Ethanol poisoning


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

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    Key Points

    1. Exploratory ethanol ingestion by children less than 6 years of age typically results in minor symptoms.
    2. However, infants and young children are prone to profound hypoglycaemia, coma, and hypothermia, despite ingesting relatively small amounts of ethanol.
    3. Even with a raised blood alcohol level, always consider potentially more dangerous contributors to decreased conscious state (including head Injury ingestion of other drugs).

    For 24 hour advice contact the Victorian Poisons Information Centre on 13 11 26 

    Background

    In adolescents, binge drinking and other forms of ethanol abuse are common problems. There are variety of forms of alcohol which children may ingest.

    Ethanol Containing Preparations and Approximate Concentrations
    Ethanol is available in a multitude of alcoholic beverages, but also concentrated in household products (e.g., vanilla extract, mouthwash, perfume, or cologne)

    • Light beer 2%
    • Beer 5-8%
    • Cider 5-8%
    • Wine 10-15%
    • Wine coolers 5%
    • Fortified wine 20%
    • Spirits 45%
    • Liqueurs 30%
    • Perfumes& colognes >60%
    • Hand sanitisers (some) 60-70%
    • Aftershaves 80%
    • Mouth washes (some) 25%
    • Methylated spirit 95% (does not contain methanol)

    NB ensure that the alcohol ingested is not one of the toxic alcohols
    e.g. methanol, ethylene glycol


    Blood alcohol concentration (BAC)
    BAC can be expressed using a variety of units
    e.g. 0.05% = 0.05g / 100mL blood = 11mmol/L

    Pharmacokinetics
    Peak BAC occurs 90 minutes after ingestion (although alcohol is often not ingested as a single dose)

    The rate at which BAC decreases varies between individuals.  In general, though a process of metabolism and elimination in urine.  BAC decreases by 0.01% to 0.02% per hour after ingestion.

    Patients requiring assessment

    All patients presenting with a history of alcohol ingestion, or with signs and symptom of alcohol intoxication need assessment.

    History:

    • Amount and type of alcohol ingested.
    • Other drug ingestion, e.g. recreational drugs, medications, other deliberate overdose.
    • Trauma / injury, especially trauma to head
    • Level of neurological depression, and progression of symptoms which could suggest evolving intracranial pathology
    • Exposure to cold environment
    • Possibility of unplanned sexual activity / assault requiring emergency contraception or forensic evaluation.

    Examination:
    CNS
    See Dose Related Toxicity (below)

    Cardiovascular
    Hypotension and tachycardia may occur as a result of ethanol-induced peripheral vasodilation, or secondary to volume loss.

    Hypothermia
    Hypothermia may occur due to vasodilatation and / or prolonged exposure to cold environment

    Hypoglycaemia
    Can cause decreased conscious state.

    Dose related toxicity 
    CNS effects of blood alcohol concentration (BAC) on non-tolerant adults, by BAC


    BAC

    Clinical effects

    0.02 to 0.05%

    Decreased inhibition, diminished fine motor coordination

    0.05% to 0.10 %

    Impaired judgement; impaired coordination

    0.10% to 0.15%

    Difficulty with gait and balance

    0.15% to 0.25%

    Lethargy; difficulty sitting upright without assistance

    0.30%

    Coma in the non-habituated drinker

    0.40%

    Respiratory depression

    Reference: Adapted from: Marx JA. Rosen's emergency medicine: concepts and clinical practice, 5th ed, Mosby, Inc., St. Louis 2002. p. 2513. Copyright © 2002 Elsevier. (from Uptodate)

    Investigations:
    Consider a lower threshold for investigation in infants and young children as neurological and behavioural signs of intoxication may be harder to interpret.

    If only mild symptoms (decreased inhibition, slight incoordination) it is reasonable to monitor and give frequent carbohydrate containing drinks with no investigations.

    If more than mild symptoms or symptoms not improving / worsening after two hours, the following investigations should be arranged

    • Blood glucose
    • U&E
    • Acid base (metabolic acidosis)
    • ECG if any consideration of poly drug overdose
    • Consider CT brain if decreased conscious state / conscious state deteriorating
    • Blood Alcohol Concentration can be considered (especially if easily available in ED).  BAC should ideally be done in all patients who require admission.

         If involved in an MVA, either as driver or passenger, you may be obliged by state law to take a Police Sample BAC

    Acute Management

    Key interventions are mainly supportive and include management of:

    • Hypoglycaemia
    • Hypovolemia
    • Hypothermia
    • Decreased conscious state (keeping in mind that this may not be due to alcohol ingestion: consider trauma, polydrug ingestion, DKA etc)
    • Respiratory depression
    • Management of co-morbidities

    Resuscitation

    Standard procedures and supportive care

    Consider consultation with local paediatric team when:

    • Need for ongoing medical management to maintain blood glucose, temp etc
    • Social risk.

    For 24 hour advice contact the Victorian Poisons Information Centre on 13 11 26

    Consider transfer when:

    • Significantly decreased conscious stage or conscious state not improving as expected.
    • Need for respiratory support

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Consider Discharge when:

    • Blood glucose / temperature normal / Investigations normal
    • Normal GCS

    Discharge information and follow-up:

    Drug and alcohol use that puts young person at risk

    • Victoria's Youth Drug and Alcohol Advice Service (YoDAA):
      1800 458 685                               http://yodaa.org.au/ 

    Mental Health needs identified

    Victorian Poisons Information Centre the prevention of poisoning  

    Kids Health Info: Poisoning prevention for children

    Intentional self-harm: Referral to local mental health services e.g. Orygen Youth Health: 1800 888 320   

    Last updated June 2017