Toxic Alcohols — Methanol & Ethylene Glycol

Meet the patient

Six patrons of a remote community gathering present over eight hours with headache, nausea, abdominal pain, and progressive visual disturbance — one is now blind. They had shared a single batch of illicit spirits. The first patient is drowsy, breathing thirty-two times a minute (Kussmaul), heart rate 110, blood pressure 96 over 60. Blood gas: pH 7.18, bicarbonate 9, PaCO2 22, anion gap 32, osmolar gap 38. Lactate 4.2.^[1]

The two questions that decide the next hour are the two that decide every toxic alcohol ingestion: is there a dual gap? (high anion gap plus high osmolar gap = toxic alcohol until proven otherwise) and have I given fomepizole yet? (block ADH before more toxic metabolites form — do not wait for the confirmatory level). Hold those two and everything below slots into place.^[1][2]

References18ShowHide

1. [1]Ross JA, Borek HA, Holstege CP, et al. Toxic Alcohol Poisoning Emerg Med Clin North Am, 2022.PMID 35461626
2. [2]Kraut JA Approach to the Treatment of Methanol Intoxication Am J Kidney Dis, 2016.PMID 27180631
3. [3]Pohanka M Antidotes Against Methanol Poisoning: A Review Mini Rev Med Chem, 2019.PMID 30864518
4. [4]Kraut JA, Kurtz I. Toxic alcohol ingestions: clinical features, diagnosis, and management Clin J Am Soc Nephrol, 2008.PMID 18045860
5. [5]Brent J, McMartin K, Phillips S, Aaron C, Kulig K. Fomepizole for the treatment of methanol poisoning N Engl J Med, 2001.PMID 11172179
6. [6]Brent J, McMartin K, Phillips S, Burkhart KK, Donovan JW, Wells M, Kulig K. Fomepizole for the treatment of ethylene glycol poisoning. Methylpyrazole for Toxic Alcohols Study Group N Engl J Med, 1999.PMID 10080845
7. [7]Barceloux DG, Krenzelok EP, Olson K, Watson W. American Academy of Clinical Toxicology Practice Guidelines on the Treatment of Ethylene Glycol Poisoning. Ad Hoc Committee J Toxicol Clin Toxicol, 1999.PMID 10497633
8. [8]Barceloux DG, Bond GR, Krenzelok EP, Cooper H, Vale JA. American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning J Toxicol Clin Toxicol, 2002.PMID 12216995
9. [9]Roberts DM, Yates C, Megarbane B, et al. Recommendations for the role of extracorporeal treatments in the management of acute methanol poisoning: a systematic review and consensus statement Crit Care Med, 2015.PMID 25493973
10. [10]Ghannoum M, Gosselin S, Hoffman RS, et al. Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup Crit Care, 2023.PMID 36765419
11. [11]McMartin K, Jacobsen D, Hovda KE Antidotes for poisoning by alcohols that form toxic metabolites Br J Clin Pharmacol, 2016.PMID 26551875
12. [12]Zakharov S, Pelclova D, Diblik P, et al. Long-term visual damage after acute methanol poisonings: Longitudinal cross-sectional study in 50 patients Clin Toxicol (Phila), 2015.PMID 26364866
13. [13]Zakharov S, Pelclova D, Navratil T, et al. Fomepizole versus ethanol in the treatment of acute methanol poisoning: Comparison of clinical effectiveness in a mass poisoning outbreak Clin Toxicol (Phila), 2015.PMID 26109326
14. [14]Mégarbane B Treatment of patients with ethylene glycol or methanol poisoning: focus on fomepizole Open Access Emerg Med, 2010.PMID 27147840
15. [15]Hall TL Fomepizole in the treatment of ethylene glycol poisoning CJEM, 2002.PMID 17609006
16. [16]Bucaretchi F, De Capitani EM, Madureira PR, et al. Suicide attempt using pure methanol with hospitalization of the patient soon after ingestion: case report Sao Paulo Med J, 2009.PMID 19597688
17. [17]McMartin K, Brent J Analysis of Fomepizole Elimination in Methanol- and Ethylene Glycol-Poisoned Patients J Med Toxicol, 2022.PMID 34697779
18. [18]Benitez JG, Swanson-Biearman B, Krenzelok EP Nystagmus secondary to fomepizole administration in a pediatric patient J Toxicol Clin Toxicol, 2000.PMID 11192468