Toxic Alcohols – Dr Eisestat

Ethylene glycol is a glycol and not an alcohol, however still included with methanol as the more toxic alcohols.

Isopropanol and ethanol can still be toxic but significantly less so than methanol and ethylene glycol.

Isopropanol

• Rubbing alcohol
• Metabolizes to acetone
• Can have GI irritation and severe intoxication from this
• Hemorrhagic gastritis can result

Methanol can be found in windshield washer fluid, solid cooking fuel, embalming fluid, and tainted beverages

• Formalin (used in cadaver labs) contains methanol and formaldehyde which is fatal in small mL doses.
• Moonshine called “white lightning” because it causes a white out of your vision with damage to the retina, much like the sensation of being struck by lightning.

Methanol

• Toxic metabolite is formate (formic acid)
• Can result in ocular toxicity, pancreatitis, basal ganglia damage

Ethylene Glycol

• Antifreeze
• Sweet taste (which is a problem for pets and small children)
• Breaks down to glyoxylic acid which involves the renal tubules which results in renal toxicity.
• Oxalate can cause hypocalcemia by precipitation as calcium oxalate.
• Oxalate crystal can form in the urine and can be examined with a wood’s lamp because antifreeze usually contains fluorescein.

Can be treated with ethanol and fomepizole

• Blood ethanol 100-105 mg/dL for treatment
• Children will often be hypoglycemic with treatment
• Adults will become “rowdy.”

Fomepizole

• Approx. $2,000 per dose
• 15mg/kg loading dose then 10mg/kg every 12 hours for 4 doses.
• Increase to 15mg/kg after that if therapy still necessary
• Administer more frequently in hemodialysis

Anyone who has acidosis, clinical symptoms, or concentration greater than 20mg/dL gets treatment.

Hemodialysis

• Half life of ethylene glycol 15 hours
• Half life of methanol 50 hours

https://www.extrip-workgroup.org/ contains a list of recommendations for hemodialysis.

Pancreas – Dr Huecker

The pancreas is retroperitoneal and may not always show signs of peritonitis until very advanced disease.

Lipase will generally have to be 3x upper limit of normal to diagnose pancreatitis

Amylase sensitivity is less than 80%. Lipase is a better test.

CT

• Sensitivity 70-80%
• On a non-contrast scan you are more likely to miss necrotizing pancreatitis

If CT is positive, the patient should be evaluated with ultrasound for concern of gallstone / biliary pathology.

Scorpions and autoimmune are rarer causes of pancreatitis

Management

• Initial 10mg/kg bolus and then 1.5 mL/kg/hr

Multiple scores such as BISAP and Marshall score can be used to risk-stratify

Most patients do not require antibiotics, however if there is extrahepatic infection or necrosis, it is necessary.

Imipenem and meropenem are specific antibiotics which can penetrate the biliary system well.

Abdominal hypertension is a potential very serious risk

Encourage early enteral feeding in mild cases

Pseudoscysts:

• Consider this diagnosis and obtain CT A/P
• If you don’t think about it, you wont diagnose it.
• Can be drained with IR or GI

Pancreatic Cancer:

• 7^th leading cause of death
• Painless jaundice is a big indicator.