Acute ethylene glycol poisoning.

Abstract

A 43-year-old man arrived at ED triage at 6:45 PM with a history of drinking beer, wine, and possibly antifreeze earlier that afternoon. A family member and police were with him. The patient admitted drinking 1 to 2 quarts of antifreeze as a suicide attempt. He denied nausea, vomiting, dyspnea, and chest pain. His family denied any other significant medical problems, including cardiac or respiratory disease. The patient admitted chronic alcohol abuse but denied use of tobacco or recreational drugs. He had been treated at a psychiatric hospital for previous suicide attempts. Initial vital signs in the emergency department were as follows: blood pressure, 150/110 mm Hg; pulse, 104 beats/min; respirations, 28 breaths/min and unlabored; and rectal temperature, 98.8’ F. Physical examination revealed a disheveled white man, alert and oriented to person only, with a slight odor of ethanol. Pupils were equal and reactive to light. Lungs were clear to auscultation. Abdomen was soft and nontender to palpation, with active bowel sounds. The patient was placed on a cardiac monitor and given oxygen at 2 L/mm by nasal cannula. IV access was obtained and 0.9% normal saline solution was infused at a rate of 200 ml/hr. Laboratory tests included arterial blood gas values (ABGs), complete blood count, serum electrolytes, serum osmolality, calcium, ethanol, and ethylene glycol levels, urinalysis, and toxicology screen. EKG revealed normal sinus rhythm with a slightly prolonged QT interval. Initial ABG values (with oxygen at 2 L/min) were pH of 7.22, oxygen tension of 149 mm Hg, carbon dioxide tension of 14 mm Hg; and bicarbonate level of 5 mmol/L. Chemistry results revealed a sodium level of 141 mmol/L, potassium of 4.2 mmol/L, chloride of 110 mmol/L, carbon dioxide of 7.5 mmol/L, anion gap of 24, and measured osmolality of 364 mosm/kg (normal, 270 to 295 mosm/kg). Serum calcium and magnesium levels were within normal limits. Urinalysis was positive for 3+ calcium oxalate crystals and from 0 to 4 red blood cells (microscopic). Because of this patient’s severe metabolic acidosis, IV fluids were changed to 5% dextrose in water and normal saline solution (2: 1) with 2 ampules of sodium bicarbonate infusing at 250 ml/hr. Thiamine la mg and pyridoxine 100 mg were given by IV. An 18F Salem sump tube was passed and after lavaginq the patient’s stomach with 1OOOml normal saline, 50 gm of activated charcoal was administered. Results of an initial qualitative ethylene glycol screen were reported to be positive (quantitative results pending), and a 10% ethanol solution was initiated through a second IV. The patient received a 10 ml/kg (7CC ml) bolus and a continuous drip was maintained at 3 ml/kg/hr (90 ml/hr). The patient’s vital signs remained stable and his level of consciousness was unchanged. He was transferred to the surgicai ICU 90 minutes after his admission to the emergency department. Less than 1 hour after transfer to the surgical ICU, the quantitative ethylene glycol serum concentration was reported at 209 mg/dl. A dialysis catheter was placed through the right subclavian vein and the pa-tient underwent 3 hours of hemodialysis without complications. His level of consciousness improved, ana he was fully alert and oriented on completion of the dialysis. Urinalysis 4 hours later revealed only occasional calcium oxalate crystals and 30+ red blood ceils (microscopic). A repeated serum ethylene glycol test revealed that concentration had decreased to 74 mg/dl. ABGs the next afternoon were pH of 7.42, oxygen tension of 85.5 mm Hg; carbon dioxide tension of 36.3 mm Hg, and bicarbonate level of 23.4 mmD/l. The ethanol drip was continued until his anion gap and serum osmolality normalized. Serum electrolytes and ethanol level were monitored every 6 hours. The ethanol drip was discontinued on the third inpatient day. The patient’s condition remained medically stable, with no change in vital signs or level of consciousness. The patient’s hospital course was complicated by