Ethanol Poisoning - Oren Zarif

Alcohol poisoning is caused by drinking too much ethanol (ethyl alcohol) in a short period of time. Ethanol is found in alcoholic beverages, perfumes, colognes, mouthwashes, some liquid medications, and uncooked rising-yeast bread dough.

Assess a history of possible ethanol ingestion in any patient who arrives in the emergency department with altered mental status. Be sure to get the name and concentration of the ethanol that was ingested.

Causes

Ethanol, the alcohol found in alcoholic drinks and other types of alcohol such as isopropyl alcohol (rubbing alcohol) or methanol, can cause poisoning if consumed in large amounts. Ethanol affects the balance of chemicals in the brain and other parts of the body. For example, it lowers levels of the neurotransmitter gamma-aminobutyric acid (GABA), which decreases central nervous system activity, and increases levels of adenosine, another chemical that promotes sleep.

The most common cause of alcohol poisoning is binge drinking. A person may also be poisoned if they take certain medications with alcohol or other substances, such as antidepressants and some stomach medicines, or if they are exposed to fumes from paint strippers or solvents.

When a person drinks alcohol, it quickly enters the bloodstream through the lining of the stomach and intestines. The blood alcohol concentration (BAC) usually peaks within 30 to 90 minutes after the start of drinking. The higher the BAC, the more intoxicated the person becomes.

Unlike food, which takes the body a long time to digest, alcohol is processed very rapidly by the liver. As a result, the liver can only remove a limited amount of alcohol from the body at one time. If a person drinks more than the liver can process, ethanol molecules build up in the body and cause poisoning.

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In addition to causing drunkenness, high BAC levels can cause many other symptoms, including slurred speech, blurred vision, impaired coordination and reaction time, blackouts, vomiting, sweating, tachycardia, dehydration and unconsciousness. If the BAC reaches levels that cause unconsciousness, the person is in a life-threatening condition and needs to be treated as an emergency.

Alcohol poisoning is a very common cause of poisoning in the United States, resulting in a number of deaths and more than 600,000 visits to the emergency department (ED) each year. In most cases, patients with a low level of alcohol intoxication do not need escalation of care to the intensive care unit. However, a recent study found that about 1% of patients with a history of alcohol intoxication were transferred to the ICU due to their altered mental status.

Symptoms

Ethanol is a central nervous system depressant and can affect the heart, blood pressure, and respiratory system (lungs and breathing). If consumed in large enough amounts, it can cause poisoning. It can also suppress the ability to metabolize sugar, leading to hypoglycemia (low blood sugar). A depressed central nervous system can slow the heart rate and decrease the blood pressure. This can lead to cardiac arrest. Ethanol poisoning can cause a buildup of lactic acid in the body, which causes metabolic acidosis. The high levels of acid can damage the kidneys, liver, and muscles. This can lead to coma, seizures, brain damage, and death.

Alcohol poisoning is most often caused by consuming too many alcoholic drinks in a short amount of time. It can also occur if children get their hands on alcohol-containing products such as perfumes or hand sanitizers. If someone you know exhibits signs or symptoms of alcohol poisoning, call 911 and get emergency medical assistance immediately. It's important to collect information while waiting for help, including the amount of alcohol consumed, other medications or substances taken, and health conditions and allergies. Be sure to roll the person on their side to prevent choking if they vomit.

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Other symptoms include a low blood pressure, slowed breathing, breath that smells fruity or like nail polish, a lack of coordination, blurred vision, confusion, blackouts, and emotional lability. It can also cause an abnormal heart rhythm and a loss of consciousness, as well as a sudden drop in body temperature called hypothermia.

The ASPCA notes that cats can experience ethanol poisoning from eating yeast dough that contains ethanol or from drinking alcoholic beverages. Symptoms of ethanol poisoning in pets can include depression, difficulty breathing, drooling, vomiting, flatulence, urinating and/or defecating involuntarily, a reduced or irregular heartbeat, low body temperature, trembling, seizures, an increased heart rate, and an increase in the amount of acid in the body (metabolic acidosis).

When a pet is showing signs of ethanol poisoning, it's important to contact a veterinarian right away. They can administer a laxative, monitor their vital signs, check for any stomach upset, and perform other tests to help diagnose the problem.

Diagnosis

Ethanol poisoning can be caused by ingestion or absorption through the skin. The amount ingested determines the level of alcohol intoxication and how quickly a person becomes sick. The person's body can quickly become dehydrated and hypothermic when drinking large amounts of alcohol.

The person's blood alcohol content (BAC) rises as the body metabolizes the alcohol. The higher the BAC, the more intoxicated the person becomes. If the BAC is very high, it can cause brain damage and death. A person with a very high BAC may also have seizures and uncontrollable vomiting.

If a person is experiencing symptoms of alcohol poisoning, they should seek emergency medical treatment immediately. A person might need sedative medications if they are agitated, violent or uncooperative. If the person is unconscious, they might need to be resuscitated. They might need to be placed on a ventilator or given liquids through a vein (intravenous fluids). The doctor will want to know if the person took any other drugs or medicines that could interfere with the alcohol's effect.

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Often, the person's history is a good indicator of what caused the poisoning. They might tell you the type and name of alcohol they drank. They might give you information about the time they drank, how many drinks they drank and what they were eating with their drink.

A patient was admitted to the ED pulseless, apneic and deeply unconscious after ingesting a full bottle (1 liter) of "methylated spirits." Their initial blood ethanol concentration was 1.127 g/dL. The patient was intubated and resuscitated and the initial ethanol level dropped rapidly, but she developed asystole two hours later and died from the associated hypothermia.

The most common cause of alcohol poisoning is ethanol or ethyl alcohol, which is found in alcoholic beverages. Other types of alcohol can also poison people, including methanol or methyl alcohol and isopropyl alcohol (rubbing alcohol), which are used in cleaning products, cosmetics and some liquid medicines. Animals can also be poisoned by methanol or isopropyl alcohol if it is fed to them or if they are exposed to rotten fruits or fermenting yeast bread dough.

Treatment

Detection and prompt treatment of toxic alcohol ingestion can reduce patient morbidity.1 Toxic alcohols (methanol, ethylene glycol, and isopropanol) cause metabolic acidosis with high anion and osmolal gaps, neurological changes ranging from confusion to deep coma, amaurosis, and death.

Ingestion of toxic alcohols can also lead to gastrointestinal and respiratory failure, hypotension, and hypothermia.2 Therefore, patients with suspected exposure should receive immediate ED evaluation and care.

Assessing a patient for possible ethanol ingestion is a challenging and time-consuming process. Obtain a thorough history from the patient or a representative, including possible workplace ingestion. Pediatric patients are particularly evasive in stating a history of possible alcohol consumption because of social stigma and concerns about legal implications.

For patients with a confirmed or suspected ingestion of ethanol, the first step is to maintain a patent airway. Initiate oxygen support if necessary and administer antiemetics for aspiration prevention. Gastrointestinal decontamination measures, such as placing a nasogastric tube and evacuation of stomach contents, are of little value in this setting because ethylene glycol is rapidly absorbed from the gastrointestinal tract.

Ethanol has an affinity for the gamma-aminobutyric acid (GABA) receptor in the central nervous system, binding to it and causing sedative effects. These effects are similar to those of benzodiazepines. Ethanol levels peak 30-60 min after ingestion and are metabolized primarily in the liver.

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Hemodialysis is used to remove the toxic parent compound and its metabolites from the bloodstream. Fomepizole is an effective antidote for methanol poisoning and is absorbed well through the gastrointestinal tract and into the bloodstream. However, the use of hemodialysis in methanol poisoning is controversial and requires close monitoring for toxicity.

In a patient with suspected methanol or ethylene glycol poisoning, the physician must consider the availability of hemodialysis and a nearby inpatient unit capable of providing critical care and resuscitation. Ideally, the patient should be admitted prior to beginning hemodialysis to ensure that a team is available to initiate treatment early in the course of the illness. It is also important to have access to other antidotal therapies, including acetaminophen.