Alcohols

Ethanol poisoning

Ethylene glycol poisoning

Methanol poisoning

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ETHANOL POISONING

T51.0 + (X45.99/X65.99/Y15.99)

DESCRIPTION

Acute poisoning usually presents with:

• Nausea and vomiting
• Depression, seizures, coma
• Hypoglycaemia
• Hypothermia
• Hypokalaemia
• Acidosis

Consider other causes for the patient’s condition, including hypoglycaemia and head trauma.

GENERAL MEASURES

• Supportive management aimed at maintaining stable cardiorespiratory function.
• Protect the airway (ventilation may be needed).
• Manage hypothermia, hypoglycaemia, and electrolyte abnormalities.

MEDICINE TREATMENT

• Thiamine, IV, 100 mg in 1 L dextrose 5%.

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ETHYLENE GLYCOL POISONING

T52.3 + (X46.99/X66.99/Y16.99)

DESCRIPTION

Ethylene glycol is the main component of motor vehicle radiator coolant/antifreeze and is occasionally found in brake fluid. It is also found in homemade toilet and drain cleaners.

Mild to moderate intoxication: resembles alcohol intoxication, with nausea and vomiting, nystagmus, ataxia, and somnolence.

Severe intoxication: associated with more severe CNS depression (coma, hypotonia, hyporeflexia) and high anion gap metabolic acidosis. Cardiovascular signs include tachycardia and hypertension. Calcium oxalate crystals cause renal failure and hypocalcaemia, which may manifest with prolongation of the QT interval on ECG or tetany.

𝐴𝑛𝑖𝑜𝑛 𝑔𝑎𝑝 = 𝑁𝑎 − (𝐶𝐿 + 𝐻𝐶𝑂₃ ) [𝑁𝑜𝑟𝑚𝑎𝑙 = 8 − 16]

GENERAL MEASURES

• Consult the Poisons Information Helpline for assistance with management.
• Treat early to reduce the risk of forming toxic metabolites.
• Monitor blood gases and administer sodium bicarbonate.
• Early haemodialysis is the treatment of choice for severe poisoning with profound acidosis.

MEDICINE TREATMENT

Ethanol 

Indications:

History of ingestion, plus any two of the following criteria:

• Arterial pH <7.3
• Serum bicarbonate <20 mmol/L
• Presence of urinary oxalate crystals (ethylene glycol only) or visual disturbances (methanol only)

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Preparation and administration of ethanol:

Step 1: Prepare an ethanol 20% solution:
If using Ethanol 96% BP, oral,

• Add 1 part ethanol 96% to 4 parts juice or water e.g. 250 mL of ethanol 96% with 1000mL water or juice to give a total volume of 1250 mL ethanol 20%.

If using Ethanol 40% v/v (gin, whiskey, vodka), oral

• Add 1 part ethanol 40% to 1 part juice or water e.g. dilute 500mL of ethanol 40% with 500mL water or juice to give a total volume of 1000mL ethanol 20%.

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Note:
Spirit liquor products in South Africa are frequently bottled at 43% v/v. These can be used interchangeably.

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Step 2: Administer a loading dose:

• Ethanol 20% (the solution prepared in Step 1), oral, 4 mL/kg over 15-30 minutes.

Step 3: Continue with maintenance doses:

• Ethanol 20% (the solution prepared in Step 1), oral:
  • Non-drinker: 0.5 mL/kg/hour
  • Chronic drinker: 1 mL/kg/hour

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WORKED EXAMPLES

For a 60kg patient who is a non-drinker:
Loading dose: 240 ml of the ethanol 20% solution orally over 15-30 minutes.
Maintenance dose: 30 mL per hour orally of the ethanol 20% solution.

For a 60kg patient who is a chronic drinker:
Loading dose: 240 ml of the ethanol 20% solution orally over 15-30 minutes.
Maintenance dose: 60 mL per hour orally of the ethanol 20% solution. 

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Note:
- If patients are not co-operative, administer ethanol via a nasogastric tube.

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CAUTION
Locally available commercial ethanol products are not approved for IV administration and should not be administered via this route.

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• Maintain ethanol levels of 1–1.3 g/L (100–130 mg/dL).
• Where ethylene glycol, methanol (see: Methanol poisoning), and ethanol levels are not available for monitoring purposes, titrate the ethanol rate of administration according to improvement in metabolic acidosis and signs of systemic toxicity.
• Increase the dose of ethanol if the patient is receiving concomitant haemodialysis.
• Several days of ethanol therapy may be required until clinical condition improves.
• Alcoholic beverages are sometimes labelled as "percentage proof". Alcohol proof values are double the alcohol percentage (volume/volume) values. i.e. an 80 proof alcohol would be 40% (v/v).

LoE:IVb^lxi 

Cofactor therapy:

• Thiamine, oral, 100 mg daily.
• Pyridoxine, oral, 100 mg daily.

LoE:IVb^lxii 

Metabolic acidosis: E87.2 + (T52.8/X46.99/X66.99/Y16.99)

• Sodium bicarbonate 8.4%, IV, 50–100 mmol/L administered over 30–45 minutes.

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Note:
- Rapid correction of acidosis may precipitate seizures in a hypocalcaemic patient. Correct severe or clinically evident hypocalcaemia.
- Monitor glucose levels and correct hypoglycaemia, if necessary.

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LoE:IVb^lxiii

REFERRAL

Severe poisoning with profound acidosis for early haemodialysis.

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METHANOL POISONING

T51.1 + (X45.99/X65.99/Y15.99)

DESCRIPTION

Methanol, once present in methylated spirits, was replaced with less toxic agents 10-20 years ago. However, it may still be found in stove or model fuels, as well as in antifreeze and windscreen washes.

Presentation:

• Ingestion of methanol results in initial mild inebriation (headache, confusion, nausea, and vomiting) similar to ethanol intoxication followed by an asymptomatic/latent period.
• After a latent period of about 12-24 hours, toxic metabolite (formic acid) formation results in severe high anion gap metabolic acidosis, and retinal toxicity (from visual impairment to total blindness).

𝐴𝑛𝑖𝑜𝑛 𝑔𝑎𝑝 = 𝑁𝑎 − (𝐶𝐿 + 𝐻𝐶𝑂₃ ) [𝑁𝑜𝑟𝑚𝑎𝑙 = 8 − 16]

MEDICINE TREATMENT

If acidotic or patient has visual disturbances;

Start with immediate ethanol antidote therapy (See: Ethylene glycol poisoning), and evaluate for urgent dialysis, if available.

 LoE:IIIa^lxiv 

Click here to access the pdf.

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Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 2.0_27 March 2025

Chapter 19 Poisoning_19.17 Alcohols