Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or reperfusion when indicated; document follow‑up and patient education.
Algorithm
- Suspect based on HAG metabolic acidosis with osmolal gap and history; call poison control/toxicology.
- Start fomepizole immediately; obtain baseline labs and send levels (do not wait).
- Correct severe acidosis with bicarbonate; give cofactors depending on suspected alcohol.
- Initiate hemodialysis for severe acidosis, visual symptoms (methanol), renal failure, or high levels per criteria.
- Continue fomepizole during dialysis with shortened interval; monitor until gap closes and levels undetectable.
Clinical Synopsis & Reasoning
Methanol/ethylene glycol ingestions cause high anion gap metabolic acidosis and osmolal gap. Start fomepizole immediately, give cofactors (folinic acid/pyridoxine/thiamine), correct acidosis, and consult poison control; initiate hemodialysis for severe toxicity.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced or procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Serum osmolality and osmolal gap | Screening | Elevated gap | Interpret with ethanol presence |
| Anion gap, lactate, ABG | Severity | High anion gap acidosis | Trend with therapy |
| Toxic alcohol levels (send-out) | Confirmation | Elevated methanol/EG | Do not delay therapy |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Fomepizole 15 mg/kg IV load → 10 mg/kg q12h | ADH inhibitor | Immediate | Blocks toxic metabolite formation | Shorten interval during dialysis |
| Sodium bicarbonate infusion | Buffer | Minutes | Treat severe acidosis | Monitor pH/Na+ |
| Folinic acid 1 mg/kg IV q6h (methanol) | Cofactor | Hours | Enhance formate metabolism | — |
| Pyridoxine 50 mg IV/PO q6h + Thiamine 100 mg IV/PO q6h (EG) | Cofactors | Hours | Shift to non-toxic metabolites | — |
| Hemodialysis | Removal | Immediate | Indications: severe acidosis, end-organ injury, high level | Coordinate with toxicology |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- EXTRIP Workgroup Recommendations: Toxic Alcohols (2019 update) — Link