ILLUSTRATIVE CASE
Acute Obtundation in a 9-Month-Old Patient Ethanol Ingestion Suzanne M. Edmunds, MD, Samuel J. Ajizian, MD, and Anthony Liguori, PhD Abstract: Alcohol ingestion in the pediatric patient can be life threatening. Younger patients consume larger volumes per body weight with accidental ingestions, and children have more serious adverse effects at lower blood alcohol levels. Complications of alcohol poisoning can include hypothermia, hypoglycemia, seizures, coma, and death. We present the course of a 9-month-old female infant who became unresponsive at home and presented to the emergency department comatose. When her blood alcohol level registered 489 mg/dL, it was revealed that she had accidentally been given a bottle of formula mixed with vodka rather than water. The infant required intubation for severely depressed level of consciousness and aggressive fluid resuscitation for hemodynamic instability. She had a peak lactate level of 24 mmol/L and a peak blood alcohol level of 524 mg/dL. Based on the severity of her initial presentation, preparations were made for hemodialysis. The infant responded to supportive measures including mechanical ventilation, fluids, and dextrose, and hemodialysis was not necessary. Her alcohol clearance followed zero-order kinetics at an average rate of 28.6 mg/dL per hour over 15.5 hours from her peak level of 524 mg/dL to the lowest measured value of 80 mg/dL. The kinetics of ethanol clearance at this level of toxicity, which is the highest reported in an infant to date, enhance our knowledge of ethanol metabolism and will assist in management decisions in cases of severe intoxication. Key Words: acute ethanol toxicity, ethanol, infant, ethanol poisoning management (Pediatr Emer Care 2014;30: 739–741)
A
cute alcohol intoxication can be life threatening, with coma, seizures, hypothermia, acidosis, and death all potential consequences at levels over 400 mg/dL.1 Alcohol poisonings can occur in pediatric patients as a result of accidental ingestion via household products such as perfume, hand sanitizer,2,3 overdose of alcohol-containing medications,4 and binge drinking in older age groups. Descriptions of the elimination kinetics of ethanol in infants and children have not been consistent.5–7 Factors that influence the rate of metabolism include chronicity of exposure, weight, nutritional status, and age.1 As cases of alcohol poisoning have been reported in infants as young as 2 months,8 information concerning elimination kinetics of alcohol in this age group would be highly relevant. We present the course of an infant with the highest blood alcohol level reported to date in the literature.
CASE K.L. is a 9-month-old infant brought by paramedics to an outside emergency department after becoming unresponsive at home. She had been in her usual state of health until the morning From the Departments of Anesthesiology and Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC. Disclosure: The authors declare no conflict of interest. Reprints: Suzanne M. Edmunds, MD, Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1009 (e‐mail: [email protected]). No reprints of this article will be available. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161
Pediatric Emergency Care • Volume 30, Number 10, October 2014
of admission when she became floppy and unresponsive shortly after a bottle feed. Paramedics found the patient to be minimally responsive to noxious stimuli. Oxygen saturations were 70% and increased to 100% on 100% nonrebreather. On arrival in the emergency department, vital signs were as follows: temperature, 96°F; blood pressure, 84/49 mm Hg; pulse rate, 118 beats per minute; respiratory rate, 24 breaths per minute; pulse oximetry, 100% on 100% nonrebreather. The patient had a fixed staring gaze and large unresponsive pupils. Gag reflex was present; otherwise, the infant was unresponsive. Color was described as gray. The examination result was otherwise unremarkable. Given her unexplained obtundation, she was given lorazepam 0.1 mg/kg intravenously for suspected seizure activity. Airway protective reflexes were lost, and the patient was intubated with a 4.0 endotracheal tube. She became hypotensive but responded to a fluid bolus. Arterial blood gas after intubation showed pH 7.36; pCO2, 33.7 mm Hg; pO2, 448 mm Hg; HCO3, 18.8 mmol/L; and BE, −5.5 mmol/L. Complete blood count and serum chemistries were unremarkable except for a low bicarbonate level of 18 meq/L. Serum glucose and liver enzymes were within normal limits and remained so throughout her course. A computerized tomography scan of the brain was within normal limits. A full septic workup including lumbar puncture was performed, and broad-spectrum antibiotics were initiated. Lactate level was elevated at 24 mmol/L. A routine urine toxicology screen was negative. The blood alcohol level, however, obtained for depressed level of consciousness, was found to be elevated at 489 mg/dL. With that information, the mother was questioned about possible exposure to alcohol. At this point, she did recall that there was a water bottle in the refrigerator that had been filled with vodka for a party at a friend's house the night before. She admitted that the infant's formula might have been mixed with the vodka from that water bottle. The infant had consumed an estimated 3 oz of her formula and had become symptomatic shortly afterwards. The mother was uncertain about the time of the ingestion. With a working diagnosis of acute alcohol poisoning, poison control had been contacted for assistance with management. Our institution had been contacted as a tertiary care referral center. The infant had had intermittent hemodynamic instability with dips in blood pressure as low as 51/22 mm Hg, which had required multiple fluid boluses of normal saline. The alcohol level rose to 524 mg/dL, the lactate level remained elevated at 12 mmol/L, and the serum osmolality was measured at 417 mOsm/k 3 hours after presentation. There had been no improvement in her neurologic status. Our transport team noted her to be flaccid, unresponsive, and with pupils pinpoint and nonreactive. Her perfusion was poor. Based on her profound obtundation, hemodynamic instability with mean arterial pressures less than 45 mm Hg, ongoing metabolic acidosis, and the rise in her alcohol level since presentation, the decision was made to initiate hemodialysis. Shortly after placement of the dialysis catheter, however, about 8 hours after initial presentation, the infant began to improve. Her hemodynamics stabilized, she became responsive to stimulation and began to exhibit spontaneous activity. Her lactate level had fallen to 2.3 mmol/L. Hemodialysis was deferred. The infant was extubated successfully approximately 11 hours after her initial presentation at the outside www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Pediatric Emergency Care • Volume 30, Number 10, October 2014
hospital. Her alcohol level at that time was 281 mg/dL. The following day, the infant was described as appropriately interactive and taking a normal diet for age. Her hemodialysis catheter was removed. Child Protective Services and law enforcement were involved from the time of her presentation. The skeletal survey was negative. Child Protective Services elected to discharge the child to the care of her parents with a safety plan in place 72 hours after her initial presentation.
A study of acute ethanol poisoning in children by Leung5 in the late 1980s described a clearance rates of 28.4 mg/dL per hour, similar to our patient. Excluding patients whose follow-up alcohol level was zero, calling into question the actual rate of decline, the rate in this series would have been calculated to be 34.5 mg/dL. Several case reports have described rates in the range of 30 mg/dL per hour during the phase of elimination that followed a first-order profile.9,11 Kinetics may follow a biphasic model, with a rapid first phase followed by a slower period of elimination.9 Chikwava et al,12 however, recently reported a 7-month-old patient with a serum alcohol level of 183 mg/dL with a calculated clearance rate of 49.7 mg/dL per hour. Morgan reported a 15-year-old patient with an initial level of 757 mg/dL who maintained a clearance rate of 51.4 mg/dL per hour before he was started on hemodialysis.7 Accidental ingestions often lead to consumption of a large volume per body weight ratio. Our patient's 3-oz ingestion can be converted to grams by using the following formula:
DISCUSSION Alcohol poisoning in the pediatric population continues to be a significant problem, and knowledge of elimination kinetics will assist in medical management of severe cases. Children can be exposed through leftover containers from parties, cold remedies and pain medications, accidental ingestion of household products, or from intentional misuse. Ethanol is rapidly absorbed from the gastrointestinal tract and generally reaches peak concentration within 60 minutes. Our patient's blood alcohol level peaked 3 hours after presentation. This pattern has been described previously6 and is presumed to be due to incomplete absorption at the time of initial presentation after rapid ingestion. In the first, rate-limiting step of its metabolism, ethanol is metabolized by alcohol dehydrogenase to acetaldehyde. Acetaldehyde is oxidized by aldehyde dehydrogenase to acetate, which enters the Krebs cycle and is ultimately converted to carbon dioxide and water.1 Alcohol is routinely believed to follow zero-order kinetics, meaning clearance is substrate independent. In several reports of patients with toxic blood alcohol levels, however, the rate of clearance was noted to be faster during the first 4 to 6 hours of observation than during subsequent measurements.6,9 Blood alcohol in these reports ranged from 369 mg/dL to more than 1000 mg/dL. This pattern of clearance is consistent with first-order kinetics, in which the rate of clearance is substrate dependent. As the initial high levels overwhelm the enzymatic pathways, excretion plays a greater role in clearance. As levels fall, metabolism becomes the rate-limiting factor, and elimination again follows zero-order kinetics. Our patient's clearance followed zero-order kinetics at an average rate of 28.6 mg/dL per hour over 15.5 hours as her level fell from its peak of 524 mg/dL to 80 mg/dL (Fig. 1). The final point of less than 5 mg/dL is not used in this calculation because it cannot be known at what time her level actually fell to this level. In adults, the rate of ethanol clearance has been established at 15 to 20 mg/dL per hour.10 The rate of ethanol clearance reported in younger patients, however, has varied widely in the toxicology literature.5–7
ð% alcoholÞ ðvolume of ingestionÞ ¼ grams alcohol: Vodka averages 80 proof or 40% alcohol. Using this calculation, the quantity of alcohol ingested would be approximately 36 g or 4 g/kg for this 9-kg infant. Her ingestion of 4 g/kg certainly was in the potentially lethal range; while an untreated ingestion of 5 g/kg is toxic to an adult, only 3 g/kg is toxic to a child.1 Potential morbidity of serious ethanol ingestions stems from respiratory depression, aspiration, hyperosmolarity, fluid shifts, hypoglycemia, and acidosis. With a serum osmolality measured at 417 mOsm/k, fluid shifts and osmotic diuresis played a significant role in our patient’s clinical in stability. Volume resuscitation played a crucial role in her resuscitation. Although supportive care with dextrose-containing intravenous fluids and respiratory support including mechanical ventilation are the mainstays of therapy, hemodialysis has been utilized as an adjunct to therapy, as it can speed the clearance by a factor of 4.13 Hemodialysis is generally reserved for severe cases of alcohol intoxication complicated by coma, acidosis, and hemodynamic instability. Its usefulness remains controversial because of the invasiveness of the procedure and the fact that ethanol will clear in time if the patient is able to be adequately supported through the period of intoxication. Despite her consumption of an estimated 4 g/kg ethanol and extremely high peak level of 524 mg/dL, our patient ultimately did well with respiratory support, dextrose, and hydration. Our patient's peak level was measured several hours after presentation, which may have been related to incomplete absorption at the time of presentation or subsequent fluid shifts due to hyperosmolality. Her clearance followed zero-order kinetics at an average rate of 28.6 mg/dL per hour over 15.5 hours of care. Although higher rates of clearance have been reported previously in the pediatric literature, metabolism is influenced by multiple factors such as hydration, nutritional status, previous exposure, weight, and age. Pediatric rates of clearance are consistently reported as higher than clearance in adults, but the exact rate of clearance cannot be projected as it has proven to be widely variable. Calculations to estimate alcohol content in cases of accidental poisoning can be helpful in estimating severity of ingestion. Blood alcohol levels should be followed serially to track the patient's clearance, but the clinical status and response to therapy will provide the most useful guidance in the treatment of severe alcohol poisoning. REFERENCES
FIGURE 1. Our patient's clearance followed zero-order kinetics at an average rate of 28.6 mg/dL per hour over 15.5 hours as her level fell from its peak of 524 mg/dL.
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www.pec-online.com
1. Kleinschmidt KC. Ethanol. In: Shannon MW, Borron SW, Burns MJ, eds. Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose. 4th ed. Philadelphia, PA: Saunders; 2007:589–604.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pediatric Emergency Care • Volume 30, Number 10, October 2014
Acute Obtundation: Ethanol Ingestion
2. Gormley NJ, Bronstein AC, Rasimas JJ, et al. The rising incidence of intentional ingestion of ethanol-containing hand sanitizers. Crit Care Med. 2012;40:209–294.
8. McCormick T, Levine M, Knox O, et al. Ethanol ingestion in two infants under 2 months old: a previously unreported cause of ALTE. Pediatrics. 2013;131:e604–e607.
3. Engel JS, Spiller HA. Acute ethanol poisoning in a 4-year-old as a result of ethanol-based hand-sanitizer ingestion. Pediatr Emerg Care. 2010;26: 508–509.
9. Hussain SZ, Rawal J, Henry JA. Gastric evacuation for acute ethanol intoxication in a three year old. J Accid Emerg Med. 1998;15:54–62.
4. Tovey C, Rana PSJB, Anderson DJ. Alcohol intoxication in a toddler. J Accid Emerg Med. 1998;15:69–70.
10. Gershman H, Steeper J. Rate of clearance of ethanol from the blood of intoxicated patients in the emergency department. J Emerg Med. 1991;9:307–311.
5. Leung AKC. Ethyl alcohol ingestion in children. Clin Pediatr (Phila). 1986;25:617–619.
11. Lopez GP, Yealy DM, Krenzelok EP. Survival of a child despite unusually high blood ethanol levels. Am J Emerg Med. 1989;7:283–285.
6. Lamminpää A, Hoppu K. First-order alcohol elimination in severe alcohol intoxication in an adolescent: a case report. Am J Emerg Med. 2009;27: 128e.5–128e.6.
12. Chikwava K, Lower DR, Frangiskakis SH, et al. Acute ethanol intoxication in a 7-month-old infant. Pediatr Dev Pathol. 2004;7:400–402.
7. Morgan DL, Durso MH, Rich BK, et al. Severe ethanol intoxication in an adolescent. Am J Emerg Med. 1995;13:416–418.
© 2014 Lippincott Williams & Wilkins
13. Wildenauer R, Kobbe P, Waydhas C. Is the osmole gap a valuable indicator for the need of hemodialysis in severe ethanol intoxication? Technol Health Care. 2010;18:203–206.
www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
741
Acute Obtundation in a 9-Month-Old Patient Ethanol Ingestion Suzanne M. Edmunds, MD, Samuel J. Ajizian, MD, and Anthony Liguori, PhD Abstract: Alcohol ingestion in the pediatric patient can be life threatening. Younger patients consume larger volumes per body weight with accidental ingestions, and children have more serious adverse effects at lower blood alcohol levels. Complications of alcohol poisoning can include hypothermia, hypoglycemia, seizures, coma, and death. We present the course of a 9-month-old female infant who became unresponsive at home and presented to the emergency department comatose. When her blood alcohol level registered 489 mg/dL, it was revealed that she had accidentally been given a bottle of formula mixed with vodka rather than water. The infant required intubation for severely depressed level of consciousness and aggressive fluid resuscitation for hemodynamic instability. She had a peak lactate level of 24 mmol/L and a peak blood alcohol level of 524 mg/dL. Based on the severity of her initial presentation, preparations were made for hemodialysis. The infant responded to supportive measures including mechanical ventilation, fluids, and dextrose, and hemodialysis was not necessary. Her alcohol clearance followed zero-order kinetics at an average rate of 28.6 mg/dL per hour over 15.5 hours from her peak level of 524 mg/dL to the lowest measured value of 80 mg/dL. The kinetics of ethanol clearance at this level of toxicity, which is the highest reported in an infant to date, enhance our knowledge of ethanol metabolism and will assist in management decisions in cases of severe intoxication. Key Words: acute ethanol toxicity, ethanol, infant, ethanol poisoning management (Pediatr Emer Care 2014;30: 739–741)
A
cute alcohol intoxication can be life threatening, with coma, seizures, hypothermia, acidosis, and death all potential consequences at levels over 400 mg/dL.1 Alcohol poisonings can occur in pediatric patients as a result of accidental ingestion via household products such as perfume, hand sanitizer,2,3 overdose of alcohol-containing medications,4 and binge drinking in older age groups. Descriptions of the elimination kinetics of ethanol in infants and children have not been consistent.5–7 Factors that influence the rate of metabolism include chronicity of exposure, weight, nutritional status, and age.1 As cases of alcohol poisoning have been reported in infants as young as 2 months,8 information concerning elimination kinetics of alcohol in this age group would be highly relevant. We present the course of an infant with the highest blood alcohol level reported to date in the literature.
CASE K.L. is a 9-month-old infant brought by paramedics to an outside emergency department after becoming unresponsive at home. She had been in her usual state of health until the morning From the Departments of Anesthesiology and Physiology and Pharmacology, Wake Forest School of Medicine, Winston-Salem, NC. Disclosure: The authors declare no conflict of interest. Reprints: Suzanne M. Edmunds, MD, Department of Anesthesiology, Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-1009 (e‐mail: [email protected]). No reprints of this article will be available. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0749-5161
Pediatric Emergency Care • Volume 30, Number 10, October 2014
of admission when she became floppy and unresponsive shortly after a bottle feed. Paramedics found the patient to be minimally responsive to noxious stimuli. Oxygen saturations were 70% and increased to 100% on 100% nonrebreather. On arrival in the emergency department, vital signs were as follows: temperature, 96°F; blood pressure, 84/49 mm Hg; pulse rate, 118 beats per minute; respiratory rate, 24 breaths per minute; pulse oximetry, 100% on 100% nonrebreather. The patient had a fixed staring gaze and large unresponsive pupils. Gag reflex was present; otherwise, the infant was unresponsive. Color was described as gray. The examination result was otherwise unremarkable. Given her unexplained obtundation, she was given lorazepam 0.1 mg/kg intravenously for suspected seizure activity. Airway protective reflexes were lost, and the patient was intubated with a 4.0 endotracheal tube. She became hypotensive but responded to a fluid bolus. Arterial blood gas after intubation showed pH 7.36; pCO2, 33.7 mm Hg; pO2, 448 mm Hg; HCO3, 18.8 mmol/L; and BE, −5.5 mmol/L. Complete blood count and serum chemistries were unremarkable except for a low bicarbonate level of 18 meq/L. Serum glucose and liver enzymes were within normal limits and remained so throughout her course. A computerized tomography scan of the brain was within normal limits. A full septic workup including lumbar puncture was performed, and broad-spectrum antibiotics were initiated. Lactate level was elevated at 24 mmol/L. A routine urine toxicology screen was negative. The blood alcohol level, however, obtained for depressed level of consciousness, was found to be elevated at 489 mg/dL. With that information, the mother was questioned about possible exposure to alcohol. At this point, she did recall that there was a water bottle in the refrigerator that had been filled with vodka for a party at a friend's house the night before. She admitted that the infant's formula might have been mixed with the vodka from that water bottle. The infant had consumed an estimated 3 oz of her formula and had become symptomatic shortly afterwards. The mother was uncertain about the time of the ingestion. With a working diagnosis of acute alcohol poisoning, poison control had been contacted for assistance with management. Our institution had been contacted as a tertiary care referral center. The infant had had intermittent hemodynamic instability with dips in blood pressure as low as 51/22 mm Hg, which had required multiple fluid boluses of normal saline. The alcohol level rose to 524 mg/dL, the lactate level remained elevated at 12 mmol/L, and the serum osmolality was measured at 417 mOsm/k 3 hours after presentation. There had been no improvement in her neurologic status. Our transport team noted her to be flaccid, unresponsive, and with pupils pinpoint and nonreactive. Her perfusion was poor. Based on her profound obtundation, hemodynamic instability with mean arterial pressures less than 45 mm Hg, ongoing metabolic acidosis, and the rise in her alcohol level since presentation, the decision was made to initiate hemodialysis. Shortly after placement of the dialysis catheter, however, about 8 hours after initial presentation, the infant began to improve. Her hemodynamics stabilized, she became responsive to stimulation and began to exhibit spontaneous activity. Her lactate level had fallen to 2.3 mmol/L. Hemodialysis was deferred. The infant was extubated successfully approximately 11 hours after her initial presentation at the outside www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
739
Edmunds et al
Pediatric Emergency Care • Volume 30, Number 10, October 2014
hospital. Her alcohol level at that time was 281 mg/dL. The following day, the infant was described as appropriately interactive and taking a normal diet for age. Her hemodialysis catheter was removed. Child Protective Services and law enforcement were involved from the time of her presentation. The skeletal survey was negative. Child Protective Services elected to discharge the child to the care of her parents with a safety plan in place 72 hours after her initial presentation.
A study of acute ethanol poisoning in children by Leung5 in the late 1980s described a clearance rates of 28.4 mg/dL per hour, similar to our patient. Excluding patients whose follow-up alcohol level was zero, calling into question the actual rate of decline, the rate in this series would have been calculated to be 34.5 mg/dL. Several case reports have described rates in the range of 30 mg/dL per hour during the phase of elimination that followed a first-order profile.9,11 Kinetics may follow a biphasic model, with a rapid first phase followed by a slower period of elimination.9 Chikwava et al,12 however, recently reported a 7-month-old patient with a serum alcohol level of 183 mg/dL with a calculated clearance rate of 49.7 mg/dL per hour. Morgan reported a 15-year-old patient with an initial level of 757 mg/dL who maintained a clearance rate of 51.4 mg/dL per hour before he was started on hemodialysis.7 Accidental ingestions often lead to consumption of a large volume per body weight ratio. Our patient's 3-oz ingestion can be converted to grams by using the following formula:
DISCUSSION Alcohol poisoning in the pediatric population continues to be a significant problem, and knowledge of elimination kinetics will assist in medical management of severe cases. Children can be exposed through leftover containers from parties, cold remedies and pain medications, accidental ingestion of household products, or from intentional misuse. Ethanol is rapidly absorbed from the gastrointestinal tract and generally reaches peak concentration within 60 minutes. Our patient's blood alcohol level peaked 3 hours after presentation. This pattern has been described previously6 and is presumed to be due to incomplete absorption at the time of initial presentation after rapid ingestion. In the first, rate-limiting step of its metabolism, ethanol is metabolized by alcohol dehydrogenase to acetaldehyde. Acetaldehyde is oxidized by aldehyde dehydrogenase to acetate, which enters the Krebs cycle and is ultimately converted to carbon dioxide and water.1 Alcohol is routinely believed to follow zero-order kinetics, meaning clearance is substrate independent. In several reports of patients with toxic blood alcohol levels, however, the rate of clearance was noted to be faster during the first 4 to 6 hours of observation than during subsequent measurements.6,9 Blood alcohol in these reports ranged from 369 mg/dL to more than 1000 mg/dL. This pattern of clearance is consistent with first-order kinetics, in which the rate of clearance is substrate dependent. As the initial high levels overwhelm the enzymatic pathways, excretion plays a greater role in clearance. As levels fall, metabolism becomes the rate-limiting factor, and elimination again follows zero-order kinetics. Our patient's clearance followed zero-order kinetics at an average rate of 28.6 mg/dL per hour over 15.5 hours as her level fell from its peak of 524 mg/dL to 80 mg/dL (Fig. 1). The final point of less than 5 mg/dL is not used in this calculation because it cannot be known at what time her level actually fell to this level. In adults, the rate of ethanol clearance has been established at 15 to 20 mg/dL per hour.10 The rate of ethanol clearance reported in younger patients, however, has varied widely in the toxicology literature.5–7
ð% alcoholÞ ðvolume of ingestionÞ ¼ grams alcohol: Vodka averages 80 proof or 40% alcohol. Using this calculation, the quantity of alcohol ingested would be approximately 36 g or 4 g/kg for this 9-kg infant. Her ingestion of 4 g/kg certainly was in the potentially lethal range; while an untreated ingestion of 5 g/kg is toxic to an adult, only 3 g/kg is toxic to a child.1 Potential morbidity of serious ethanol ingestions stems from respiratory depression, aspiration, hyperosmolarity, fluid shifts, hypoglycemia, and acidosis. With a serum osmolality measured at 417 mOsm/k, fluid shifts and osmotic diuresis played a significant role in our patient’s clinical in stability. Volume resuscitation played a crucial role in her resuscitation. Although supportive care with dextrose-containing intravenous fluids and respiratory support including mechanical ventilation are the mainstays of therapy, hemodialysis has been utilized as an adjunct to therapy, as it can speed the clearance by a factor of 4.13 Hemodialysis is generally reserved for severe cases of alcohol intoxication complicated by coma, acidosis, and hemodynamic instability. Its usefulness remains controversial because of the invasiveness of the procedure and the fact that ethanol will clear in time if the patient is able to be adequately supported through the period of intoxication. Despite her consumption of an estimated 4 g/kg ethanol and extremely high peak level of 524 mg/dL, our patient ultimately did well with respiratory support, dextrose, and hydration. Our patient's peak level was measured several hours after presentation, which may have been related to incomplete absorption at the time of presentation or subsequent fluid shifts due to hyperosmolality. Her clearance followed zero-order kinetics at an average rate of 28.6 mg/dL per hour over 15.5 hours of care. Although higher rates of clearance have been reported previously in the pediatric literature, metabolism is influenced by multiple factors such as hydration, nutritional status, previous exposure, weight, and age. Pediatric rates of clearance are consistently reported as higher than clearance in adults, but the exact rate of clearance cannot be projected as it has proven to be widely variable. Calculations to estimate alcohol content in cases of accidental poisoning can be helpful in estimating severity of ingestion. Blood alcohol levels should be followed serially to track the patient's clearance, but the clinical status and response to therapy will provide the most useful guidance in the treatment of severe alcohol poisoning. REFERENCES
FIGURE 1. Our patient's clearance followed zero-order kinetics at an average rate of 28.6 mg/dL per hour over 15.5 hours as her level fell from its peak of 524 mg/dL.
740
www.pec-online.com
1. Kleinschmidt KC. Ethanol. In: Shannon MW, Borron SW, Burns MJ, eds. Haddad and Winchester's Clinical Management of Poisoning and Drug Overdose. 4th ed. Philadelphia, PA: Saunders; 2007:589–604.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pediatric Emergency Care • Volume 30, Number 10, October 2014
Acute Obtundation: Ethanol Ingestion
2. Gormley NJ, Bronstein AC, Rasimas JJ, et al. The rising incidence of intentional ingestion of ethanol-containing hand sanitizers. Crit Care Med. 2012;40:209–294.
8. McCormick T, Levine M, Knox O, et al. Ethanol ingestion in two infants under 2 months old: a previously unreported cause of ALTE. Pediatrics. 2013;131:e604–e607.
3. Engel JS, Spiller HA. Acute ethanol poisoning in a 4-year-old as a result of ethanol-based hand-sanitizer ingestion. Pediatr Emerg Care. 2010;26: 508–509.
9. Hussain SZ, Rawal J, Henry JA. Gastric evacuation for acute ethanol intoxication in a three year old. J Accid Emerg Med. 1998;15:54–62.
4. Tovey C, Rana PSJB, Anderson DJ. Alcohol intoxication in a toddler. J Accid Emerg Med. 1998;15:69–70.
10. Gershman H, Steeper J. Rate of clearance of ethanol from the blood of intoxicated patients in the emergency department. J Emerg Med. 1991;9:307–311.
5. Leung AKC. Ethyl alcohol ingestion in children. Clin Pediatr (Phila). 1986;25:617–619.
11. Lopez GP, Yealy DM, Krenzelok EP. Survival of a child despite unusually high blood ethanol levels. Am J Emerg Med. 1989;7:283–285.
6. Lamminpää A, Hoppu K. First-order alcohol elimination in severe alcohol intoxication in an adolescent: a case report. Am J Emerg Med. 2009;27: 128e.5–128e.6.
12. Chikwava K, Lower DR, Frangiskakis SH, et al. Acute ethanol intoxication in a 7-month-old infant. Pediatr Dev Pathol. 2004;7:400–402.
7. Morgan DL, Durso MH, Rich BK, et al. Severe ethanol intoxication in an adolescent. Am J Emerg Med. 1995;13:416–418.
© 2014 Lippincott Williams & Wilkins
13. Wildenauer R, Kobbe P, Waydhas C. Is the osmole gap a valuable indicator for the need of hemodialysis in severe ethanol intoxication? Technol Health Care. 2010;18:203–206.
www.pec-online.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
741
