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Ethylene Glycol Exposure: an Evidence-Based Consensus Guideline for Out-of-Hospital Management#

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In 2002, poison centers in the US reported 5816 human exposures to ethylene glycol. A guideline that effectively determines the threshold dose for emergency department referral and need for pre-hospital decontamination could potentially avoid unnecessary emergency department visits, reduce health care costs, optimize patient outcome, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with a suspected exposure to ethylene glycol by (1) describing the process by which the exposure might be evaluated, (2) identifying the key decision elements in managing the case, (3) providing clear and practical recommendations that reflect the current state of knowledge, and (4) identifying needs for research. This guideline is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care, considering all of the circumstances involved. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. (1) A patient with exposure due to suspected self-harm, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the dose reported (Grade D). (2) Patients with inhalation exposures will not develop systemic toxicity and can be managed out-of-hospital if asymptomatic (Grade B). Patients with clinically significant mucous membrane irritation should be referred for evaluation (Grade D). (3) Decontamination of dermal exposures should include routine cleansing with mild soap and water. Removal of contact lenses and immediate irrigation with room temperature tap water is recommended for ocular exposures. All patients with symptoms of eye injury should be referred for an ophthalmologic exam (Grade D). (4) Patients with symptoms of ethylene glycol poisoning should be referred immediately for evaluation regardless of the reported dose (Grade C). (5) The absence of symptoms shortly after ingestion does not exclude a potentially toxic dose and should not be used as a triage criterion (Grade C). (6) Adults who ingest a "swallow" (10-30 mL), children who ingest more than a witnessed taste or lick, or if the amount is unknown of most ethylene glycol products should be referred immediately for evaluation. The potential toxic volume of dilute solutions (e.g., concentration <20%) is larger and can be estimated by a formula in the text (Grade C). (7) A witnessed taste or lick only by a child, or an adult who unintentionally drinks and then expectorates the product without swallowing, does not need referral (Grade C). (8) Referral is not needed if it has been >24 hours since a potentially toxic unintentional exposure, the patient has been asymptomatic, and no alcohol was co-ingested (Grade D). (9) Gastrointestinal decontamination with ipecac syrup, gastric lavage or activated charcoal is not recommended. Transportation to an emergency department should not be delayed for any decontamination procedures (Grade D). (10) Patients meeting referral criteria should be evaluated at a hospital emergency department rather than a clinic. A facility that can quickly obtain an ethylene glycol serum concentration and has alcohol or fomepizole therapy available is preferred. This referral should be guided by local poison center procedures and community resources (Grade D). (11) The administration of alcohol, fomepizole, thiamine, or pyridoxine is not recommended in the out-of-hospital setting (Grade D).
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PRACTICE GUIDELINE
Ethylene Glycol Exposure: an Evidence-Based Consensus
Guideline for Out-of-Hospital Management
#
E. Martin Caravati, M.D., M.P.H., Andrew R. Erdman, M.D.,
Gwenn Christianson, M.S.N., Anthony S. Manoguerra, Pharm.D.,
Lisa L. Booze, Pharm.D., Alan D. Woolf, M.D., M.P.H., Kent R. Olson, M.D.,
Peter A. Chyka, Pharm.D., Elizabeth J. Scharman, Pharm.D., Paul M. Wax, M.D.,
Daniel C. Keyes, M.D., M.P.H., and William G. Troutman, Pharm.D.
American Association of Poison Control Centers, Washington, District of Columbia, USA
In 2002, poison centers in the US reported 5816 human
exposures to ethylene glycol. A guideline that effectively
determines the threshold dose for emergency department referral
and need for pre-hospital decontamination could potentially
avoid unnecessary emergency department visits, reduce health
care costs, optimize patient outcome, and reduce life disruption
for patients and caregivers. An evidence-based expert consensus
process was used to create this guideline. Relevant articles were
abstracted by a trained physician researcher. The first draft of
the guideline was created by the primary author. The entire panel
discussed and refined the guideline before distribution to
secondary reviewers for comment. The panel then made changes
based on the secondary review comments. The objective of this
guideline is to assist poison center personnel in the out-of-hospital
triage and initial management of patients with a suspected
exposure to ethylene glycol by 1) describing the process by which
the exposure might be evaluated, 2) identifying the key decision
elements in managing the case, 3) providing clear and practical
recommendations that reflect the current state of knowledge, and
4) identifying needs for research. This guideline is based on an
assessment of current scientific and clinical information. The
panel recognizes that specific patient care decisions may be at
variance with this guideline and are the prerogative of the patient
and health professionals providing care, considering all of the
circumstances involved. Recommendations are in chronological
order of likely clinical use. The grade of recommendation is in
parentheses. 1) A patient with exposure due to suspected self-
harm, misuse, or potentially malicious administration should be
referred to an emergency department immediately regardless of
the dose reported (Grade D). 2) Patients with inhalation
exposures will not develop systemic toxicity and can be managed
out-of-hospital if asymptomatic (Grade B). Patients with clinical-
ly significant mucous membrane irritation should be referred for
evaluation (Grade D). 3) Decontamination of dermal exposures
should include routine cleansing with mild soap and water.
Removal of contact lenses and immediate irrigation with room
temperature tap water is recommended for ocular exposures. All
patients with symptoms of eye injury should be referred for an
ophthalmologic exam (Grade D). 4) Patients with symptoms of
ethylene glycol poisoning should be referred immediately for
evaluation regardless of the reported dose (Grade C). 5) The
absence of symptoms shortly after ingestion does not exclude a
potentially toxic dose and should not be used as a triage criterion
(Grade C). 6) Adults who ingest a ‘‘swallow’’ (10 30 mL),
children who ingest more than a witnessed taste or lick, or if the
amount is unknown of most ethylene glycol products should be
referred immediately for evaluation. The potential toxic volume
of dilute solutions (e.g., concentration < 20%) is larger and can be
estimated by a formula in the text (Grade C). 7) A witnessed taste
or lick only by a child, or an adult who unintentionally drinks and
then expectorates the product without swallowing, does not need
referral (Grade C). 8) Referral is not needed if it has been >24
hours since a potentially toxic unintentional exposure, the patient
has been asymptomatic, and no alcohol was co-ingested (Grade
D). 9) Gastrointestinal decontamination with ipecac syrup, gastric
lavage or activated charcoal is not recommended. Transportation
to an emergency department should not be delayed for any
decontamination procedures (Grade D). 10) Patients meeting
referral criteria should be evaluated at a hospital emergency
department rather than a clinic. A facility that can quickly obtain
an ethylene glycol serum concentration and has alcohol or
fomepizole therapy available is preferred. This referral should be
guided by local poison center procedures and community
resources (Grade D). 11) The administration of alcohol,
fomepizole, thiamine, or pyridoxine is not recommended in the
out-of-hospital setting (Grade D).
Keywords Ethylene glycol/poisoning; Poison control centers/
standards; Practice guidelines
#
Guidelines for the Management of Poisoning. Supported in full
by Cooperative Agreement 8 U4BHS00084 between the American
Association of Poison Control Centers and the Maternal and Child
Health Bureau, Health Resources and Services Administration,
Department of Human Services.
Address correspondence to American Association of Poison
Control Centers, 3201 New Mexico Ave. NW, Suite 3301,
Washington, DC 20016, USA; E-mail: info@aapcc.org
327
Clinical Toxicology, 43:327–345, 2005
Copyright D Taylor & Francis Inc.
ISSN: 0731-3810 print / 1097-9875 online
DOI: 10.1080/07313820500184971
Order reprints of this article at www.copyright.rightslink.com
INTRODUCTION
Scope of the Problem
Ethylene glycol has been utilized in a variety of industrial
and home settings since the 1930s. Today it is used primarily
as antifreeze for vehicle radiators and some water pipe
systems. It is not present in all radiator antifreeze products,
however, as some contain propylene glycol as the active
ingredient. It is readily available to people of all ages in the
home and workplace. Human poisoning has occurred in
isolated cases and in epidemics. In 1987, 29 patients had
symptoms of toxicity after drinking a beverage unintentionally
contaminated with ethylene glycol at a picnic (1). A
summertime cluster of 22 intentional ingestions occurred in
Illinois in 1996 that might have been related to descriptions in
the mass media of an index case (2).
In 2002, poison centers in the United States reported 5816
human exposures to ethylene glycol. The routes of exposure
included ingestion (54%), dermal (19%), inhalation (15%),
and ocular (11%). Of these exposures, 4767 (82%) were
unintentional and 676 (12%) involved children under 6 years
of age. The most common sites of exposure were the home
(75%) and workplace (10%). Chronic dermal or inhalation
exposures were uncommon; 94% of reported exposures were
acute in nature (3). Acute unintentional ingestions are as-
sociated with less risk of toxicity than intentional ingestions.
An analysis of the American Association of Poison Control
Centers’ Toxic Exposure Surveillance System (TESS) data-
base for ingestion of ethylene glycol by all ages revealed that
unintentional ingestions were 37 times more likely than
intentional ingestions to have no effect or minor effects
(Table 1). Nevertheless, unintentional ingestions are still
potentially dangerous because 6.3% (129/2041) of them were
associated with moderate or severe clinical toxicity (3).
In 2003, 2241 patients were evaluated in healthcare
facilities and 23 died according to TESS. Ethylene glycol
was the most common chemical agent responsible for deaths
reported by US poison centers in 2003 (4). These deaths were
exclusively in adolescents and adults. No deaths of patients
under the age of 12 years or from unintentional exposure were
reported by poison centers to TESS from 1985 through 2002
(WA Watson, PharmD, Associate Director, AAPCC, written
communication, May 2004).
Substances and Definitions
This guideline is intended to address exposures to ethylene
glycol only. Guidance for exposures to other glycols, such as
propylene glycol and diethylene glycol, or glycol ethers is not
included in this document. The term ‘‘out-of-hospital’’ is
defined as the period before a patient reaches a health care
facility. An acute ingestion is defined as any number of
ingestions that occur within a period of no more than 8 hours.
A child is defined as a person less than 6 years of age.
Current Poison Center Practice and Importance
of the Guideline
The triage and management of unintentional ethylene
glycol ingestion by US poison centers appears to be variable.
The guideline consensus panel solicited local referral and
management guidelines for ethylene glycol from 64 US poison
centers in 2003 and received 13 documents (Table 2). One
state poison center system (four poison centers) and 12 other
individual poison centers submitted guidelines. Eleven centers
specifically replied that they did not have guidelines for
ethylene glycol. The remaining 40 centers did not respond to
the request. Review of the submitted guidelines revealed that
there were referral thresholds for ingestion of ‘‘any amount,’’
‘‘a mouthful,’’ an amount that exceeded a hypothetical
calculated serum concentration, and various weight-based
formulas (0.05 2 mL/kg of ethylene glycol). Out-of-hospital
decontamination was not addressed by most of the guidelines
but ipecac-induced emesis was recommended by two guide-
lines in certain situations. This wide range of approaches
suggests the need for a clear, evidence-based guideline. A
guideline that effectively determines the threshold dose for
emergency department referral and need for pre-hospital
decontamination could potentially avoid unnecessary emer-
gency department visits, reduce health care costs, optimize
patient outcome, and reduce life disruption for patients and
TABLE 1
Known outcome by reason for ingestion of ethylene glycol for all ages 2000 2002
Reason No or minor effect (% of total)
Moderate, major, or death
effect (% of total) Total (%)
Unintentional 1912 (63) 129 (4) 2041 (67)
Intentional 286 (9) 715 (24) 1001 (33)
Total 2198 (72) 844 (28) 3042
Unintentional ingestions were 37 times more likely to have no effects or minor effects than intentional ingestions of ethylene glycol. Odds
ratio= 37.1 (95% CI: 29.6, 46.4).
From Ref. (3).
E. M. CARAVATI ET AL.
328
caregivers. In addition, a more consistent approach to this
exposure might facilitate research.
Sources and Physical Properties of Ethylene Glycol
Ethylene glycol (C
2
H
6
O
2
; 1,2-ethanediol; CAS Reg. No.
107-21-1) is a polyhydric alcohol solvent. It is a clear, sweet-
tasting, viscous and odorless liquid. Its physical properties
include: specific gravity 1.12 g/mL, boiling point 198°C
(388°F), vapor pressure 0.092 mmHg at 25°C and evaporation
rate less than 0.01 (relative to butyl acetate= 1). Many
commercial antifreeze products contain a yellow-green
fluorescent dye (sodium fluorescein) to allow for detection
of coolant system leaks.
Ethylene glycol is produced commercially in large amounts
and is widely used as antifreeze (concentration range, 80
99%) or deicing solutions (concentration range, 3 40%) for
cars, boats, and aircraft. It is also used in the chemical
synthesis of plastics, films, and solvents. It can be found in
many consumer products including solvents, paints, and
coolants (concentration range, 20 95%).
Pharmacokinetics and Pathophysiology of
Ethylene Glycol
Ethylene glycol has an oral bioavailability in rodents of
92 100% (5). It is rapidly absorbed from the gastrointestinal
tract in humans as symptoms of intoxication and elevated
TABLE 2
Summary of US Poison Control Center guidelines 2003
Poison
Center
Recommend
ipecac?
Recommend
gastric lavage?
Recommend
charcoal?
Observe at
home dose
Referral
(toxic) dose
Toxic serum
ethylene glycol
(mg/dL)
1 No If < 1 hr after
ingestion
No Accidental taste
or < mouthful
2 cc/kg or
>mouthful
25
2 If estimated serum
level <20 mg/dL
Estimated serum
level >20 mg/dL
20
3 Yes, if
<20 minutes
from ingestion
If < 1 hr 20
4 20
5 If < 1 hr Adult mouthful of
‘‘50% diluted’’
product
Adult: >mouthful
of >50%
solution.
20
-All children
6 If < 2 hr No Treat 0.2 cc/kg
100%
20
7 For large
ingestion if
ED> 30 minutes
away.
‘‘iron-clad lick
or taste,’’
<0.5 mL total
-Adult: 15 cc of
100% solution or
one mouthful
-Child: 35 cc
or >‘‘taste’’
8 Nasogastric
suction if
recent
ingestion
‘‘Consider’’ Estimated peak
serum level
<25 mg/dL
Estimated peak
serum level
25 mg/dL
25
9 Ingests
<0.05 mL/kg
-All ingestions of
95% EG or
0.05 cc/kg
20
10 No If < 1 hr No 20
11 ‘‘Consider’’ Taste or lick only Full swallow 20
12 No If < 2 hr Yes, for
co-ingestants
All ingestions
0.1 mL/kg
25
13 No No Witnessed
taste only
>lick/taste in
child or adult
20
329
OUT-OF-HOSPITAL MANAGEMENT OF ETHYLENE GLYCOL EXPOSURE
serum concentrations have occurred 20 30 minutes after
ingestion (6,7). It has a relatively low volume of distribution
(0.5 0.8 L/kg). Twenty percent of the parent compound is
eliminated unchanged in the urine. The other 80% is
metabolized in the liver by alcohol dehydrogenase to
glycoaldehyde and then by aldehyde dehydrogenase to several
acid metabolites (glycolic acid, glyoxylic acid, oxalic acid).
These metabolites are responsible for the anion gap metabolic
acidosis, calcium oxalate crystals, and renal injury that occur
with ethylene glycol poisoning (813). The glycolic acid
metabolite is the only metabolite that appreciably accumulates
in the blood and it appears to be primarily responsible for the
metabolic acidosis (11 14). Glycolic acid is converted to
glyoxylic acid, which is toxic to renal tubular cells (15).
Glyoxylic acid is metabolized to oxalic acid, which can
combine with calcium to form calcium oxalate crystals and
cause subsequent hypocalcemia (6,1618). Thiamine and
pyridoxine facilitate the conversion of glyoxylic acid to a-
hydroxy-b-ketoadipic acid, glycine, and hippuric acid, which
are considered less toxic than oxalate. The elimination half-
life of the parent compound is 38.5 hours (11,19,20).
Fomepizole (4-methylpyrazole) is an inhibitor and alcohol a
preferred substrate of alcohol dehydrogenase. They will
increase the first-order elimination half-life of ethylene glycol
to approximately 17 hours in patients with normal renal
function (19,20).
The clinical manifestations of ethylene glycol poisoning
range from being initially asymptomatic to seizures, coma,
renal failure, and cardiovascular collapse (6,18,21). The
etiology of the central nervous system, metabolic, cardiopul-
monary, and renal toxicities are primarily due to the formation
and accumulation of toxic intermediary metabolites, especially
aldehyde metabolites (9), glycolic acid, and to a lesser extent
oxalate production and excretion (8,22). Unchanged ethylene
glycol is thought to be responsible for the initial signs and
symptoms of intoxication, which include altered mental status,
slurred speech, and ataxia (23). Gastrointestinal symptoms
such as nausea, vomiting, and abdominal pain are often
present soon after ingestion (21). Infants can demonstrate
irritability, lethargy, vomiting, pallor, hypotonia, and poor
feeding (24,25). A patient who presents with coma, hyper-
kalemia, seizures, and severe acidosis has a poor prognosis.
Considerations for Estimating a Potentially
Toxic Ingestion
Determining a Potentially Toxic Serum Concentration
as a Basis for Referral
Determining the minimum potentially toxic ethylene glycol
serum concentration could help guide poison centers in
determining a potentially toxic dose. A peak serum concen-
tration of 20 mg/dL or greater has been cited as potentially
toxic and treatment has been recommended at this threshold
(7,18). The source of this toxic threshold concentration is not
clear, as human studies have not specifically addressed this
parameter. However, based on the few available case reports
(level 4) of patients presenting early with serum concen-
trations less than this, it seems reasonable. One case report
described a 2 1/2-year-old girl who presented 3 hours after
ingestion of an unknown amount of antifreeze. Her ethylene
glycol serum concentration was 9.3 mg/dL. She developed
metabolic acidosis (serum bicarbonate 12.5 mEq/L, anion gap
17) and elevated urine oxalate and glycolate concentrations
but no renal injury (26). Two adults presented 1.5 hours after
ingestion with ethylene glycol concentrations of 13 and 9 mg/
dL. These concentrations are well below the traditional toxic
serum concentration. The patients developed mild anion gap
acidosis (bicarbonate 19 mEq/L, anion gap 18) and no
metabolic abnormalities, respectively (13). An adult presented
4 hours after ingestion with a serum concentration of 8 mg/dL,
mild metabolic acidosis (bicarbonate 17 mEq/L), and no renal
failure but with a serum alcohol of 27 mg/dL that might have
affected the outcome. Another adult presented 10 hours after
ingestion with an ethylene glycol concentration 6 mg/dL,
arterial pH 7.35, bicarbonate 16 mEq/L, and elevated serum
glycolate (5.1 mmol/L) and no renal failure (13). Thus, an
estimated peak ethylene glycol serum concentration of less
than 20 mg/dL appears relatively safe based on limited case
reports. Patients who develop clinically important toxicity
such as altered mental status, renal injury, seizures, hypoten-
sion, or respiratory depression routinely present either late
(e.g., greater than 4 6 hours after ingestion) or early with
serum concentrations greater than 20 mg/dL (12,13,27,28).
Data could not be found on the outcome of untreated
patients with serum concentrations greater than 20 mg/dL.
Whether the threshold peak concentration for potential
toxicity is greater than 20 mg/dL is not known. This toxic
concentration estimate does not account for possible risk
factors such as pre-existing renal failure. Peak ethylene
glycol serum concentrations occur early after ingestion
(i.e., 30 60 minutes) and this must be taken into account
when obtaining serum concentrations in patients with
delayed presentation.
Volume of a Swallow for Dose Estimation
Ethylene glycol is a liquid; therefore, the fixed dosage units
associated with tablets or capsules do not exist, making dose
estimates more difficult and unreliable. The liquid volume in
an unmarked container before ingestion is often unknown. The
estimated dose is often based on whether more or less than a
‘‘swallow’’ or ‘‘mouthful’’ was ingested. The volume of a
swallow of water has been investigated in children, adoles-
cents, and adults (29 33). The estimated average volume of a
swallow in a child 18 66 months of age is 5 10 mL with a
range of 1 29 mL. The average swallow volume in children
aged 6 9 years is also approximately 10 mL and increases to
20 mL in 11- to 13-year-old boys. The volume of a swallow in
children less than 18 months of age has not been studied.
Older males (age greater than 12 years) demonstrate larger
swallow volumes compared to females of similar age (30).
E. M. CARAVATI ET AL.
330
Adolescent males can consume up to 40 mL in a single
swallow (30). The average volume of a swallow in an adult
has been estimated as 25.6 mL (32). Along with the
concentration of the ethylene glycol product, knowledge of
the potential volume of a swallow aids in estimating the dose
of ethylene glycol ingested and potential serum concentration
as demonstrated in the next section.
Estimating the Peak Ethylene Glycol Serum
Concentration from Dose
Based on standard pharmacokinetic principles and assuming
complete absorption (F =1), a hypothetical peak ethylene
glycol serum concentration can be conservatively estimated if
the volume ingested, ethylene glycol concentration, and patient
weight are known. Although not validated in human studies of
ethylene glycol ingestion, a common formula (34) used is:
Formula 1: Estimated peak ethylene glycol serum concentra-
tion (mg/dL)= [volume ingested (mL) concentration of
ethylene glycol (%) specific gravity (g/mL)]/[volume of
distribution (L/kg) patient weight (kg)]. The V
d
is 0.6 L/
kg and specific gravity is 1.12 g/mL for ethylene glycol.
Use a whole number, not a fraction for product concentra-
tion (e.g., 95 not 0.95).
An estimate of the potential peak serum concentration
resulting from ingestion can be made using the above formula
as in the following examples for a child and an adult:
1. A 2-year-old, 10-kg child who ingests ‘‘a small swallow’’
(estimated volume 5 mL) of 95% ethylene glycol solution
could potentially attain a serum concentration of (5
mL 95 1.12 g/mL)/(0.6 L/kg 10 kg) or 88 mg/dL.
The same volume of a 25% solution could result in a serum
concentration of 23 mg/dL.
2. A 70-kg man who ingests ‘‘one swallow’’ (estimated
volume 25 mL) of 95% ethylene glycol solution could
potentially attain a serum concentration of (25
mL 95 1.12 g/mL)/(0.6 L/kg 70 kg) or 63 mg/dL.
The same volume of a 25% solution would result in a
serum concentration of 17 mg/dL.
It appears that the pharmacokinetics of ethylene glycol
and the average swallow volumes of children and adults
support the likelihood of ‘‘one swallow’’ and possibly less to
produce a potentially toxic serum concentration of 20 mg/dL
or greater over a range of product concentrations (e.g.,
25 100%).
By rearranging formula 1 and using a potential toxic serum
concentration of 20 mg/dL, a toxic dose in mL per kg can be
estimated with varying product concentrations:
Formula 2: Potential toxic dose (mL/kg)= (0.6 L/kg 20 mg/
dL)/[product concentration (%) 1.12] =10.7/product con-
centration (%).
Using formula 2, the minimum toxic oral dose of a 99%
ethylene glycol solution should be approximately 0.1 mL/kg. If
the product is known to be very dilute, such as a 3% deicing
solution, then the potential toxic dose would be greater, ap-
proximately 3.5 mL/kg. These calculations rely on the accuracy
of ingestion history, a single exposure, no complicating co-
ingestants (e.g., alcohol), complete absorption, and no elimi-
nation or hepatic metabolism. The formula is based on several
pharmacokinetic assumptions but can provide a framework for
risk estimation until more valid human data are available. Over-
reliance on the calculation to the exclusion of other historical or
clinical data may lead to erroneous decision-making.
Intended Users of This Guideline
The intended users of this guideline are personnel in US
poison centers. This guideline has been developed for the
conditions prevalent in the United States. While the toxicity of
ethylene glycol is not expected to vary in a clinically
significant manner in other nations, the out-of-hospital
conditions could be much different. This guideline should not
be extrapolated to other settings unless it has been determined
that the conditions assumed in this guideline are present.
Objective of This Guideline
The objective of this guideline is to assist poison center
personnel in the appropriate out-of-hospital triage and initial
management of patients with a suspected exposure to ethylene
glycol by 1) describing the process by which an exposure to
ethylene glycol might be evaluated, 2) identifying the key
decision elements in managing cases of ethylene glycol
exposure, 3) providing clear and practical recommendations
that reflect the current state of knowledge, and 4) identifying
needs for research. This guideline applies to exposure to
ethylene glycol alone. Exposure to additional substances could
require different referral and management recommendations
depending on the combined toxicities of the substances.
This guideline is based on an assessment of current
scientific and clinical information. The expert consensus
panel recognizes that specific patient care decisions may be at
variance with this guideline and are the prerogative of the
patient and health professionals providing care, considering all
of the circumstances involved.
METHODOLOGY
The methodology used for the preparation of this guideline
was developed after reviewing the list of key elements of
guidelines described by Shaneyfelt et al. (35). An expert
consensus panel was established to oversee the guideline
development process (Appendix 1). The American Associa-
tion of Poison Control Centers (AAPCC), the American
Academy of Clinical Toxicology (AACT), and the American
College of Medical Toxicology (ACMT) appointed members
of their organizations to serve as panel members. To serve on
331
OUT-OF-HOSPITAL MANAGEMENT OF ETHYLENE GLYCOL EXPOSURE
the expert consensus panel, an individual had to have an
exceptional track record in clinical care and scientific research
in toxicology, board certification as a clinical or medical
toxicologist, significant US poison center experience, and be
an opinion leader with broad esteem. Two specialists in poison
information were included as full panel members to provide
the viewpoint of potential end-users of the guideline.
Literature Search
The National Library of Medicine’s MEDLINE database
was searched (1966 September 2003) using ethylene glycol as
a MeSH term with the subheadings poisoning (po) or toxicity
(to), limited to humans. The MEDLINE and PreMEDLINE
(1966 September 2003) were searched using ethylene glycol
as textwords (title, abstract, MeSH term, CAS registry) plus
poison
*
or overdos
*
or tox
*
, limited to humans. This same
process was repeated in International Pharmaceutical Abstracts
(1970September 2003, excluding abstracts of meeting
presentations), Science Citation Index (1977 September
2003), Database of Abstracts of Reviews of Effects (accessed
September 2003), Cochrane Database of Systematic Reviews
(accessed September 2003), and Cochrane Central Register of
Controlled Trials (accessed September 2003). Reactions
(1980 September 2003), the ethylene glycol poisoning man-
agement in POISINDEX (36), and the bibliographies of re-
covered articles were reviewed to identify previously
undiscovered articles. Furthermore, North American Congress
of Clinical Toxicology abstracts published in the Journal of
Toxicology-Clinical Toxicology (1995 2003) were reviewed
for original human data. The chapter bibliographies in four
major toxicology textbooks (37 40) were reviewed for cita-
tions of additional articles with original human data. Finally,
The Toxic Exposure Surveillance System (TESS) maintained
by the American Association of Poison Control Centers, was
searched for deaths resulting from unintentional ethylene glycol
poisoning or any deaths from ethylene glycol poisoning in
children. These cases were abstracted for use by the panel.
Article Selection
The recovered citations were entered into an EndNote
library and duplicate entries were eliminated. The abstracts of
these articles were reviewed, looking specifically for those that
dealt with estimations of exposure doses with or without
subsequent signs or symptoms, time of onset of symptoms, and
management techniques that might be suitable for out-of-
hospital use (e.g., gastrointestinal decontamination). Articles
were excluded that didn’t meet the preceding criteria, didn’t
add new data (e.g., some reviews, editorials), or that
exclusively described inpatient-only procedures (e.g., dialysis).
Data Extraction
All articles retrieved by the search were reviewed by a single
abstractor. Each article was assigned a level of evidence score
from 1 to 6 using the rating scheme developed by the Centre for
Evidence-based Medicine at Oxford University (Appendix 2);
the complete paper was reviewed for original human data
regarding the toxic effects of ethylene glycol or original human
data directly relevant to the out-of-hospital management of
patients with ethylene glycol toxicity or overdose. Relevant
data (e.g., dose of ethylene glycol, resultant effects, time of
onset of effects, therapeutic interventions or decontamination
measures given, efficacy or results of any interventions, and
overall patient outcome) were compiled into a table and a brief
summary description of each article was written. This full
evidence table is available at http://www.aapcc.org/DiscGuide-
lines/EGEvidenceTable.pdf. The completed table of all ab-
stracted articles was then forwarded to the panel members for
review and consideration in developing the guideline. Every
attempt was made to locate significant foreign language articles
and have their crucial information translated and tabulated.
Copies of all of the articles were made available for reading by
the panel members on a secure AAPCC website.
Guideline Writing and Review
A guideline draft was prepared by the primary author. The
draft was submitted to the expert consensus panel for comment.
Using a modified Delphi process, comments from the expert
consensus panel members were collected, copied into a table of
comments, and submitted to the primary author for response.
The primary author responded to each comment in the table and,
when appropriate, the guideline draft was modified to
incorporate changes suggested by the panel. The revised
guideline draft was again reviewed by the panel and, if there
was no strong objection by any panelist to any of the changes
made by the primary author, the draft was prepared for the
external review process. External review of the second draft
was conducted by distributing it electronically to AAPCC,
AACT, and ACMT members and the secondary review panel.
The secondary review panel consisted of representatives from
the federal government, public health, emergency services,
pediatrics, pharmacy practice, and consumer organizations
(Appendix 3). Comments were submitted via a discussion
thread on the AAPCC web site or privately through email
communication to AAPCC staff. All submitted comments were
stripped of any information that would identify their sources,
copied into a table of comments. The primary author responded
to each comment in the table and his responses and subsequent
changes in the guideline were reviewed and accepted by the
panel. Following a meeting of the expert consensus panel, the
final revision of the guideline was prepared.
EVALUATION OF EVIDENCE
Route of Exposure
Inhalation
Exposure to ethylene glycol vapor can occur in the
occupational or private setting. One situation might be a
E. M. CARAVATI ET AL.
332
leaking automobile radiator with potential vapor exposure to
the occupant via the ventilation system. Fifteen percent
(n= 911) of ethylene glycol exposures reported to US poison
centers in 2002 involved inhalation. There were no moderate
or major clinical effects or deaths associated with this route of
exposure (3).
One controlled study of ethylene glycol vapor exposure in
humans has been published (level 2b). Twenty male prisoner
volunteers were placed in an enclosed room for 20 22 hours
per day for 30 days. Aerosolized ethylene glycol (1 5 m
droplets) was continuously vented into the room. A control
group of 14 prison volunteers were kept in another room of the
same building. A peak air concentration of 188 mg/m
3
was
tolerated for only 15 minutes and 244 mg/m
3
for only 1
2 minutes due to mucous membrane irritation. An air
concentration of 308 mg/m
3
was completely intolerable. The
mean weekly air concentration of ethylene glycol ranged from
17 to 49 mg/m
3
. There were no differences in the urine or
serum ethylene glycol concentrations, serum bicarbonate
concentration, and serum electrolytes between the exposed
and control groups. The serum ethylene glycol ranged from
9.4 to 18.2 mg/dL for the exposure group and 8 to 21.0 mg/dL
in the control group (41).
Increasing the air concentration by almost two-fold was not
associated with an increase in serum or urine ethylene glycol
concentration in the study group. Symptoms of nose and throat
irritation, slight headache, and low backache were reported.
No renal impairment or metabolic abnormalities were noted.
One possible limitation of the study is the accuracy of the
serum and urine ethylene glycol concentrations.
Mice and rats were exposed to ethylene glycol vapor
concentration of 400 mg/m
3
for 8 hours/day for up to
16 weeks and did not demonstrate any histological evidence
of toxicity. Ethylene glycol blood concentrations were not
measured (42).
Based on pharmacokinetic assumptions, an exposure to an
ethylene glycol concentration of 600 mg/m
3
for more than 24
hours would be required to achieve a serum concentration of
30 mg/dL in an adult (43). Humans do not tolerate this vapor
concentration due to mucous membrane irritation (41). The
panel concluded that exposure to ethylene glycol vapor can
result in mucus membrane irritation but has not been reported
to cause systemic toxicity.
Dermal
Skin exposure was the route in 19% (n= 1155) of ethylene
glycol cases reported to US poison centers in 2002 (3).
Ethylene glycol has not been reported to be a skin irritant. No
human cases of systemic toxicity from dermal absorption of
ethylene glycol were identified from the literature review. In
vitro experiments suggest that ethylene glycol can be absorbed
when left in prolonged contact with human skin. In one study,
approximately 27% of the applied dose (8 mg/cm
2
) was
absorbed over a 24-hour period (44). The panel concluded that
absorption of ethylene glycol through intact skin is minimal
and not clinically significant.
Ocular
Ocular exposures comprised 11% of ethylene glycol related
calls to US poison centers in 2002 (3). The only published
report of a human eye exposure occurred in 1951. In that case,
a ‘‘concentrated’’ ethylene glycol antifreeze solution splashed
into the eye of a gasoline station attendant and resulted in
eyelid edema, conjunctival inflammation, chemosis, keratitis,
and iritis (45). Animal studies have demonstrated that splashes
to rabbit eyes result in immediate discomfort and temporary
conjunctival inflammation with significant corneal damage.
Repeated exposure to concentrations of 20 40% cause
corneal injury in rabbit eyes (46). The panel concluded that
eye exposure to ethylene glycol can result in conjunctival or
corneal injury.
Ingestion
Ingestion was the most common route of exposure (54%)
for ethylene glycol cases reported to US poison centers in
2002 (3). All systemic toxicity and fatalities reported in the
literature occurred by this route. The remaining key decision
elements all relate to the ingestion of ethylene glycol.
In 1991, the addition of a bittering agent (denatonium
benzoate) to consumer automotive products containing more
than 10% ethylene glycol or more than 4% methanol was
mandated by the Oregon Legislature. A study of the Oregon
Poison Center database (level 4) did not demonstrate a
decrease in the frequency of unintentional childhood expo-
sures related to this change in product formulation (47). The
effect on adult exposures was not evaluated in the study.
Patient Age and Intent
There were no articles identified that directly addressed the
relationship between patient age and intent (e.g., unintentional
vs. suicidal ingestion). A review of ethylene glycol ingestions
for all ages with known outcomes reported to TESS from
2000 2002 revealed that 6.3% of unintentional and 71% of
intentional ingestions resulted in a moderate effect, major
effect, or death (Table 1) (3). A review of US poison center
fatality data for the 18-year period 1985 2002 did not find
any suspected suicides or deaths from ethylene glycol reported
in children under the age of 12 years. There were 74 ethylene
glycol fatalities reported to the TESS database during 2001
2002. All reported fatalities occurred in patients 17 years of
age or older. The intent was suicide in 80%, unknown in 12%,
and intentional misuse/abuse in 3% of these cases (3). Other
published reports of fatalities found in the literature review
were primarily adults with suicidal or intentional misuse intent
(8,16,48 50). Use of products contaminated with ethylene
glycol (1) or mislabeled as other products have also resulted in
serious toxicity and death. Twelve adolescents (aged 12
15 years) mistakenly drank antifreeze (range 30 200 mL)
333
OUT-OF-HOSPITAL MANAGEMENT OF ETHYLENE GLYCOL EXPOSURE
thinking it was wine. A range of clinical toxicity occurred,
including the death of a 14-year-old boy (level 4) (21). Cases
of intentional administration to infants resulting in severe
toxicity have also been reported (24,25). The panel noted that
it is widely believed among poison centers that older children
and adults are much more likely to have suicidal or homicidal
intent. The earliest age at which suicidal intent might first be
involved is not known but is very unlikely for children less
than 6 years old. In 2003, only 119 of 1,227,381 (0.01%)
poison exposures in children less than 6 years old reported to
TESS were coded as suicidal intent and it is possible that these
were coding errors (3).
The panel concluded that ingestions secondary to self-
harm, intentional misuse, or malicious intent result in severe
outcomes (e.g., moderate, major effect or fatality) much more
frequently than unintentional ingestions. This is likely to be a
consequence of a larger dose and delayed time to treatment.
Onset of Symptomatic Toxic Effects
The precise time course for the onset of effects after
ingestion of ethylene glycol was extremely difficult to
determine from the literature. The wide range of doses,
effects of co-ingestants, historical inaccuracies in reported
dose and time of ingestion, and lack of out-of-hospital
monitoring make this assessment difficult. In many articles,
only those symptoms that were observed at hospital presen-
tation were noted, but symptom onset likely occurred before
presentation. For such cases only an upper time limit for onset
of effect can be assigned. For example, patients who presented
12 hours after ingestion with coma would be labeled as having
had their effects occur less than 12 hours after ingestion.
No level 1 3 studies were found that investigated the time
of onset of effects after acute ingestion. Four case series (level
4) contained onset of effect data but it was not the primary
goal of the studies (12,13,27,28). A retrospective review of 11
patients with ethylene glycol poisoning seen at two hospitals
over a 4 5 year period noted both time and the specific
clinical effects at presentation to the hospital. The onset of
symptoms out-of-hospital was not addressed. Patients were
grouped into those presenting less than 12 hours after
ingestion (n =6) and those presenting more than 12 hours
after ingestion (n= 5, range 48 120 hours). Thus, the
maximum time at which clinical effects could have possibly
developed after ingestion was 120 hours. Patients who
presented within 10 hours of exposure had fewer complica-
tions than those who presented 12 or more hours after
exposure (28). A retrospective case series of seven patients
noted that patients presenting 12 hours or longer after
ingestion developed renal failure and required more prolonged
hospitalization (27). In a prospective case series, seven
patients presented between 3.5 and 21.5 hours and three at
unknown times after ingestion, suggesting a maximum time of
21.5 hours to symptom onset (12). A retrospective review of
39 patients found that the longer the delay to presentation, the
more severe the metabolic acidosis and outcome. The time to
presentation ranged from 3 to 30 hours (13).
There were seven patients described in seven articles (level
4) in which the exact time of effect onset was documented
(6,7,9,51 54). None of these patients had ingested alcohol and
only one had taken co-ingestants (diazepam and caffeine) (52).
Clinical effects began within 30 minutes to 6 hours for six of
the seven cases. Symptoms began 2 days after ingestion in one
case (54).
Two teenaged boys drank 1 2 ounces of antifreeze at an
evening party and ‘‘remained well until the morning’’ when
they complained of dizziness, poor coordination, confusion,
and urinary difficulty. They developed calcium oxalate
crystalluria, metabolic acidosis, and renal impairment over
the next 3 days and recovered after 7 10 days (55). Five adult
male soldiers drank an antifreeze and water mixture and
developed symptoms of vomiting, stupor, and respiratory
distress within 8 hours. No antidote was administered and all
died 1832 hours after ingestion (48).
Occasionally, patients developed effects over the course of
several days. One patient did not present to a medical facility
for up to 11 days after the acute exposure but the time of onset
of symptoms was not documented (56). Whether symptoms
actually developed earlier in some patients but were not severe
enough to prompt them to seek medical care is unknown.
No studies were identified that evaluated the correlation
of serum ethylene glycol concentration with symptoms. Adult
and pediatric patients with relative lack of central nervous
system symptoms and documented serum ethylene glycol
concentrations are listed in Tables 3 and 4, respectively.
These cases indicate that patients may have elevated se-
rum ethylene glycol concentrations and not manifest concur-
rent neurological symptoms suggestive of the severity of
the intoxication.
The expert consensus panel concluded that after an acute
ingestion most clinical effects develop within hours but can
be delayed for days, particularly if alcohol is also ingested.
The absence of symptoms in the hours following a po-
tentially toxic dose does not preclude toxicity. Referral for
evaluation should not be withheld based on the absence of
symptoms unless it has been more than 24 hours after an
unintentional exposure. All patients with symptoms attributed
to ethylene glycol should be referred to an emergency
department for evaluation.
Chronic Dosing
There were no level 1 3 studies of ethylene glycol toxicity
from chronic or repeated ingestion. In one case report, a
patient was given ‘‘repeated’’ doses of an ethylene glycol-
contaminated beverage and died (level 4) (13). There is
insufficient evidence to distinguish the toxicity of chronic
versus acute ingestion. The expert consensus panel concluded
E. M. CARAVATI ET AL.
334
that all chronic or repeated ingestions of ethylene glycol
should be evaluated in an emergency department.
Toxic Dose of Ethylene Glycol by Ingestion
Evidence regarding the relationship between ethylene
glycol dose and toxicity is limited to one prospective cohort
study (level 2b), one case-control study (level 3b), many case
reports, and a few case series (level 4). The minimal toxic dose
is difficult to evaluate from the literature for several reasons.
Patient histories regarding the dose ingested can be unreliable
and are often obtained during a period of extreme emotional
stress for the patients and their family. Often, the exact
product and ethylene glycol concentration are not known or
documented. The co-ingestion of alcohol might have affected
the outcome or affected the time to presentation. In addition,
there are often confounding factors such as co-ingestion of
drugs that affect the central nervous system. In most reports,
the accuracy of the history was not addressed and the history
was not confirmed by outside sources (e.g., family members)
or objective evidence (e.g., empty product containers).
Acute Ingestion by Children
No level 1 or 2 studies were found specifically investigat-
ing a threshold dose for the development of toxicity or
containing specific dose-response information for children.
One case-control study (level 3b) of 19 children under 10
years of age demonstrated a dose-response effect. The children
drank a beverage made from a powdered soft drink mixture
that was reconstituted with water containing 9% ethylene
glycol. Ten percent of children ingesting up to 1/2 cup, 42%
consuming 1/2 to 1 1/2 cups, and 80% consuming more than 1
1/2 cups of the beverage became symptomatic with fatigue or
ataxia (Fig. 1). Serum ethylene glycol concentrations and the
volume of the cup were not reported (1).
There were an additional eight pediatric cases (level 4)
reported with dose-response information (Table 5) (5759).
The lowest published toxic doses of ethylene glycol occurred
TABLE 3
Reported cases of adult ethylene glycol toxicity with lack of CNS effects
Serum ethylene glycol (mg/dL) CNS symptoms Time since exposure Serum HCO
3
(mEq/L)
260 Unremarkable >12 hr 13
470 Nauseated 1 hr 17
6 Unremarkable 10 hr 16
13 (EtOH
*
160) Unremarkable 1.5 hr 19
8 (EtOH 27) Unremarkable 4 hr 17
343 (EtOH 84) Unremarkable 4 hr 24
77 (EtOH 215) Apprehensive > 7 hr 25
9 Unremarkable 1.5 hr 23
*
EtOH = serum alcohol concentration (mg/dL).
From Ref. (13).
TABLE 4
Ethylene glycol toxicity and CNS symptoms reported in children
Age Reason
Serum ethylene
glycol (mg/dL) CNS symptoms
Time since
exposure
Serum HCO
3
(mEq/L) Reference
8 mo Malicious 68 Lethargy, weakness 24 hr? (25)
8 mo All unintentional 384 Lethargy 3 hr 17 (57)
3.5 yr 70 Irritable, ataxia 3 hr 16 (26)
2.5 yr 9 None 3 hr 15 (26)
6 yr Not reported None 8 hr 6 (58)
4 yr Not reported None 8 hr 10 (58)
22 mo 304 Dizzy, vomiting
lethargy, or
ataxia present
among the group
Not reported 4 (59)
11 yr 133 12
7 yr 162 15
335
OUT-OF-HOSPITAL MANAGEMENT OF ETHYLENE GLYCOL EXPOSURE
in two siblings in 1954. A 6-year-old boy drank 2 3 ounces of
a 1:1 aqueous antifreeze solution (<50% ethylene glycol) and
became critically ill with central nervous system depression,
muscle spasms, metabolic acidosis (serum bicarbonate 3.0
mEq/L), and bilateral plantar extension response. He was
treated with intravenous infusion of sodium lactate and
calcium gluconate. His 4-year-old brother drank ‘‘less than
an ounce’’ of the same diluted ethylene glycol solution,
developed drowsiness and metabolic acidosis (serum bicar-
bonate 10 mEq/L), and recovered with sodium lactate
TABLE 5
Reported doses in acute ingestion of ethylene glycol by children
Product Dose % EG Age
Mitigating
factors Effect
*
Symptom
onset
y
Laboratory
confirmation Reference
Antifreeze < 1 oz Antifreeze-
water mix
(1:1)
4 yr None Moderate 17 hr No (58)
23 oz Antifreeze-
water mix
(1:1)
6 yr None Severe 17 hr No (58)
30 100 mL 95% 4 patients
713 yr
None Moderate
to severe
Not
reported
Yes (59)
<120 mL 95% 8 mo None Moderate
(dialysis)
3 hr Yes (57)
Radiator fluid ‘‘one glass’’ Antifreeze-
water mix
(unknown %)
3.5 yr None Moderate 4 hr Yes (60)
Ethylene glycol-
contaminated
beverage
None to
>1.5 cups
9% 19 children
<10 yr
None Mild to
moderate
‘‘Hours’’ No (1)
*
Mild = local symptoms only (e.g., GI or mild neurological effects); moderate= minimal acidosis or renal insufficiency; severe= coma,
severe acidosis or renal failure (e.g., requiring dialysis).
y
Maximum time of onset, symptoms were present on admission but might have begun earlier.
FIG. 1. Dose-response for 19 patients less than 10 years of age who drank an ethylene glycol-contaminated soft drink mixture (9% ethylene glycol) (1).
*
Subjects complaining of fatigue or ataxia were considered symptomatic.
E. M. CARAVATI ET AL.
336
infusion. Serum ethylene glycol concentrations were not
reported. Both boys recovered without signs of renal injury
(58). Four children drank 30 100 mL of antifreeze and
developed serum concentrations ranging from 113 to 270 mg/
dL. All four recovered after treatment with fomepizole (59).
An 8-month-old infant drank ‘‘up to 120 mL’’ of a 95%
ethylene glycol solution and developed lethargy and a serum
ethylene glycol concentration of 384 mg/dL (57).
Estimating doses in children is often unreliable, as parents
might over- or underestimate the actual ingested dose depend-
ing on the circumstances. Since the ethylene glycol concen-
tration of a ‘‘diluted’’ solution is usually unknown, it should be
assumed to be a high concentration product (e.g., greater than
20%) unless credible evidence suggests otherwise.
The expert consensus panel concluded that ingestions by
children of an unknown amount or more than a witnessed taste
or lick of concentrated (>20%) ethylene glycol solution should
be considered potentially toxic.
Acute Ingestion by Older Children,
Adolescents and Adults
No level 1 3 studies were found specifically investigating
a threshold dose for the development of toxicity or containing
specific dose-response information in older children, adoles-
cents, or adults.
Multiple case reports and case series (level 4) were found
with dose-response information (Table 6). There were two case
series that contained some dose-response data but establishing a
toxic threshold was not the primary goal of the studies. A
retrospective review of 11 patients compared patient outcome
between different types of treatment and times to presentation
(28). Partial dose information was available for only one patient
TABLE 6
Minimum reported toxic doses in acute ethylene glycol ingestion by patients 10 years of age and older
Estimated dose
Product or
%EG
Mitigating
factors Effect
*
Symptom
onset
y
Laboratory
confirmation Reference
10 mL Antifreeze History not
verified
Renal failure NR No (61)
20 mL Antifreeze None Moderate NR No (49)
25 mL Antifreeze None Moderate NR No (49)
30 mL Antifreeze None Moderate NR No (49)
30 mL Antifreeze None Severe NR No (49)
30 mL Antifreeze None Moderate NR No (21)
30 mL Antifreeze None Moderate NR No (21)
30 mL Antifreeze None Hematuria NR No (21)
1 oz Antifreeze in
mixed drink
Possible alcohol
co-ingestion
Moderate Next
morning
No (55)
50 mL Antifreeze None Death NR NT (49)
60 mL NR None Severe <68 hr EG= 0 (28)
2 oz Antifreeze in
mixed drink
Possible alcohol
co-ingestion
Moderate Next
morning
No (55)
70 90 mL 95% None Severe <20 min No (6)
70 90 mL 95% None Severe 2 hr No (6)
75 mL NR None Severe 2 days No (54)
100 mL Antifreeze Alcohol co-ingest Death 1 hr No (49)
100 mL NR Alcohol co-ingest;
alcoholic
Severe <15 24 hr Yes (14)
100 130 mL Antifreeze Alcohol co-ingest Mild NR Yes (62)
100 150 mL NR None Severe <few hr No (63)
34 oz Antifreeze in
mixed drink
Possible alcohol
co-ingestion
Death <12 hr No (55)
4 oz Antifreeze in
mixed drink
Possible alcohol
co-ingestion
Death Next
morning
No (55)
NR = not reported.
*
Mild = local symptoms only (e.g., GI); moderate= minimal systemic effects (e.g., acidosis, CNS changes, or renal insufficiency);
severe = significant systemic effects (e.g., coma, severe acidosis or renal failure requiring dialysis).
y
Maximum time to onset, symptoms were present on admission and probably began earlier.
337
OUT-OF-HOSPITAL MANAGEMENT OF ETHYLENE GLYCOL EXPOSURE
who ingested 60 mL of an ethylene glycol solution (unknown
strength) and subsequently developed severe toxicity. Factors
contributing to lethal outcomes were evaluated in a retrospec-
tive review of 17 cases of acute poisoning (50). Doses were
known for eight of the patients and were presented as a range of
250 800 mL. Unfortunately, the authors did not correlate these
doses with specific individual outcomes and, therefore, a dose-
response relationship could not be established.
The lowest amount reported to cause toxicity was a case
report of an adult ingestion of 10 mL of an unspecified
antifreeze solution. It had been taken along with cough syrup
and led to acute renal failure requiring dialysis (61). The
history of exposure was obtained retrospectively from the
patient without corroboration. The next lowest toxic dose was
20 mL of an unknown ethylene glycol product that resulted in
somnolence in one patient (49). Four adult patients ingested
20 30 mL of ‘‘pure’’ antifreeze and developed somnolence;
one developed anuria (49). Finally, there were several
published cases of adults ingesting 30 mL of antifreeze or
other ethylene glycol products resulting in clinical effects
ranging from moderate to severe (Table 6).
Most fatalities occurred as a result of suspected suicide or
misuse of ethylene glycol (3,64). In 1932, Hunt (65) suggested
that a lethal adult dose would be approximately 100 mL based
on data extrapolated from animal experiments. This estimate
has been borne out in a few reported human fatalities.
Ingestion of 50 100 mL resulted in death in two cases (49).
The expert consensus panel concluded that ingestion of
10 30 mL of a highly concentrated (80 99%) ethylene glycol
solution is potentially toxic and 50 100 mL is potentially
lethal to an older child, adolescent, or adult. There were no
reports of toxicity resulting from ingestion of less than 10 mL
in this age group.
Out-of-Hospital Detection of Ethylene Glycol by
Urine Fluorescence
Some commercial antifreeze products contain a fluorescent
dye, such as sodium fluorescein, in order to facilitate detection
of leaks by using an ultraviolet light. Adult urine can fluoresce
under ultraviolet light (Wood’s lamp) for up to 2 hours after
ingesting an amount of sodium fluorescein (0.6 mg) that is
present in 30 mL of antifreeze (66). However, false positives
can occur, particularly in children (67). Plastic urine specimen
containers have a high native fluorescence (66). A blinded
study (level 3b) of examination of urine samples with a
Wood’s lamp (ultraviolet light) for fluorescence before and
after ingestion 0.6 mg of fluoroscein had an optimal sensitivity
42%, specificity 75%, and accuracy 50% (68).
The expert consensus panel concluded that the out-of-
hospital use of ultraviolet light to diagnosis ethylene glycol
ingestion by urine fluorescence is unreliable and should not be
performed. The definitive diagnosis of ethylene glycol
poisoning in patients with a recent history of ingestion can
only be made by measuring the serum ethylene glycol
concentration (18).
Potential Out-of-Hospital Management to Prevent or
Ameliorate Ethylene Glycol Toxicity
The expert consensus panel identified potential methods for
reducing ethylene glycol toxicity in the out-of-hospital setting.
These were reducing gastrointestinal absorption and inhibiting
metabolism of absorbed ethylene glycol. Absorption could
theoretically be decreased by early gastrointestinal decontam-
ination, such as emesis, gastric aspiration, or administration of
activated charcoal soon after ingestion of large amounts.
Drugs such as alcohol or fomepizole can inhibit ethylene
glycol metabolism. No studies were found that specifically
addressed out-of-hospital decontamination or use of antidotes
or treatments.
Decontamination
Inhalation
There were no reports of significant absorption from vapor
exposure or of bystanders or rescue personnel being exposed
to ‘‘off-gassing’’ from patients exposed to ethylene glycol
vapors. The panel concluded that routine decontamination of
patients exposed to ethylene glycol vapors is not warranted.
Dermal
There are no reports of significant cutaneous effects or
systemic absorption of ethylene glycol when applied to intact
skin. The panel concluded that routine cleansing with mild
soap and water should be performed after skin or hair
exposure to ethylene glycol.
Ocular
Concentrated ethylene glycol exposure to the eye can result
in conjunctival irritation and corneal injury (45). There are no
studies of eye decontamination after exposure. The panel
concluded that ethylene glycol eye exposures should be treated
as other irritating chemical ocular exposures. Removal of
contact lenses and immediate irrigation with room temperature
tap water is recommended. All patients with symptoms of eye
injury (e.g., eye pain or foreign body sensation) after irrigation
should be referred for an ophthalmologic exam.
Ingestion
There were no level 1 3 studies that investigated the effects
of decontamination measures on ethylene glycol absorption in
the out-of-hospital or in-hospital settings. Various decontam-
ination measures such as activated charcoal, gastric lavage, and
gastric aspiration were reported in a number of case reports,
case series, and abstracts but their efficacy was impossible to
assess. There were no human studies located that assessed the
binding capacity of activated charcoal for ethylene glycol.
However, an in vitro stomach model demonstrated that 68% of
E. M. CARAVATI ET AL.
338
ethylene glycol was adsorbed by a 5:1 ratio of activated
charcoal to ethylene glycol (69). There were no reports on the
use of ipecac syrup after ethylene glycol ingestion.
The panel concluded that there was no evidence that out-of-
hospital gastrointestinal decontamination offered benefit to the
patient. Induction of emesis with ipecac syrup is not
recommended because of the potential risk of pulmonary
aspiration of gastric contents if the patient subsequently loses
consciousness. The efficacy of oral activated charcoal in
preventing the absorption of ethylene glycol has not been
adequately studied and thus is not recommended for routine
administration. Transportation to an emergency department
should not be delayed in order to attempt activated char-
coal administration.
Alteration of Ethylene Glycol Metabolism: Alcohol
and Fomepizole
Alcohol and fomepizole have been frequently used as
antidotes for ethylene glycol poisoning (17 19,57,59).
Fomepizole is approved by the Food and Drug Administration
for ethylene glycol toxicity and is administered intravenously.
There were no studies that evaluated the use of fomepizole in
the pre-hospital environment.
Alcohol has the advantage of being available without
prescription and can be administered orally. There were no
studies evaluating the out-of-hospital use of alcohol as an
antidote. However, it has been suggested that alcohol be
administered orally for the treatment of ethylene glycol
poisoning (19). One patient reportedly ingested alcohol and
antifreeze concurrently and presented 6 hours later with a
serum alcohol concentration 116 mg/dL, ethylene glycol 150
mg/dL, and no signs of acidosis (70). However, several patients
have consumed alcohol concurrently with ethylene glycol and
presented to emergency departments with evidence of
metabolic acidosis (14,49,71,72). A randomized cross-over
trial (level 1b) of oral versus intravenous alcohol in 20 human
adult male volunteers found that the mean time to peak alcohol
concentration was approximately 105 minutes after ingesting
a 20% alcohol solution (700 mg/kg) in orange juice over
10 minutes. This was about 1 hour later than the peak achieved
with intravenous administration (73). Although no subject had
clinical manifestations of hypoglycemia, it is notable that 90%
(18/20) had at least one episode of blood glucose less than
80 mg/dL and 65% (13/20) had blood glucose less than 59 mg/
dL following alcohol administration. Most of the oral group
failed to reach the target concentration of 100 mg/dL (mean
peak concentration 71 mg/dL, range 39 119 mg/dL), whereas
the mean peak concentration for the intravenous group was
104 mg/dL. Risks of oral alcohol include vomiting, hypogly-
cemia, altered mental status, lethargy, and electrolyte dis-
turbances, particularly in children (74).
The expert consensus panel concluded that the risks of out-
of-hospital administration of alcohol outweigh any demon-
strated benefits and does not recommend its routine use in this
setting. The risks and benefits of out-of-hospital use of
fomepizole are not known.
Detoxification of Ethylene Glycol Metabolites
(Glyoxylic Acid)
Thiamine and pyridoxine are cofactors that theoretically
facilitate the conversion of glyoxylic acid to metabolites less
toxic than oxalate (level 5) (9,10,17,18). Thiamine and
pyridoxine are available as over-the-counter dietary supple-
ments and as parenteral solutions. There were no level 1 3
studies evaluating the efficacy of these co-factors in the out-
of-hospital or hospital setting. There are many reports of
patients receiving cofactor supplementation during hospitali-
zation but no outcome analysis has been performed. There is
no evidence that cofactor administration alters patient
outcome and the expert consensus panel does not recommend
its use in the out-of-hospital setting.
Poison Center Referral of a Patient to an
Emergency Department
Time of Referral
Three retrospective case series (level 4) found that earlier
presentation times to the hospital were associated with a better
outcome (13,27,28). Whether this difference was due to more
rapid institution of decontamination measures, treatment
measures, or some other factor is not clear. However, another
case series (level 4) found no association between time to
presentation or treatment and clinical outcome (50). Peak
serum ethylene glycol concentrations occur early in the
intoxication (6,7).
Since the primary objective is to prevent metabolism of
ethylene glycol to its toxic metabolites, the expert consensus
panel concluded that patients who require health care
evaluation should be referred to an emergency department
immediately after exposure.
Type of Healthcare Facility and Mode of Travel
There were no studies that addressed the type of healthcare
facility to which patients should be referred or how they
should be transported. Ethylene glycol ingestion can result in
severe toxicity that requires sophisticated laboratory, clinical
assessment, and management resources.
The expert consensus panel concluded that patients should
be referred to facilities that have the ability to assess and
manage altered mental status, metabolic abnormalities, and
renal injury and to measure blood and urine laboratory
parameters in a timely manner. This requires referral to a
hospital emergency department rather than an outpatient
clinic. Facilities that can obtain ethylene glycol serum
concentrations, perform hemodialysis, and have alcohol or
fomepizole therapy available are preferred but not required.
The patient’s clinical condition, local protocols, and transpor-
tation resources should dictate the mode of transportation.
339
OUT-OF-HOSPITAL MANAGEMENT OF ETHYLENE GLYCOL EXPOSURE
CONCLUSIONS
Key Decision Elements
The expert consensus panel identified the patient’s age,
weight, intent, route of exposure, estimated dose of ethylene
glycol, time since exposure, and symptoms as critical
information needed in order to make a sound triage decision.
Patient Intent
All patients in whom suicidal or malicious intent (e.g.,
child abuse, neglect, or homicide) is known or suspected
should be referred to an emergency department for medical
evaluation regardless of the dose ingested. Unintentional
exposures have a low rate of associated clinical toxicity but
this reason alone cannot be used to exclude potential adverse
clinical effects.
Route of Exposure
Exposure to ethylene glycol can occur by inhalation,
ingestion, and dermal or eye contact. Systemic toxicity and
death has only been documented by ingestion. Inhalation of
vapors or liquid contact with the skin is very unlikely to result
in significant toxicity other than local irritation. Eye exposure
can cause localized tissue irritation or injury.
Dose of Ethylene Glycol
The minimum toxic dose has not been established for
children or adults. Limited evidence (level 4) supports
ingestion of as little as 10 to 30 mL, or a ‘‘swallow’’, of
concentrated (8099%) ethylene glycol solution as poten-
tially toxic to an adult. Likewise, children have manifested
toxic effects with ingestion of less than 30 mL of dilute
(<50%) solutions.
Time of Onset of Toxicity After Overdose
Ethylene glycol is rapidly absorbed from the gastrointes-
tinal tract and patients have become symptomatic as soon as
30 60 minutes after ingestion (6,51). There are many case
reports of delayed presentation to the hospital but assessment
of onset of symptoms before presentation was not possible. It
is possible that some patients might not become symptomatic
from metabolic acidosis or renal failure until many hours or
days after ingestion.
Presence of Symptoms
Potentially toxic serum concentrations of ethylene glycol
(e.g., 20 30 mg/dL) do not appear to reliably produce early
symptoms in children or adults. Therefore, the lack of
symptoms does not exclude a potentially toxic ingestion and
should not be used as a triage criterion unless it has been more
than 24 hours after an unintentional exposure.
Potential Out-of-Hospital Management Techniques
Decontamination
Routine decontamination of inhalation exposures is not
warranted. Dermal and ocular exposures should be decon-
taminated according to local protocols for chemical exposures.
There is no evidence that out-of-hospital induction of emesis,
use of gastric aspiration, or administration of activated
charcoal will improve outcome and are therefore not
recommended. Their risk-benefit ratios are unknown and an
effective antidote is available. Induction of emesis is not
advised due to the possibility of the onset of decreased mental
status resulting in the inability to protect the airway and
possible aspiration of gastric contents. Delay in transportation
to the emergency department should not occur in order to
institute any gastrointestinal decontamination.
Alteration of Ethylene Glycol Metabolism
The out-of-hospital uses of alcohol or fomepizole as an
antidote have not been studied. Their routine use in this setting
can not be advocated at this time.
Cofactor Therapy
There are no published data evaluating the efficacy of
supplemental thiamine or pyridoxine in ethylene glycol
poisoned patients. The panel does not recommend adminis-
tration of these cofactors in the out-of-hospital setting.
Limitations of the Published Data
The strength of evidence for this guideline is limited to
case series, case reports (level 4), one cohort inhalation
study (level 2b) and one case-control study of ingestion
(level 3b). Level 4 data do not provide a sound basis for
toxic dose estimation or triage recommendations. The case
reports and case series varied widely in the level of clinical
detail presented, severity of clinical effects of the poisoning,
timing of interventions, co-ingestants, estimated dose, and
treatments administered.
The lack of precision in dose measurement is a major
limitation of this literature analysis. The estimates are subject
to many assumptions. Data for amount ingested are often
inaccurate or incomplete. The history might be obtained from
an intoxicated patient or an emotionally stressed friend or
relative. Parents might under- or overestimate the ingested
dose because of denial or anxiety. Poison center staffs often
record the dose taken as the worst case scenario in order to
provide a wide margin of safety. Estimating the volume
ingested from examining most containers is unreliable. In
most case reports and case series the estimates of exposure
were not independently verified.
In most of the reports the exact time of ingestion was not
reported or was not known. The time of onset of toxicity could
only be estimated as occurring within a range of hours after
the suspected ingestion in the majority of cases.
E. M. CARAVATI ET AL.
340
RECOMMENDATIONS
Recommendations are in chronological order of likely
clinical use. The grade of recommendation is in parentheses.
1. Patients with exposure due to suspected self-harm, misuse,
or potentially malicious administration should be referred
to an emergency department immediately regardless of the
doses reported (Grade D).
2. Patients with inhalation exposures will not develop
systemic toxicity and can be managed out-of-hospital if
asymptomatic (Grade B). Patients with clinically signif-
icant mucous membrane irritation should be referred for
evaluation (Grade D).
3. Decontamination of dermal exposures should include
routine cleansing with mild soap and water. Removal of
contact lenses and immediate irrigation with room
temperature tap water is recommended for ocular ex-
posures. All patients with symptoms of eye injury should be
referred for an ophthalmologic exam (Grade D).
4. Patients with symptoms of ethylene glycol poisoning (e.g.,
vomiting, slurred speech, ataxia, altered mental status)
should be referred immediately for evaluation regardless
of the reported doses (Grade C).
5. The absence of symptoms shortly after ingestion does not
exclude a potentially toxic dose and should not be used as
a triage criterion (Grade C).
6. Adults who ingest a ‘‘swallow’’ (1030 mL), children
who ingest more than a witnessed taste or lick, or if the
amount is unknown of most ethylene glycol products
should be referred immediately for evaluation. The
potential toxic volume of very dilute solutions (e.g.,
product concentration known to be < 20%) is larger and can
be estimated by the formula (Formula 2) in the text. If the
concentration of the product is not known, it should be
assumed to be a concentrated (>20%) product (Grade C).
7. A witnessed ‘‘taste or lick’’ only in a child, or an adult
who unintentionally drinks and then expectorates all of a
concentrated product without swallowing, does not need
referral (Grade C).
8. Referral is not needed if it has been more than 24 hours
since a potentially toxic unintentional exposure, the
patient has been asymptomatic, and no alcohol was co-
ingested (Grade D).
9. Gastrointestinal decontamination in the out-of-hospital
setting with ipecac syrup, gastric lavage, or activated
charcoal is not recommended. Transportation to an
emergency department should not be delayed for any
decontamination procedures (Grade D).
10. Patients meeting referral criteria should be evaluated at a
hospital emergency department rather than a clinic. A facility
that can quickly obtain an ethylene glycol serum concentra-
tion and has alcohol or fomepizole therapy available is
preferred. This referral should be guided by local poison
center procedures and community resources (Grade D).
11. The administration of alcohol, fomepizole, thiamine, or
pyridoxine is not recommended in the out-of-hospital
setting (Grade D).
These recommendations are summarized in Appendix 4.
IMPLICATIONS FOR RESEARCH
The expert consensus panel identified the following topics
where additional research is needed or analysis of existing
databases might be useful.
1. Determine how well symptoms correlate with serum
ethylene glycol concentrations.
2. Determine whether any subgroup of adult or pediatric
patients has increased susceptibility to ethylene glycol
toxicity.
3. Evaluate the feasibility, effectiveness, and safety of the
pre-hospital use of alcohol and fomepizole for patients
with prolonged transportation times.
4. Evaluate the pharmacokinetics and adverse effects of
orally administered fomepizole.
5. Further research on the efficacy of adsorbents, such as
activated charcoal, as decontaminants for ethylene glycol.
6. Evaluate the effectiveness of thiamine and pyridoxine
administration on clinical outcome.
7. Evaluate the effectiveness of adding bittering agents to
ethylene glycol products in order to limit ingestion.
8. Evaluate the utility of gastric aspiration by nasogastric
tube soon after ingestion to prevent absorption.
9. Evaluate the relationship between the dose ingested and
subsequent serum concentration in children and adults.
10. Evaluate the sources of exposure in children (e.g., open
containers, not original containers).
11. Study the role of pre-existing renal disease on the risk for
renal toxicity.
12. Evaluate the efficacy of regulations promoting the
substitution of equally effective but less toxic glycols in
commercial products in reducing the incidence of
ethylene glycol poisonings.
DISCLOSURES
There are no potential conflicts of interest reported by the
expert consensus panel or project staff regarding this
guideline.
APPENDIX I
Expert Consensus Panel Members
Lisa L. Booze, Pharm.D.
Certified Specialist in Poison Information
Maryland Poison Center
University of Maryland School of Pharmacy
Baltimore, Maryland
341
OUT-OF-HOSPITAL MANAGEMENT OF ETHYLENE GLYCOL EXPOSURE
E. Martin Caravati, M.D., M.P.H., F.A.C.M.T., F.A.C.E.P.
Professor of Surgery (Emergency Medicine)
University of Utah
Medical Director
Utah Poison Center
Salt Lake City, Utah
Gwenn Christianson, R.N., M.S.N.
Certified Specialist in Poison Information
Indiana Poison Center
Indianapolis, Indiana
Peter A. Chyka, Pharm.D., F.A.A.C.T., D.A.B.A.T.
Professor, Department of Pharmacy
University of Tennessee Health Science Center
Memphis, Tennessee
Daniel C. Keyes, M.D., M.P.H.
Medical Director
Pine Bluff Chemical Demilitarization Facility
Associate Professor, Southwestern Toxicology Training
Program
Dallas, Texas
Anthony S. Manoguerra, Pharm.D., D.A.B.A.T.,
F.A.A.C.T.
Professor of Clinical Pharmacy and Associate Dean
School of Pharmacy and Pharmaceutical Sciences
University of California San Diego
Former Director, California Poison Control System, San
Diego Division
San Diego, California
Kent R. Olson, M.D., F.A.C.E.P., F.A.A.C.T., F.A.C.M.T.
Medical Director
California Poison Control System, San Francisco Division
Clinical Professor of Medicine and Pharmacy
University of California, San Francisco
San Francisco, California
Elizabeth J. Scharman, Pharm.D., D.A.B.A.T., B.C.P.S.,
F.A.A.C.T.
Director, West Virginia Poison Center
Professor, West Virginia University School of Pharmacy,
Department of Clinical Pharmacy
Charleston, West Virginia
Paul M. Wax, M.D., F.A.C.M.T.
Managing Director
Banner Poison Center
Professor of Clinical Emergency Medicine
University of Arizona School of Medicine
Phoenix, Arizona
Alan D. Woolf, M.D., M.P.H., F.A.C.M.T.
Director, Program in Environmental Medicine
Children’s Hospital, Boston
Associate Professor of Pediatrics
Harvard Medical School
Boston, Massachusetts
APPENDIX 2
Grades of Recommendation and Levels
of Evidence
Grade of
recommendation
Level of
evidence
Description
of study design
A 1a Systematic review
(with homogeneity)
of randomized
clinical trials
1b Individual randomized
clinical trials (with narrow
confidence interval)
1c All or none (all patients
died before the drug
became available,
but some now survive
on it; or when some
patients died before the
drug became available,
but none now die on it.)
B 2a Systematic review
(with homogeneity) of
cohort studies
2b Individual cohort study
(including low quality
randomized clinical trial)
2c ‘‘Outcomes’’ research
3a Systemic review
(with homogeneity) of
case-control studies
3b Individual case-control study
C 4 Case series, single case
reports (and poor quality
cohort and case
control studies)
D 5 Expert opinion without
explicit critical appraisal
or based on physiology
or bench research
Z 6 Abstracts
E. M. CARAVATI ET AL.
342
APPENDIX 3
Secondary Review Panel Organizations
Ambulatory Pediatric Association
American Academy of Breastfeeding Medicine
American Academy of Emergency Medicine
American Academy of Pediatrics
American Association for Health Education
American College of Clinical Pharmacy
American College of Emergency Physicians
American College of Occupational and Environmental
Medicine
American Public Health association
American Society of Health System Pharmacists
Association of Maternal and Child Health Programs
Association of Occupational and Environmental Clinics
Association of State and Territorial Health Officials
Canadian Association of Poison Control Centres
Centers for Disease Control and Prevention-National
Center for Injury Prevention and Control
Consumer Federation of America
Consumer Product Safety Commission
Department of Transportation
Emergency Medical Services for Children
Emergency Nurses Association
Environmental Protection Agency
European Association of Poisons Control Centres and
Clinical Toxicologists
Food and Drug Administration
National Association of Children’s Hospitals and Related
Institutions
National Association of Emergency Medical Services Physicians
National Association of Emergency Medical Technicians
National Association of School Nurses
National Association of State Emergency Medical Services
Directors
National Safe Kids Campaign
Teratology Society
World Health Organization International Programme on
Chemical Safety
APPENDIX 4
Triage Algorithm for Ethylene Glycol Ingestion*
343
OUT-OF-HOSPITAL MANAGEMENT OF ETHYLENE GLYCOL EXPOSURE
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... Ethylene glycol is a toxic alcohol that is mainly introduced into an organism through the digestive pathway, rarely dermal, respiratory or ocular. Chronic dermal and inhalation exposure are uncommon [1]. Its priority toxic metabolites are glycolic acid and oxalic acid. ...
... Ingestion is often accompanied or preceded by alcohol consumption. Ethylene glycol is a colorless, odorless and viscous dihydroxy liquid, it has a sweet taste and it is water, acetone and ethanol soluble [1,2]. The lethal dose is 1-1.4 mL/kg body weight of pure ethylene glycol. ...
... Ethylene glycol is often used as a cooling liquid in radiators and in the synthesis industry (textile, cosmetics, varnishes, etc.). It can also be found in several commercially available chemicals: antifreeze, brake fluid, various solvents, stabilizer of sparkling agents, liquid for domestic radiators, plasticizer for glue [1,2,5]. ...
Article
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Ethylene glycol is a toxic alcohol that is mainly introduced into an organism through the digestive pathway. Its priority toxic metabolites are glycolic acid and oxalic acid. We present the case of a young person, of the male persuasion, without any personal pathological history, found unconscious and presenting signs of violence. The patient is emergency hospitalized presenting coma, convulsive syndrome, severe metabolic acidosis and a positive result for alcoholism. Anamnestic data is extremely poor. The results of the clinical and paraclinical examinations suggest a possible poisoning with toxic alcohols. Despite the drug treatment and the hemodialysis, the evolution is unfavorable, resulting in death one week after admission. Through the forensic examination, the followings were found: cerebral and leptomeningeal edema, focal cerebral microhemorrhages, bronchopneumonia, septic spleen, shock kidney, hepatic fatty dystrophy, excoriated plaques in the head area. The histopathological (HP) examination confirms the macroscopic diagnosis and identifies the presence of calcium oxalate crystals in the kidney tubules. Subsequently, the toxicological examination of the biological samples taken from the corpse at the forensic examination, confirms the presence of the glycolic acid. Postmortem, the investigation conducted by the criminal investigation authorities confirms the oral ingestion of antifreeze. The absence of a positive history, along with alcohol consumption, nonspecific clinical symptomatology and the absence of calcium oxalate in urine are trap elements in the diagnosis of acute ethylene glycol poisoning. The presence of calcium oxalate in tissues, identified through the HP examination, is an extremely important factor when establishing the cause of death.
... The ratelimiting step in this cascade is the conversion of glycolic to glyoxylic acid. Accumulation of glycolic acid in the body is mainly responsible for toxicity (Brent, 2001). Ethylene glycol has been shown to be toxic to humans (Friedman et al., 1962) and is also toxic to domestic pets such as cats and dogs. ...
... That is roughly 16 mL of 50 % ethylene glycol for an 80 kg adult and 4 mL for a 20 kg child. Poison control centers often use more than a lick or taste in a child or more than a mouthful in an adult as a dose requiring hospital assessment (Caravati et al., 2005). The orally lethal dose in humans has been reported as approximately 1.4 mL/kg of pure ethylene glycol (Friedman et al.). ...
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Origanum vulgare Linn has traditionally been used as a diuretic and antispasmodic. Therefore, we investigated the active extract of Origanum vulgare for possible andrological effect and preventive effects against testicular damage using ethylene glycol rat model of testicular damage, to rationalize its medicinal use. Male Wistar rats received lithogenic treatment comprising of 0.75 % ethylene glycol injection twice with one day interval, then in drinking water, active extract of Origanum vulgare treatment (20 mg/kg) was given for 3 weeks to prevent toxic damage including loss of body weight gain and appetite, Following oral administration of EGME, a rapid decrease in testis weight associated with testicular cell damage was observed. Origanum vulgare treatment (20 mg/kg) prevented as well as reversed toxic changes including loss of body weight gain.
... Ethylene glycol is present in several commonly available commercial products, notably automotive antifreeze, and cases of toxic ingestion have been reported as far back as the 1930s [1]. More recently, the 2019 Annual Report by the National Poison Data System (NPDS) recorded 7,260 cases of ethylene glycol intoxication, of which 874 were intentional, 2,287 received medical treatment, and 19 resulted in death [2]. ...
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Ethylene glycol is commonly used in antifreeze, and ingestion of even a small amount can result in acute kidney injury, severe metabolic acidosis, and neurological injury. When cases are recognized early, treatment involves administration of alcohol dehydrogenase inhibitors to prevent conversion to toxic metabolites of glycolate, glyoxolate, and oxalate. In later presentations with more severe renal injury, hemodialysis may be required for clearance of toxic metabolites and supportive care for renal failure. We present the first reported case of severe ethylene glycol intoxication requiring support of extracorporeal membrane oxygenation (ECMO) due to refractory cardiopulmonary collapse.
... In younger children, a common clinical manifestation occurs when a child swallows one or two amounts of a concentrated methanol solution. These children should be transferred to the hospital [176]. ...
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Background Methanol poisoning (MP) occurs often via ingestion, inhalation, or dermal exposure to formulations containing methanol in base. Clinical manifestations of MP include gastrointestinal symptoms, central nervous system (CNS) suppression, and decompensated metabolic acidosis occurred with blurred vision and early or late blindness. Objective This study reviewed the clinical manifestations, laboratory and radiology findings, and treatment approaches in MP. Discussion Methanol is usually rapidly absorbed after ingestion and metabolized by alcohol dehydrogenase (ADH), then distributed to the body water to reach a volume distribution approximately equal to 0.77 L/Kg. It is also eliminated from the body as unchanged parent compounds. Clinical manifestations of MP alone initiate within 0.5–4 h after ingestion and include gastrointestinal symptoms and CNS suppression. After a latent period of 6–24 h, depending on the absorbed dose, decompensated metabolic acidosis occurs with blurred vision and early or late blindness. Blurred vision with normal consciousness is a strong suspicious sign of an MP. The mortality and severity of intoxication are well associated with the severity of CNS depression, hyperglycemia, and metabolic acidosis, but not with serum methanol concentration. After initial resuscitation, the most important therapeutic action for patients with known or suspected MP is correction of acidosis, inhibition of ADH, and hemodialysis. Conclusion Since MP is associated with high morbidity and mortality, it should be considered seriously and instantly managed. Delay in treatment may cause complications, permanent damage, and even death.
... Treatments of ethylene glycol poisoning include stabilization, gastric decontamination, vitamins to minimize complications, inhibition of metabolism, and enhanced elimination [2,19]. The standard stabilization includes securing the airway, breathing, and circulation. ...
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Background: Brake oil is an automobile transmission fluid composed of a mixture of toxic alcohols such as ethylene glycols and glycol ethers. Both accidental and intentional ingestion cases have been reported and they can present with multisystem involvement. Life-threatening complications evolve from deleterious effects on cardiopulmonary and renal systems. Effects on neurological and gastrointestinal systems give rise to a multitude of complications although non-fatal in nature. The biochemical panel consists of a high concentration of ethylene glycol with severe metabolic acidosis, high anion gap, high osmolar gap, oxaluria, and hypocalcemia. The mainstay of treatment is enhanced elimination of ethylene glycol and its metabolites by hemodialysis, together with general supportive care, gastric decontamination, and vitamins such as thiamine and pyridoxine to minimize the adverse effects of intoxication. Case presentation: A 26-year-old Sinhalese woman presented with reduced urine output, shortness of breath, reduced level of consciousness, abdominal pain, and vomiting with mild degree fever of 2 days' duration. She had bilateral lower limb edema, crepitations over bilateral lower lung fields, and right-sided lower motor type facial nerve palsy. Investigations showed severe metabolic acidosis with high anion gap and high osmolar gap. With regular hemodialysis she made a complete recovery after 3 months. Conclusion: Even without a clear history of poisoning, the presence of a high anion, high osmolar gap metabolic acidosis should prompt one to search for ethylene glycol ingestion. Uncommon manifestations like cranial neuropathies need to be examined and considered. Timely aggressive treatment leads to a better prognosis.
... Etilen glikol, 1930'lardan beri çeşitli endüstriyel ve ev ortamlarında kullanılmıştır. EG, ticari olarak büyük miktarlarda üretilir ve otomobiller, tekneler ve uçaklar için yaygın olarak antifriz veya saptırma çözeltileri olarak kullanılır (2). Bu çalışmada 81 yaşında erkek hastada yanlışlıkla birkaç yudum antifriz içmesi sonrası erken tedaviye rağmen koma hali, ciddi metabolik asidoz ve akut böbrek yetmezliği (ABY) tablosu gelişmiş olan bir olgunun sunulması amaçlandı. ...
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SUMMARY First discovered by French chemist Charles Wurtz in 1859, ethylene glycol (EG) is a liquid alcohol which is odorless in its pure form, colorless, non-volatile, sweet in taste, syrup in consistency with its chemical formula being C2H6O2. Although it is not toxic, it is an alcohol of which metabolites are toxic. Minimal lethal dose of 95% solution of EG for an adult has been reported as 1.4 ml/kg based on body weight. A case report was presented in this study who developed acute renal failure (ARF) due to EG. Fomepizole was used as antidote in 81 years old male patient presenting with coma, serious metabolic acidosis, and ARF following accidental ingestion of a few drops of antifreeze. The patient was referred to nephrology ward after treatment in the intensive care unit.
... Die Indikation zur Hämodialyse sowie zur Verabreichung von Ethanol war zum Zeitpunkt der Aufnahme des Patienten bei Organschäden und lebensbedrohlichem Zustand klar gegeben. Eine Giftelemination über Magenspülungen, die Verabreichung von Aktivkohle oder gar das Erzwingen von Erbrechen sind durch die schnelle und fast vollständige enterale Absorption des Ethylenglykols selten zielführend [2]. ...
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Eine akzidentielle oder (para)suizidale Intoxikation mit Ethylenglykol kann zu einer schweren Acidose, zu verschiedenen Organsystemschäden und zum Tod führen. Wirksame Therapien stellen die Hämodialyse und die sofortige Gabe von Fomepizol bzw. von Ethanol dar. Wir beschreiben einen Patienten nach wiederholter Ethylenglykolintoxikation mit einer schweren metabolischen Acidose und einem akuten Nierenversagen. Durch Hämodialyse mit ethanolhaltigem Dialysat und i. v.-Gabe von Ethanol konnten wir gravierende Folgeschäden verhindern.
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Ethylene glycol (EG), in addition to its neurotoxic and nephrotoxic effects, evokes oxidative stress. The aim of this study was to assess the influence of the ethylene glycol on the biochemical indicators and oxidoreductive balance of patients treated for acute poisoning. The total study group consisted of 56 persons including 26 alcoholics who took EG as a substitute for ethyl alcohol in the course of alcohol dependence syndrome and 30 controls. Severity of poisoning, results of acid-base parameters, biochemical, and toxicological tests as well as biomarkers of the oxidative stress in blood were analyzed during the patients’ hospitalization. The key issue was to assess the oxidative stress and biochemical disturbances caused by EG and the type of treatment applied in the course of poisoning. Significant changes in some parameters were found both at time of diagnosis and after treatment initiation (ethanol as an antidote and hemodialysis). The most important differences included the activity of hepatic parameters (aspartate aminotransferase, AST) and oxidative stress markers like catalase (CAT); correlation of the lipid peroxidation products level (TBARS) with urea concentration has been shown. On the last day of the hospitalization, in some cases, the mutual correlation between the evaluated markers were observed, for example, between alanine transaminase (ALT) and glutathione reductase (GR), and urea concentration and glutathione level (GSH/GSSG). The concentration of ions (H ⁺ ) had a major impact on the oxidoreductive balance, correlating with the elevated GR and GSH/GSSG levels.
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We treated a 64-year-old man who recovered completely from a massive antifreeze ingestion with ethylene glycol levels well above those of previously described survivors. Rapid and aggressive treatment of the patient with recognized methods, including hemodialysis, resulted in the favorable outcome. (Arch Intern Med. 1992;152:1311-1313)
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ETHYLENE glycol is potentially lethal in adults when ingested in amounts greater than 100 mL.1 Even smaller amounts can be lethal in children and can produce renal, cardiac, and CNS toxic reactions. The patient in the case reported in this article ingested many times the lethal dose. Because therapy was instituted rapidly, she recovered without any of the sequelae classically ascribed to ethylene glycol poisoning. This case provides evidence that the principles of toxicity and its prevention derived from animal models are applicable to man.Report of a Case A 33-year-old woman was brought to the Parkland Hospital emergency room one hour after drinking 2 L of ethylene glycol. She had been unable to self-induce vomiting. She was taking thioridazine for chronic paranoid schizophrenia and had attempted suicide on at least one other occasion. On examination she appeared mildly intoxicated but was noncombative. The blood pressure was 105/90 mm