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case report

Case Report. 15 year-old, previously healthy boy19:00 Drank 250ml of antifreeze, ribena and sugar07:00 Awoke feeling

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case report

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    3. In emergency department... GCS 13/15 (E3, V4, M6) RR 28/min, Sats 96% on air HR 80, BP 103/73 Confessed to drinking antifreeze

    4. Initial Investigations

    5. Pre-ITU Treatment Naloxone 400mcg (ambulance crew) N-Acetyl Cysteine loading dose Ethanol 10%, 375ml IV Sodium Bicarbonate 50mmol IV No attempts made to reduce toxin absorption No cardiovascular or respiratory support required Ethylene Glycol levels taken and sent to Guys Poisons

    6. On Transfer to PICU CVVHDF started: exchange 4.5l/hr Ethanol 10% infusion: target 100mg/dl 6 hourly biochemistry and 2 hourly ethanol levels Required no further organ support Further investigations...

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    8. Outcome Day 5: discharged from PICU Day 5: converted to intermittent HD (3x per week) Day 9: off dialysis Day 12: discharged home 1 year later: discharged from renal clinic

    9. About Ethylene Glycol... Chemical name 1,2-Ethanediol An alcohol (contains CHOH) Used due to its low freezing point (60% sol: -55oC)

    10. ...About Ethylene Glycol Clear, viscous fluid Sweet taste Concentrated antifreeze 80-100% by volume Often dyed blue

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    14. Toxicity Toxic quantities only likely through ingestion Antidote required if >0.15g/kg ingested Adult fatal dose around 100g pure Ethylene Glycol (approx 100ml concentrated antifreeze)1 Rapid gut absorption Peak concentrations 1-4 hrs after ingestion1 Usually zero-order metabolism Almost all toxicity is from metabolites2

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    17. Early Features (30 min- 12 hrs) Intoxication without alcohol odour Nausea, vomiting, haematemesis Seizures and cranial nerve palsies High osmolar gap Developing metabolic acidosis

    18. Intermediate Features (12- 24 hrs) Osmolar gap normalised Severe metabolic acidosis from glycolate metabolite (large anion gap) High lactate on ABG may be artefact or genuine Pulmonary oedema Congestive cardiac failure

    19. Late Features (24-72 hrs) Acute tubular necrosis Hypocalcaemia (from oxalate binding) Calcium oxalate crystalluria Multi-organ failure

    20. Treatment... General Measures Ethylene glycol levels not available quickly Support CNS and respiratory depression Treat any mixed overdose Prevention of absorption Gastric aspiration only works within 1st hour Activated charcoal ineffective

    21. ...Treatment Prevention of Metabolism Ethanol Fomepizole Removal of Toxins Patients kidneys Haemodialysis/ Haemofiltration Treatment of Biochemical Abnormalities Sodium bicarbonate in severe acidosis Avoid treating mild/moderate hypocalcaemia

    22. Ethanol Competes with Ethylene Glycol for Alcohol Dehydrogenase Load 600-800mg/kg (3 double G&Ts); aim 100-150 mg/100ml Pros Cheap and always available (oral/NG if not IV) More widely used than Fomepizole in UK Cons Narrow therapeutic index Risks CNS depression, hypoglycaemia & pancreatitis Need frequent plasma levels and ITU/HDU care

    23. Fomepizole (4-methylpyrazole) Competitive Alcohol Dehydrogenase inhibitor 15mg/kg load (IV or oral) Pros Wide therapeutic index: level monitoring not required Few side effects (headache, nausea, dizziness)3,4 Evidence of successful treatment without HD/HF5 Cons Expensive to stock and to use 1,000 per box No prospective study comparing against ethanol Not widely available in UK

    25. Renal replacement therapy Removes Ethylene Glycol and metabolites Treats metabolic acidosis Supports acute kidney injury Considerations Antidotes require dose-adjustment May be unnecessary in patients with normal renal function at presentation treated with Fomepizole (but only case reports and one, small, possibly biased, prospective study)4,6

    26. Whats Available to Us? Ethylene Glycol levels processed during working hours at Guys Hospital Fomepizole not stocked in Wessex- specially imported to the UK; possibly available from Guys 10% Ethanol stocked in most hospitals Usually an off-licence nearby Ethanol levels available out-of hours in most hospitals (but may not be automated) Plenty of beds in ITU for RRT?

    27. My Conclusions Important not to delay treatment Low threshold for ethanol load in ED based on history, ABGs or osmolality Use HD/HF in all significant cases of poisoning Case for Fomepizole not completely proven but Id use it if available

    28. Any Questions?

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