Welcome and Episode Introduction
- Hosts: Dr. Pradip Kamat (Children’s Healthcare of Atlanta/Emory University) and Dr. Rahul Damania (Cleveland Clinic Children’s Hospital)
- Mission: A podcast dedicated to current and aspiring pediatric intensivists, exploring intriguing PICU cases and acute care pediatric management
- Focus of the Episode: Managing toxic alcohol ingestion in the PICU with emphasis on ethanol, methanol, ethylene glycol, propylene glycol, and isopropyl alcohol
Case Presentation
- Patient Details: A 7-month-old male presented with accidental ethanol ingestion after his formula was mixed with vodka
- Key Symptoms: Lethargy, uncoordinated movements, decreased activity, and ethanol odor
- Initial Labs & Findings:
- EtOH level: 420 mg/dL.
- Glucose: 50 mg/dL.
- Normal CXR and EKG.
- PICU Presentation: Tachycardic, normotensive, lethargic, with signs of CNS depression
- Initial Management: Dextrose infusion, glucose monitoring, neurological observation, and ruling out complications
Key Learning Points from the Case
- Toxic alcohol ingestion in pediatrics requires rapid stabilization and targeted interventions
- Hypoglycemia and CNS depression are common features of ethanol toxicity in infants
- Management prioritizes glucose correction, airway support, and close neurological monitoring
Deep Dive: Toxic Alcohols in the PICU
1. Ethanol
- Typical Presentation in Infants/Toddlers: Hypotonia, ataxia, coma, hypoglycemia, hypotension, and hypothermia
- Diagnostic Workup:
- Focus on CNS and metabolic effects
- Labs: Glucose, electrolytes, bicarbonate, anion gap, ketones, toxicology screen
- Imaging (head CT) if indicated
- Management: Stabilization, IV dextrose for hypoglycemia, NPO status until alert, and consultation with poison control and social work
2. Methanol
- Sources: Windshield fluids, cleaning agents, moonshine
Clinical Stages:
- Early: Dizziness, nausea, vomiting (0–6 hours)
- Latent: Asymptomatic (6–30 hours)
- Late: Vision disturbances, seizures, respiratory failure (6–72 hours)
- Key Symptoms: “Snowstorm blindness” from retinal toxicity
- Management: Fomepizole, correction of metabolic acidosis, and hemodialysis in severe cases
3. Ethylene Glycol
- Sources: Antifreeze, brake fluids, household cleaners
- Pathophysiology: Metabolism to glycolic acid (acidosis) and oxalic acid (renal failure due to calcium oxalate crystals)
- Red Flags: Hypocalcemia, renal failure, QT prolongation
- Management: Fomepizole, supportive care, and hemodialysis for severe toxicity
4. Propylene Glycol
- Sources: Medications like lorazepam and pentobarbital
- Presentation: High anion gap metabolic acidosis at high doses, with renal and liver dysfunction
- Management: Discontinue offending agent, supportive care, and hemodialysis if severe
5. Isopropyl Alcohol
- Sources: Disinfectants, hand sanitizers
- Presentation: CNS depression, GI irritation, fruity acetone breath, but no metabolic acidosis
- Management: Supportive care; fomepizole and ethanol are ineffective
Key Laboratory Insights
- Osmolar Gap Formula:
- Measured Osmolality - Calculated Osmolality
- A high osmolar gap indicates unmeasured osmoles like toxic alcohols.
- Lactate Gap in Ethylene Glycol: Discrepancy between bedside and lab lactate levels due to glycolate interference
Management Pearls
