, Aguilo S, Castro P, Nogue S. Life-threatening isopropyl alcohol intoxication: is hemodialysis really necessary? Vet Hum Toxicol 2004; 46:282.; Stremski E, Hennes H. Accidental isopropanol ingestion in children. Pediatr Emerg Care 2000; 16:238.;  Bekka R, Borron SW, Astier A, et al. Treatment of methanol and isopropanol poisoning with intravenous fomepizole. J Toxicol Clin Toxicol 2001; 39:59.;  Su M, Hoffman RS, Nelson LS. Error in an emergency medicine textbook: isopropyl alcohol toxicity. Acad Emerg Med 2002; 9:175.; picture

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