Management of Alcohol Poisoning Beyond Fluid Bolus
For alcohol poisoning, beyond fluid bolus, treatment should include supportive care, antidotes for toxic alcohols, correction of metabolic abnormalities, and consideration of extracorporeal treatment for severe cases.
Initial Assessment and Supportive Care
- Airway management: Secure airway with early endotracheal intubation for life-threatening poisoning 1
- Position: Place unconscious patients in left lateral head-down position to prevent aspiration 1
- Glucose administration: Administer glucose injection if patient is unconscious to treat potential hypoglycemia 1
- Vital sign management:
Specific Interventions Based on Type of Alcohol
Ethanol Poisoning
- Supportive care is the mainstay of treatment for ethanol intoxication
- Electrolyte correction: Monitor and correct electrolyte imbalances 2
- Vitamin supplementation: Administer complex B and C vitamins 2
- Metadoxine: Consider to accelerate alcohol elimination in severe intoxication (blood alcohol concentration >1 g/L) 2
- Observation: Clinical observation with vital signs monitoring for 24 hours is often sufficient for mild-moderate cases 2
Toxic Alcohols (Methanol, Ethylene Glycol)
Antidotes
Fomepizole: Preferred antidote for toxic alcohol poisoning 3
- Blocks alcohol dehydrogenase to prevent formation of toxic metabolites
- Easier to dose and monitor than ethanol
- Fewer side effects than ethanol
Ethanol: Alternative if fomepizole is unavailable 3
- Competes for alcohol dehydrogenase
- More complex dosing and monitoring required
Metabolic Support
Sodium bicarbonate: Correct metabolic acidosis with IV sodium bicarbonate 4
- Adult dose: 50-150 mEq
- Pediatric dose: 1-3 mEq/kg 1
Folinic acid: Enhance formic acid metabolism in methanol poisoning 4
Extracorporeal Treatment (ECTR)
ECTR should be considered based on specific criteria:
Clinical indications requiring ECTR 5:
- Coma due to toxic alcohol poisoning
- Seizures
- Acute kidney injury (KDIGO stage 2 or 3)
- Chronic kidney disease (eGFR <45 mL/min/1.73m²)
Laboratory indicators for ECTR 5:
- Anion gap >27 mmol/L (recommend ECTR)
- Anion gap 23-27 mmol/L (suggest ECTR)
- Glycolate concentration >12 mmol/L (recommend ECTR)
- Glycolate concentration 8-12 mmol/L (suggest ECTR)
ECTR modality preference 5:
- First choice: Intermittent hemodialysis
- Second choice: Continuous kidney replacement therapy if hemodialysis unavailable
When to stop ECTR 5:
- When anion gap <18 mmol/L
- When toxic alcohol concentration <4 mmol/L
- When acid-base abnormalities are corrected
Monitoring and Follow-up
- Continuous cardiac monitoring for at least 24-36 hours after ingestion 1
- Serial assessment of vital signs and mental status 1
- Laboratory monitoring: Myocardial enzymes, renal and hepatic function 1
- Neurologic assessment: Monitor for seizures, coma, and persistent cognitive or visual impairment, especially with methanol poisoning 6
Prognostic Indicators
- In methanol poisoning, anion gap ≥28 and lower Glasgow Coma Scale score are independent predictors of poor outcome 6
- Methanol poisoning has higher risk of poor neurologic outcomes compared to other toxic alcohols, with >20% of patients dying or having persistent cognitive or visual impairment 6
Pitfalls to Avoid
- Delaying antidote administration while waiting for confirmatory testing 1
- Administering anything by mouth unless advised by poison control 1
- Failing to consider early ECTR in severe cases 5
- Underestimating the severity of methanol and ethylene glycol poisoning, which can lead to significant morbidity and mortality if not promptly recognized and treated 7
Remember to contact regional poison centers (1-800-222-1222 in the US) for expert guidance in managing alcohol poisoning cases 1.