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Kolosionek TJ, Amaducci AM, Fikse DJ, Katz KD. Combined Ethylene Glycol Poisoning with Methemoglobinemia Due to Antifreeze Ingestion. J Emerg Med 2023; 65:e438-e440. [PMID: 37734990 DOI: 10.1016/j.jemermed.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/26/2023] [Accepted: 06/13/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Antifreeze poisoning is potentially life-threatening and often requires multiple antidotal therapies and hemodialysis. Ethylene or propylene glycol toxicity is commonly caused by antifreeze ingestion. However, ingestion of antifreeze is typically not associated with methemoglobinemia. Currently, only one other case of antifreeze ingestion causing combined ethylene glycol poisoning and methemoglobinemia has been reported. CASE REPORT A 56-year-old man presented after a witnessed, intentional, large-volume antifreeze ingestion. Evaluation revealed dark brown blood and significantly elevated methemoglobin and ethylene glycol levels. He was successfully treated with methylene blue, fomepizole, and hemodialysis. No other potential cause for methemoglobinemia was elucidated, and further research indicated that minor components of the specific antifreeze product served as an oxidizing agent. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the impact of minor, unreported product components that may significantly contribute to clinical toxicity, as well as the need to remain vigilant when reviewing product information and potential limitations therein.
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Affiliation(s)
- Timothy J Kolosionek
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania
| | - Alexandra M Amaducci
- Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania
| | - Derek J Fikse
- Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania
| | - Kenneth D Katz
- Department of Emergency and Hospital Medicine, Division of Medical Toxicology, Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania
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Büyükkaragöz B, Bakkaloğlu SA. Serum osmolality and hyperosmolar states. Pediatr Nephrol 2023; 38:1013-1025. [PMID: 35779183 DOI: 10.1007/s00467-022-05668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/26/2022] [Accepted: 06/14/2022] [Indexed: 11/26/2022]
Abstract
Serum osmolality is the sum of the osmolalities of every single dissolved particle in the blood such as sodium and associated anions, potassium, glucose, and urea. Under normal conditions, serum sodium concentration is the major determinant of serum osmolality. Effective blood osmolality, so-called blood tonicity, is created by the endogenous (e.g., sodium and glucose) and exogenous (e.g., mannitol) solutes that are capable of creating an osmotic gradient across the membranes. In case of change in effective blood osmolality, water shifts from the compartment with low osmolality into the compartment with high osmolarity in order to restore serum osmolality. The difference between measured osmolality and calculated osmolarity forms the osmolal gap. An increase in serum osmolal gap can stem from the presence of solutes that are not included in the osmolarity calculation, such as hypertonic treatments or toxic alcoholic ingestions. In clinical practice, determination of serum osmolality and osmolal gap is important in the diagnosis of disorders related to sodium, glucose and water balance, kidney diseases, and small molecule poisonings. As blood hypertonicity exerts its main effects on the brain cells, neurologic symptoms varying from mild neurologic signs and symptoms to life-threatening outcomes such as convulsions or even death may occur. Therefore, hypertonic states should be promptly diagnosed and cautiously managed. In this review, the causes and treatment strategies of hyperosmolar conditions including hypernatremia, diabetic ketoacidosis, hyperglycemic hyperosmolar syndrome, hypertonic treatments, or intoxications are discussed in detail to increase awareness of this important topic with significant clinical consequences.
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Affiliation(s)
- Bahar Büyükkaragöz
- Department of Pediatric Nephrology, Gazi University, 06560, Besevler, Ankara, Turkey.
| | - Sevcan A Bakkaloğlu
- Department of Pediatric Nephrology, Gazi University, 06560, Besevler, Ankara, Turkey
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Ghannoum M, Gosselin S, Hoffman RS, Lavergne V, Mégarbane B, Hassanian-Moghaddam H, Rif M, Kallab S, Bird S, Wood DM, Roberts DM, Anseeuw K, Berling I, Bouchard J, Bunchman TE, Calello DP, Chin PK, Doi K, Galvao T, Goldfarb DS, Hoegberg LCG, Kebede S, Kielstein JT, Lewington A, Li Y, Macedo EM, MacLaren R, Mowry JB, Nolin TD, Ostermann M, Peng A, Roy JP, Shepherd G, Vijayan A, Walsh SJ, Wong A, Yates C. Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup. Crit Care 2023; 27:56. [PMID: 36765419 PMCID: PMC9921105 DOI: 10.1186/s13054-022-04227-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 10/18/2022] [Indexed: 02/12/2023] Open
Abstract
Ethylene glycol (EG) is metabolized into glycolate and oxalate and may cause metabolic acidemia, neurotoxicity, acute kidney injury (AKI), and death. Historically, treatment of EG toxicity included supportive care, correction of acid-base disturbances and antidotes (ethanol or fomepizole), and extracorporeal treatments (ECTRs), such as hemodialysis. With the wider availability of fomepizole, the indications for ECTRs in EG poisoning are debated. We conducted systematic reviews of the literature following published EXTRIP methods to determine the utility of ECTRs in the management of EG toxicity. The quality of the evidence and the strength of recommendations, either strong ("we recommend") or weak/conditional ("we suggest"), were graded according to the GRADE approach. A total of 226 articles met inclusion criteria. EG was assessed as dialyzable by intermittent hemodialysis (level of evidence = B) as was glycolate (Level of evidence = C). Clinical data were available for analysis on 446 patients, in whom overall mortality was 18.7%. In the subgroup of patients with a glycolate concentration ≤ 12 mmol/L (or anion gap ≤ 28 mmol/L), mortality was 3.6%; in this subgroup, outcomes in patients receiving ECTR were not better than in those who did not receive ECTR. The EXTRIP workgroup made the following recommendations for the use of ECTR in addition to supportive care over supportive care alone in the management of EG poisoning (very low quality of evidence for all recommendations): i) Suggest ECTR if fomepizole is used and EG concentration > 50 mmol/L OR osmol gap > 50; or ii) Recommend ECTR if ethanol is used and EG concentration > 50 mmol/L OR osmol gap > 50; or iii) Recommend ECTR if glycolate concentration is > 12 mmol/L or anion gap > 27 mmol/L; or iv) Suggest ECTR if glycolate concentration 8-12 mmol/L or anion gap 23-27 mmol/L; or v) Recommend ECTR if there are severe clinical features (coma, seizures, or AKI). In most settings, the workgroup recommends using intermittent hemodialysis over other ECTRs. If intermittent hemodialysis is not available, CKRT is recommended over other types of ECTR. Cessation of ECTR is recommended once the anion gap is < 18 mmol/L or suggested if EG concentration is < 4 mmol/L. The dosage of antidotes (fomepizole or ethanol) needs to be adjusted during ECTR.
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Affiliation(s)
- Marc Ghannoum
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada ,grid.137628.90000 0004 1936 8753Nephrology Division, NYU Langone Health, NYU Grossman School of Medicine, New York, NY USA ,grid.5477.10000000120346234Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Sophie Gosselin
- grid.420748.d0000 0000 8994 4657Centre Intégré de Santé et de Services Sociaux (CISSS) de la Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, QC Canada ,grid.86715.3d0000 0000 9064 6198Faculté de Médecine et Sciences de la Santé, Université de Sherbrooke, Sherbrooke, Canada ,Centre Antipoison du Québec, Quebec, QC Canada
| | - Robert S. Hoffman
- grid.137628.90000 0004 1936 8753Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY USA
| | - Valery Lavergne
- grid.14848.310000 0001 2292 3357Research Center, CIUSSS du Nord-de-l’île-de-Montréal, University of Montreal, Montreal, QC Canada
| | - Bruno Mégarbane
- grid.411296.90000 0000 9725 279XDepartment of Medical and Toxicological Critical Care, Lariboisière Hospital, INSERM UMRS-1144, Paris Cité University, Paris, France
| | - Hossein Hassanian-Moghaddam
- grid.411600.2Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran ,grid.411600.2Department of Clinical Toxicology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Siba Kallab
- grid.411323.60000 0001 2324 5973Department of Internal Medicine-Division of Nephrology, Lebanese American University - School of Medicine, Byblos, Lebanon
| | - Steven Bird
- Department of Emergency Medicine, U Mass Memorial Health, U Mass Chan Medical School, Worcester, MA USA
| | - David M. Wood
- grid.13097.3c0000 0001 2322 6764Clinical Toxicology, Guy’s and St Thomas’ NHS Foundation Trust and King’s Health Partners, and Clinical Toxicology, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Darren M. Roberts
- grid.430417.50000 0004 0640 6474New South Wales Poisons Information Centre, Sydney Children’s Hospitals Network, Westmead, NSW Australia ,grid.413249.90000 0004 0385 0051Drug Health Services, Royal Prince Alfred Hospital, Sydney, NSW Australia
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Beaulieu J, Roberts DM, Gosselin S, Hoffman RS, Lavergne V, Hovda KE, Megarbane B, Lung D, Thanacoody R, Ghannoum M. Treating ethylene glycol poisoning with alcohol dehydrogenase inhibition, but without extracorporeal treatments: a systematic review. Clin Toxicol (Phila) 2022; 60:784-797. [PMID: 35311442 DOI: 10.1080/15563650.2022.2049810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CONTEXT Ethylene glycol is metabolized to toxic metabolites that cause acute kidney injury, metabolic acidemia, and death. The treatment of patients with ethylene glycol poisoning includes competitively inhibiting alcohol dehydrogenase with ethanol or fomepizole to prevent the formation of toxic metabolites, and extracorporeal treatments such as hemodialysis to remove ethylene glycol and its metabolites. In the absence of significant metabolic acidemia or kidney injury, it is hypothesized that extracorporeal treatments may be obviated without adverse outcomes to the patient if alcohol dehydrogenase inhibitors are used. OBJECTIVES The objectives of this study are to: (1) identify indicators predicting ADH inhibitor failure in patients with ethylene glycol poisoning treated with either ethanol or fomepizole for whom extracorporeal treatment was not performed (aside from rescue therapy, see below) (prognostic study), and (2) validate if the anion gap, shown in a previous study to be the best surrogate for the glycolate concentration, is associated with acute kidney injury and mortality (anion gap study). METHODS We conducted a systematic review to identify all reported patients with ethylene glycol poisoning treated without extracorporeal treatments but with either fomepizole (fomepizole monotherapy) or ethanol (ethanol monotherapy). Analyses were performed using both one case per patient and all cases (if multiple events were reported for a single patient). Data were compiled regarding poisoning, biochemistry, and outcomes. Treatment failure was defined as mortality, worsening of acid-base status, extracorporeal treatments used as rescue, or a worsening of kidney or neurological function after alcohol dehydrogenase inhibition was initiated. Also, we performed an analysis of previously described anion gap thresholds to determine if they were associated with outcomes such as acute kidney injury and mortality. RESULTS Of 115 publications identified, 96 contained case-level data. A total of 180 cases were identified with ethanol monotherapy, and 231 with fomepizole monotherapy. Therapy failure was noted mostly when marked acidemia and/or acute kidney injury were present prior to therapy, although there were cases of failed ethanol monotherapy with minimal acidemia (suggesting that ethanol dosing and/or monitoring may not have been optimal). Ethylene glycol dose and ethylene glycol concentration were predictive of monotherapy failure for ethanol, but not for fomepizole. In the anion gap study (207 cases), death and progression of acute kidney injury were almost nonexistent when the anion gap was less than 24 mmol/L and mostly observed when the anion gap was greater than 28 mmol/L. CONCLUSION This review suggests that in patients with minimal metabolic acidemia (anion gap <28 mmol/L), fomepizole monotherapy without extracorporeal treatments is safe and effective regardless of the ethylene glycol concentration. Treatment failures were observed with ethanol monotherapy which may relate to transient subtherapeutic ethanol concentrations or very high ethylene glycol concentrations. The results are limited by the retrospective nature of the case reports and series reviewed in this study and require prospective validation.
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Affiliation(s)
- Jessie Beaulieu
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, QC, Canada
| | - Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,Drug Health Clinical Services, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Sophie Gosselin
- Centre Intégré de Santé et de Services Sociaux (CISSS) de la Montérégie-Centre Emergency Department, Hôpital Charles-Lemoyne, Greenfield Park, QC, Canada.,McGill University Emergency Medicine Department Montreal, Montreal, QC, Canada.,Centre Antipoison du Québec, Quebec City, QC, Canada
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, NY, USA
| | - Valery Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, QC, Canada
| | - Knut Erik Hovda
- The Norwegian CBRNE Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, Lariboisiere Hospital, University of Paris, Paris, France
| | | | - Ruben Thanacoody
- NPIS (Newcastle Unit), Regional Drug and Therapeutics Centre, Newcastle-upon-Tyne, UK
| | - Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, QC, Canada.,Division of Nephrology, NYU Langone Health and NYU Grossman School of Medicine, NY, USA
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Methanol poisoning as a new world challenge: A review. Ann Med Surg (Lond) 2021; 66:102445. [PMID: 34141419 PMCID: PMC8187162 DOI: 10.1016/j.amsu.2021.102445] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/21/2021] [Accepted: 05/23/2021] [Indexed: 02/07/2023] Open
Abstract
Background Methanol poisoning (MP) occurs often via ingestion, inhalation, or dermal exposure to formulations containing methanol in base. Clinical manifestations of MP include gastrointestinal symptoms, central nervous system (CNS) suppression, and decompensated metabolic acidosis occurred with blurred vision and early or late blindness. Objective This study reviewed the clinical manifestations, laboratory and radiology findings, and treatment approaches in MP. Discussion Methanol is usually rapidly absorbed after ingestion and metabolized by alcohol dehydrogenase (ADH), then distributed to the body water to reach a volume distribution approximately equal to 0.77 L/kg. It is also eliminated from the body as unchanged parent compounds. Clinical manifestations of MP alone initiate within 0.5–4 h after ingestion and include gastrointestinal symptoms and CNS suppression. After a latent period of 6–24 h, depending on the absorbed dose, decompensated metabolic acidosis occurs with blurred vision and early or late blindness. Blurred vision with normal consciousness is a strong suspicious sign of an MP. The mortality and severity of intoxication are well associated with the severity of CNS depression, hyperglycemia, and metabolic acidosis, but not with serum methanol concentration. After initial resuscitation, the most important therapeutic action for patients with known or suspected MP is correction of acidosis, inhibition of ADH, and hemodialysis. Conclusion Since MP is associated with high morbidity and mortality, it should be considered seriously and instantly managed. Delay in treatment may cause complications, permanent damage, and even death. We attempt to review clinical manifestations, laboratory and radiology findings, and treatment approaches in Methanol poisoning (MP). The most important therapeutic action for patients with known MP is correction of acidosis, inhibition of alcohol dehydrogenase, and hemodialysis. The review emphasizes that MP has a high morbidity and mortality rate and it must be taken seriously and treated immediatly.
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Reisinger A, Rabensteiner J, Hackl G. Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 2: markers for specific intoxications. Biomarkers 2020; 25:112-125. [PMID: 32011177 DOI: 10.1080/1354750x.2020.1725787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In medical intensive care units, acute intoxications contribute to a large proportion of all patients. Epidemiology and a basic overview on this topic were presented in part one. The purpose of this second part regarding toxicological biomarkers in the ICU setting focuses on specific poisons and toxins. Following the introduction of anion and osmol gap in part one, it's relevance in toxic alcohols and other biomarkers for these poisonings are presented within this publication. Furthermore, the role of markers in the blood, urine and cerebrospinal fluid for several intoxications is evaluated. Specific details are presented, amongst others, for cardiovascular drug poisoning, paracetamol (acetaminophen), ethanol, pesticides, ricin and yew tree intoxications. Detailed biomarkers and therapeutic decision tools are shown for carbon monoxide (CO) and cyanide (CN-) poisoning. Also, biomarkers in environmental toxicological situations such as mushroom poisoning and scorpion stings are presented.
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Affiliation(s)
- Alexander Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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The Role of Renal Replacement Therapy in the Management of Pharmacologic Poisonings. Int J Nephrol 2016; 2016:3047329. [PMID: 28042482 PMCID: PMC5155094 DOI: 10.1155/2016/3047329] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 10/13/2016] [Accepted: 10/24/2016] [Indexed: 01/20/2023] Open
Abstract
Pharmacologic toxicities are common and range from mild to life-threatening. The aim of this study is to review and update the data on the role of renal replacement therapy (RRT) in the management of various pharmacologic poisonings. We aim to provide a focused review on the role of RRT in the management of pharmacological toxicities. Relevant publications were searched in MEDLINE with the following search terms alone or in combination: pharmacologic toxicity, hemodialysis, hemofiltration, renal replacement therapy, toxicology, poisonings, critical illness, and intensive care. The studies showed that a pharmacologic substance should meet several prerequisites to be deemed dialyzable. These variables include having a low molecular weight (<500 Da) and low degree of protein binding (<80%), being water-soluble, and having a low volume of distribution (<1 L/kg). RRT should be strongly considered in critically ill patients presenting with toxic alcohol ingestion, salicylate overdose, severe valproic acid toxicity, metformin overdose, and lithium poisoning. The role of RRT in other pharmacologic toxicities is less certain and should be considered on a case-by-case basis.
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Beatty L, Green R, Magee K, Zed P. A systematic review of ethanol and fomepizole use in toxic alcohol ingestions. Emerg Med Int 2013; 2013:638057. [PMID: 23431453 PMCID: PMC3574646 DOI: 10.1155/2013/638057] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 12/25/2012] [Indexed: 11/26/2022] Open
Abstract
Objectives. The optimal antidote for the treatment of ethylene glycol or methanol intoxication is not known. The objective of this systematic review is to describe all available data on the use of ethanol and fomepizole for methanol and ethylene glycol intoxication. Data Source. A systematic search of MEDLINE and EMBASE was conducted. Study Selection. Published studies involving the use of ethanol or fomepizole, or both, in adults who presented within 72 hours of toxic alcohol ingestion were included. Our search yielded a total of 145 studies for our analysis. There were no randomized controlled trials, and no head-to-head trials. Data Extraction. Variables were evaluated for all publications by one independent author using a standardized data collection form. Data Synthesis. 897 patients with toxic alcohol ingestion were identified. 720 (80.3%) were treated with ethanol (505 Me, 215 EG), 146 (16.3%) with fomepizole (81 Me, 65 EG), and 33 (3.7%) with both antidotes (18 Me, 15 EG). Mortality in patients treated with ethanol was 21.8% for Me and 18.1% for EG. In those administered fomepizole, mortality was 17.1% for Me and 4.1% for EG. Adverse events were uncommon. Conclusion. The data supporting the use of one antidote is inconclusive. Further investigation is warranted.
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Affiliation(s)
- Lorri Beatty
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Robert Green
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
- Division of Critical Care Medicine, Department of Anesthesia, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Kirk Magee
- Department of Emergency Medicine, Dalhousie University, Room 377, Bethune Building, 1276 South Park Street, Halifax, NS, Canada B3H 2Y9
| | - Peter Zed
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada V6T 1Z3
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Brooks DE, Levine M, O'Connor AD, French RNE, Curry SC. Toxicology in the ICU: Part 2: specific toxins. Chest 2011; 140:1072-1085. [PMID: 21972388 DOI: 10.1378/chest.10-2726] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
This is the second of a three-part series that reviews the generalized care of poisoned patients in the ICU. This article focuses on specific agents grouped into categories, including analgesics, anticoagulants, cardiovascular drugs, dissociative agents, carbon monoxide, cyanide, methemoglobinemia, cholinergic agents, psychoactive medications, sedative-hypnotics, amphetamine-like drugs, toxic alcohols, and withdrawal states. The first article discussed the general approach to the toxicology patient, including laboratory testing; the third article will cover natural toxins.
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Affiliation(s)
- Daniel E Brooks
- Department of Medical Toxicology, Banner Good Samaritan Medical Center, Phoenix, AZ
| | - Michael Levine
- Department of Medical Toxicology, Banner Good Samaritan Medical Center, Phoenix, AZ.
| | - Ayrn D O'Connor
- Department of Medical Toxicology, Banner Good Samaritan Medical Center, Phoenix, AZ
| | - Robert N E French
- Department of Medical Toxicology, Banner Good Samaritan Medical Center, Phoenix, AZ
| | - Steven C Curry
- Department of Medical Toxicology, Banner Good Samaritan Medical Center, Phoenix, AZ
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Mégarbane B. Treatment of patients with ethylene glycol or methanol poisoning: focus on fomepizole. Open Access Emerg Med 2010; 2:67-75. [PMID: 27147840 PMCID: PMC4806829 DOI: 10.2147/oaem.s5346] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ethylene glycol (EG) and methanol are responsible for life-threatening poisonings. Fomepizole, a potent alcohol dehydrogenase (ADH) inhibitor, is an efficient and safe antidote that prevents or reduces toxic EG and methanol metabolism. Although no study has compared its efficacy with ethanol, fomepizole is recommended as a first-line antidote. Treatment should be started as soon as possible, based on history and initial findings including anion gap metabolic acidosis, while awaiting measurement of alcohol concentration. Administration is easy (15 mg/kg-loading dose, either intravenously or orally, independent of alcohol concentration, followed by intermittent 10 mg/kg-doses every 12 hours until alcohol concentrations are <30 mg/dL). There is no need to monitor fomepizole concentrations. Administered early, fomepizole prevents EG-related renal failure and methanol-related visual and neurological injuries. When administered prior to the onset of significant acidosis or organ injury, fomepizole may obviate the need for hemodialysis. When dialysis is indicated, 1 mg/kg/h-continuous infusion should be provided to compensate for its elimination. Side-effects are rarely serious and with a lower occurrence than ethanol. Fomepizole is contraindicated in case of allergy to pyrazoles. It is both efficacious and safe in the pediatric population, but is not recommended during pregnancy. In conclusion, fomepizole is an effective and safe first-line antidote for EG and methanol intoxications.
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Affiliation(s)
- Bruno Mégarbane
- Réanimation Médicale et Toxicologique, Hôpital Lariboisière and Université Paris-Diderot, Paris, France
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Pomara C, Fiore C, D'Errico S, Riezzo I, Fineschi V. Calcium oxalate crystals in acute ethylene glycol poisoning: A confocal laser scanning microscope study in a fatal case. Clin Toxicol (Phila) 2009; 46:322-4. [PMID: 18363130 DOI: 10.1080/15563650701419011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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