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ethylene glycol intoxication

Etiology: - ingestion of ethylene glycol Epidemiology: - ethylene glycol in found in antifreeze & de-icing solutions Pathology: 1) when ingested, ethylene glycol is rapidly metabolized to oxalate 2) calcium oxalate precipitation in renal tubules (nephrocalcinosis) & crystals in urine 3) acute renal failure 4) hypocalcemia 5) cardiogenic shock 6) neurotoxicity 7) pulmonary edema Clinical manifestations: 1) metabolic acidosis 2) central nervous system dysfunction 3) nephrocalcinosis (calcium oxalate cystals) - flank pain 4) renal failure, hematuria, oliguria 5) hypotension [1] 6) sweet, fruity breath Laboratory: 1) anion gap metabolic acidosis a) arterial blood gas b) chem8 (calculate anion gap) 1] serum Na+ 2] serum K+ 3] serum bicarbonate (< 10 meq/L) 4] serum chloride 5] serum calcium, hypocalcemia 2) serum ketones are negative 3) serum osmolality, osmolal gap > 10 mOsm/kg H2O [1] 4) urinalyis: a) hematuria b) oxalate crystals in urine (rectangular) 5) direct measurement of ethylene glycol in serum Differential diagnosis: - methanol intoxication (renal manifestations not prominent feature) Management: 1) fomepizole (Antizol) agent of choice [1] - in conjunction with hemodialysis if evidence of renal injury or anion gap metabolic acidosis [1] 2) ethanol 10% solution a) loading dose: 10 mL/kg b) maintenance dose: 1.5 mL/kg c) titrate to blood alcohol level of 22 mmol/L (100 mg/dL) 3) hemodialysis 4) sodium bicarbonate [1] 5) gastric decontamination with activated charcoal generally not useful* 6) pyridoxine & thiamine 7) ICU may be appropriate * unless timing of large ingestion is known & decontamination can be performed within 1 hour of ingestion [1]

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ethylene glycol

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References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018.
  2. Jammalamadaka D, Raissi S. Ethylene glycol, methanol and isopropyl alcohol intoxication. Am J Med Sci. 2010 Mar;339(3):276-81 PMID: 20090509
  3. eMedicine: Toxicity, Ethylene Glycol http://www.emedicine.com/emerg/topic177.htm
  4. Cooper CM, Baron JM. Case records of the Massachusetts General Hospital. Case 4-2015. A 49-year-old man with obtundation followed by agitation and acidosis. N Engl J Med. 2015 Jan 29;372(5):465-73 PMID: 25629745 http://www.nejm.org/doi/full/10.1056/NEJMcpc1410940
  5. Kruse JA Methanol and ethylene glycol intoxication. Crit Care Clin. 2012 Oct;28(4):661-711 PMID: 2299899
  6. Kruse JA Methanol and ethylene glycol intoxication. Crit Care Clin. 2012 Oct;28(4):661-711 PMID: 2299899