Pediatric emergency medicine trisk 3101 3101
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elimination. Supportive care includes close monitoring of vital signs and
anticipation of life-threatening events, particularly cardiac arrhythmias secondary
to hypocalcemia. Replenish intravascular volume, obtain an EKG, and place the
patient on a cardiac monitor. Intubation and mechanical ventilation should be
provided as needed for airway protection and control of acid–base balance.
Correct acidosis immediately with sodium bicarbonate and appropriate
ventilation. Hypocalcemia may present as skeletal muscle disturbances (tetany) or
cardiac dysfunction (prolonged QT interval). These may be alleviated by the
prompt administration of calcium (e.g., 10% calcium gluconate, 0.3 to 0.6
mL/kg). Thiamine and pyridoxine are vitamins that act as cofactors in the
nontoxic metabolic pathways of ethylene glycol and, theoretically, divert its
metabolism toward formation of nontoxic metabolites. Therefore, thiamine (0.25
to 0.5 mg/kg) and pyridoxine (1 to 2 mg/kg) are recommended for the first 24
hours of treatment.
Fomepizole (or ethanol if fomepizole is unavailable) administration inhibits
ethylene glycol metabolism by alcohol dehydrogenase (previously discussed
under “Methanol”). Start treatment as soon as possible to interrupt further
formation of organic acids. As with methanol, alcohol dehydrogenase inhibition
is indicated for ethylene glycol concentrations of 20 mg/dL or higher. If a serum
ethylene glycol level cannot be obtained in a timely fashion, it can be estimated
by the formula (osmolar gap × 6), assuming no other alcohols are contributing to
the osmolar gap. Hemodialysis is indicated if there is renal failure, metabolic
acidosis, or severe electrolyte disturbances, regardless of the serum ethylene
glycol concentration. Hemodialysis may be considered for patients who are stable
hemodynamically but who have very elevated blood ethylene glycol levels. For
patients with normal acid–base status and renal function, the decision to perform
hemodialysis versus continued, prolonged fomepizole therapy depends on the
serum concentration and local resources. Consulting a regional poison control
center can help guide management.
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