Pediatric emergency medicine trisk 3094 3094
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In any patient with coma and an unexplained osmolal gap (the
difference between calculated and observed osmolarity), a toxic alcohol
should be strongly considered.
Ingestion of ethanol in young children can lead to hypoglycemia,
hypothermia, and coma.
Isopropyl alcohol toxicity classically presents as intoxication with
ketosis, but without metabolic acidosis.
Methanol and ethylene glycol ingestion can lead to severe metabolic
acidosis and should be treated with fomepizole, an alcohol
dehydrogenase inhibitor that prevents the metabolism to their toxic
metabolites. In severe cases, hemodialysis is also indicated.
The alcohols and glycols are some of the most commonly available organic
compounds. Ethanol is best known as the psychoactive ingredient in beer, wine,
and liquor; it is also a commonly encountered solvent and is used as a topical
antiseptic, chemical intermediate, and in some instances, a rubbing alcohol.
Methanol, or methyl alcohol, functions as an antifreeze (in windshield
washers/deicers and gasoline antifreeze) and as a solvent in many industrial and
home products. Isopropyl alcohol serves as a rubefacient. Ethylene glycol is used
primarily as a deicer or antifreeze. A related class of compounds, the glycol
ethers, is widely used in rug shampoos and brake fluids. The toxicity of these
glycol ethers is complex and beyond the scope of this discussion.
Ethanol
The most commonly ingested alcohol is ethanol. After ingesting ethanol, children
may develop nausea, vomiting, stupor, and ataxia. Coma and death from apnea
may occur if significant quantities are consumed. In adolescents, blood
concentrations of less than 50 mg/dL rarely result in overt sensory or motor
impairment. Values of 80 to 150 mg/dL are consistent with intoxication and cause
mild neurologic findings. Lethal blood alcohol concentrations are generally
higher than 500 mg/dL. Infants and toddlers who ingest ethanol have a clinical
course that is significantly different from that in adolescents and adults; a triad of
coma, hypothermia, and hypoglycemia appears once ethanol levels exceed 50 to
100 mg/dL. This triad may be accompanied by metabolic acidosis. Ethanol
decreases physical coordination, and increases risk taking behavior, so consider
the possibility of head trauma in patients with coma after ethanol intoxication.
