Isopropyl alcohol toxicity: Difference between revisions

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== Background ==
== Background ==
*Isopropyl alcohol acts directly as CNS depressant and is broken down by alcohol dehydrogenase to acetone, which further compounds effect
==Background==
*Main component of rubbing alcohol
*Hallmark is osmolar gap without acidosis
**Metabolized to acetone, not to an acid
*Takes 30-60min for acetone to appear in blood; 3hr to appear in urine
*Lethal Dose: 4-8 g/kg or 250mL in average adult
*Lethal Dose: 4-8 g/kg or 250mL in average adult


== Clinical Features ==
== Clinical Features ==
*Symptoms of inebriation, disinhibition, sedation, and coma usually peak in the first hour of ingestion
*CNS depression
*"Fruity breath" can be seen as a result of acetone production
**Similar to ETOH intoxication, but longer-lasting
**Usually peak in first hour of ingestion
*GI
**N/V / abd pain / hemorrhagic gastritis
*Respiratory depression
*Hypotension
*Hypoglycemia (in malnourished pts)


== Work-Up ==
== Work-Up ==
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== Diagnosis ==
== Diagnosis ==
*Positive serum isopropyl alcohol level (if available)
*Osmolal gap > 10; see [[Osmolal or Osmolar Gap]]
*Osmolal gap > 10, see [[Osmolal or Osmolar Gap]]
*Absence of anion gap
*Absence of anion gap
*Absence of metabolic acidosis
*Absence of metabolic acidosis
*Absence of serum beta hydroxybutyrate
*Absence of serum beta hydroxybutyrate
*Presence of serum and urine ketones
*Presence of serum and urine ketones
**Consider other diagnosis if absent 2 hours after ingestion
**Consider other diagnosis if absent 2hr after ingestion
*Elevated creatinine may be falsely elevated as a result of acetone interference with laboratory measurement of creatinine
*Creatinine may be falsely elevated d/t acetone interference w/ laboratory measurement of Cr


== DDX ==
== DDX ==
*Ethanol ingestion
*Ethanol ingestion
*Methanol or ethylene glycol ingestion
*[[Methanol Toxicity]]
*[[Ethylene Glycol Toxicity]]
*Starvation ketoacidosis
*Starvation ketoacidosis
*Diabetic ketoacidosis
*[[Diabetic Ketoacidosis]]
*Inborn errors of metabolism  
*Inborn errors of metabolism  
*Salicylate ingestion
*[[Salicylate Toxicity]]
*Acetone ingestion
*Acetone ingestion


== Treatment ==
==Treatment==
*GI decontamination
**Activated charcoal ineffective (absorbed too quickly)
*Airway
*Airway
*Breathing
**Mechanical ventilation may be necessary
**Consider intubation to secure airway
*Hypotension
*Circulation
**Usually responsive to IVF; pressors may be necessary
**Fluid rehydration
*Fomepizole
*Minimal role in GI decontamination due to rapid absorption
**Unnecessary
**May consider nasogastric aspiration if done within 1 hour of ingestion
***Metabolite, acetone, is no more toxic than the parent compound
*Hemodialysis should be considered in persistently hypotensive patient after aggressive fluid hydration and vasopressor support or for Siopropyl levels greater than 400 mg/dL
***Use may lead to prolonged CNS toxicity
*Hemodialysis
**Consider for:
***Hypotension refractory to conventional therapy
***Isopropanol level >400


== Disposition ==
== Disposition ==
*Unintentional ingestions may be safely discharged if asymptomatic after 2 hours of observation
*Consider d/c if asymptomatic x4-6hr
*Any intentional ingestions should be screened for suicidal ideation and alcohol addiction


== Source ==
== Source ==
*Uptodate
*Uptodate
*Rosen
*Rosen
*Tintinalli


[[Category:Tox]]
[[Category:Tox]]

Revision as of 17:19, 21 February 2012

Background

Background

  • Main component of rubbing alcohol
  • Hallmark is osmolar gap without acidosis
    • Metabolized to acetone, not to an acid
  • Takes 30-60min for acetone to appear in blood; 3hr to appear in urine
  • Lethal Dose: 4-8 g/kg or 250mL in average adult

Clinical Features

  • CNS depression
    • Similar to ETOH intoxication, but longer-lasting
    • Usually peak in first hour of ingestion
  • GI
    • N/V / abd pain / hemorrhagic gastritis
  • Respiratory depression
  • Hypotension
  • Hypoglycemia (in malnourished pts)

Work-Up

  • Fingerstick glucose
  • Complete metabolic panel
  • Serum ketones
  • Serum Osmolality
  • Uinarlysis
  • VBG
  • Aspirin/Tylenol levels
  • ECG
  • Serum isopropyl alcohol level (if available)
  • Total CK

Diagnosis

  • Osmolal gap > 10; see Osmolal or Osmolar Gap
  • Absence of anion gap
  • Absence of metabolic acidosis
  • Absence of serum beta hydroxybutyrate
  • Presence of serum and urine ketones
    • Consider other diagnosis if absent 2hr after ingestion
  • Creatinine may be falsely elevated d/t acetone interference w/ laboratory measurement of Cr

DDX

Treatment

  • GI decontamination
    • Activated charcoal ineffective (absorbed too quickly)
  • Airway
    • Mechanical ventilation may be necessary
  • Hypotension
    • Usually responsive to IVF; pressors may be necessary
  • Fomepizole
    • Unnecessary
      • Metabolite, acetone, is no more toxic than the parent compound
      • Use may lead to prolonged CNS toxicity
  • Hemodialysis
    • Consider for:
      • Hypotension refractory to conventional therapy
      • Isopropanol level >400

Disposition

  • Consider d/c if asymptomatic x4-6hr

Source

  • Uptodate
  • Rosen
  • Tintinalli