01Approach to the Critical Patient/attcp51

Immediate priorities

›Airway and breathing threats

›Respiratory depression from CNS depression

›GCS < 8 mandates airway protection

›Aspiration risk with obtundation and vomiting

›If unable to protect airway, proceed to rapid sequence intubation

›Class I recommendation

›Anticipate regurgitation risk

›Oxygenation and ventilation monitoring

›SpO2 target >= 94%

›Capnography if intubated

›Circulation threats

›Cardiovascular collapse from myocardial depression

›Isopropanol direct myocardial depressant effect

›SBP < 90 mmHg requires IV fluid resuscitation

›Isotonic crystalloid 1 to 2 L IV bolus for hypotension

›Reassess after each bolus

›Vasopressors if refractory to fluids

›Hemorrhagic gastritis with hemodynamic instability

›GI bleed as source of shock

›Hematemesis mandates urgent GI assessment

Monitoring and escalation

›Monitoring bundle

›Continuous cardiac monitoring

›Arrhythmia from electrolyte shifts

›QTc prolongation if coingestants present

›Serial mental status reassessment every 30 to 60 minutes

›Glasgow Coma Scale trending

02History/hx55

Exposure and ingestion details

›Substance and formulation

›Rubbing alcohol (70% isopropanol solution)

›Most common source of acute poisoning

›As little as 1 mL/kg of 70% solution produces symptoms

›Hand sanitizers and household products

›Variable isopropanol concentrations

›Often co-ingested with other agents

›Concentrated industrial products

›99% isopropanol solvents

›Occupational or substitution use

›Ingestion context

›Amount ingested and time of ingestion

›Peak plasma levels within 30 minutes of oral ingestion

›Rapid CNS depression onset

›Route of exposure

›Oral ingestion most common

›Inhalation or dermal absorption less toxic but possible

›Intentional vs accidental

›Intentional: suicidal ideation or ethanol substitute

›Accidental: most common in children under 6 years

Symptom timeline

›Symptom progression pattern

›Early phase: inebriation and ataxia

›Slurred speech

›Dizziness and headache

›Intermediate phase: CNS depression

›Obtundation

03Physical Exam/exam60

Vitals and general appearance

›Vital sign patterns

›Blood pressure

›Hypotension from myocardial depression or vasodilation

›SBP < 90 mmHg as alarm finding

›Heart rate

›Tachycardia common from volume depletion

›Bradycardia with severe poisoning

›Respiratory rate

›Depression and hypoventilation at high levels

›No Kussmaul breathing (distinguishes from methanol and ethylene glycol)

›Temperature

›Hypothermia from CNS depression and vasodilation

›General appearance

›Acetone odor on breath

›Fruity or sweet smell

›Classic and distinguishing feature of isopropanol poisoning

›Level of consciousness

›Ranges from inebriation to deep coma

›GCS documentation essential

Neurological examination

›CNS findings

›Mental status

›Confusion to obtundation to coma

›GCS < 8 triggers airway protection

›Cerebellar findings

›Ataxia

›Slurred speech

04Differential Diagnosis/ddx48

Life threats to exclude first

›Other toxic alcohol ingestions

›Methanol poisoning

›ICD-10 T51.1

›High anion-gap metabolic acidosis distinguishes from isopropanol

›Visual changes including blindness

›Onset 6 to 24 hours after ingestion

›Ethylene glycol poisoning

›ICD-10 T51.8

›High anion-gap metabolic acidosis

›Calcium oxalate crystalluria

›Acute kidney injury and hypocalcemia

›Ethanol intoxication

›ICD-10 T51.0

›No ketonemia

›Positive serum ethanol

›No osmol gap elevation from other sources

Ketosis producing diagnoses

›Diabetic ketoacidosis

›ICD-10 E11.10

›Hyperglycemia and elevated beta-hydroxybutyrate

›High anion-gap metabolic acidosis

›Glucose distinguishes from isopropanol

›Alcoholic ketoacidosis

›ICD-10 G31.2 related

›Elevated beta-hydroxybutyrate (isopropanol has low or absent beta-hydroxybutyrate)

›High anion-gap metabolic acidosis in alcoholic ketoacidosis

›Chronic ethanol use history

05Laboratory Tests/lt64

Core diagnostic labs

›Serum chemistry panel

›Electrolytes and anion gap calculation

›Anion gap = Na - (Cl + HCO3); normal 8 to 12 mEq/L

›Normal anion gap is hallmark of isopropanol toxicity

›Elevated anion gap mandates consideration of methanol or ethylene glycol

›Renal function

›BUN and creatinine

›Creatinine may be spuriously elevated via Jaffe assay interference from acetone

›Glucose

›Rule out hypoglycemia in altered mental status

›Point of care glucose as immediate bedside test

›Osmolality and osmol gap

›Measured serum osmolality by freezing-point depression

›Calculated osmolality = 2(Na) + glucose(mmol/L) + urea(mmol/L)

›Osmol gap = measured minus calculated osmolality

›Osmol gap > 10 mOsm/kg is significant

›Elevated osmol gap confirms presence of osmotically active substance

›Isopropanol and acetone both contribute to osmol gap

›Osmol gap magnitude correlates with serum isopropanol level

Specific toxicology tests

›Serum isopropanol and acetone levels

›Gas chromatography or HPLC quantification

›Definitive identification and quantification

›Not always rapidly available at point of care

›Clinical significance thresholds

›> 8 mmol/L (50 mg/dL) clinically significant

›> 25 mmol/L (150 mg/dL) associated with deep coma

06Diagnostic Tests/dt60

Scoring Systems

›Toxicology severity assessment tools

›Poisoning Severity Score

›Grades toxicity as none, minor, moderate, severe, fatal

›Based on signs and symptoms not serum level alone

›Guides disposition and intensity of monitoring

›Serum isopropanol level as clinical guide

›> 8 mmol/L (50 mg/dL): symptomatic, monitoring required

›> 25 mmol/L (150 mg/dL): deep coma expected

›>= 83 mmol/L (500 mg/dL): hemodialysis consideration

›GCS for neurological severity grading

›GCS < 8: airway protection mandatory

›GCS 9 to 13: close monitoring, low threshold for intubation

›GCS 14 to 15: alert, supportive care adequate

MRI

›MRI role in isopropanol toxicity

›Limited role in acute management

›Availability and time constraints in acute poisoning

›Patient cooperation impaired with CNS depression

›Potential indications

›Disproportionate or prolonged neurological deficit

›Concern for concurrent structural brain injury

›Basal ganglia injury if chronic or repeated toxic exposure

›Contraindications considerations

›Unstable patient is absolute contraindication

›Implant screening required

CT

›CT head indications

07Disposition/dispo46

Level of care criteria

›ICU admission indications

›Altered mental status with GCS < 13

›Airway protection concern

›Continuous monitoring required

›Hemodynamic instability

›Refractory hypotension

›Vasopressor requirement

›Respiratory depression

›Intubated patients

›High-flow oxygen requirement

›Very high serum isopropanol level

›>= 83 mmol/L (500 mg/dL)

›Hemodialysis planning or initiation

›General medical admission indications

›Symptomatic with improving trajectory

›GCS 13 to 15 and improving

›Stable hemodynamics without vasopressors

›Intentional ingestion requiring psychiatric evaluation

›All intentional ingestions admitted for monitoring and assessment

›Safety assessment before discharge

Discharge criteria

›Criteria for safe discharge

›Return to full baseline mental status

›GCS 15

›Normal cognition and gait

›Hemodynamically stable for observation period

›Minimum 4 to 6 hour observation after last exposure

08Treatment/t88

Immediate supportive care

›Airway management

›Endotracheal intubation for GCS < 8 or airway compromise

›Rapid sequence intubation preferred

›Ketamine 1 to 2 mg/kg IV as induction agent

›Succinylcholine 1.5 mg/kg IV or rocuronium 1.2 mg/kg IV

›Aspiration precautions before intubation

›Head up 30 degrees

›Suction oropharynx

›Volume resuscitation

›Isotonic crystalloid for hypotension

›Normal saline or lactated Ringer's 1 to 2 L IV bolus

›Reassess after each 500 mL increment

›Target MAP >= 65 mmHg

›Vasopressors for refractory hypotension

›Norepinephrine 0.01 to 3 mcg/kg/min IV infusion

›Titrate to MAP >= 65 mmHg

›Central venous access preferred for vasopressor infusion

Antiemetic therapy

›Nausea and vomiting management

›Ondansetron IV

›4 mg IV every 4 to 6 hours as needed

›Preferred: low QTc prolongation risk

›Maximum 24 mg per day

›Metoclopramide IV

›10 mg IV every 6 to 8 hours as needed

›Caution: extrapyramidal effects

›Avoid in CNS depression (compounds sedation)

›Prochlorperazine

›10 mg IV or IM

›Alternative if ondansetron unavailable

›Monitor for dystonic reaction

Agents to avoid

›Contraindicated or unhelpful treatments

›Fomepizole (4-methylpyrazole)

›Inhibits alcohol dehydrogenase

›Slows conversion of isopropanol to acetone

›Prolongs isopropanol half-life and clinical toxicity

›Ethanol

›Also inhibits alcohol dehydrogenase

›Compounds CNS depression

›No therapeutic role in isopropanol poisoning

›Activated charcoal

›Isopropanol absorbed rapidly (peak within 30 minutes)

›Poor adsorption to charcoal

›Aspiration risk outweighs benefit

›Sedatives and opioids

›Compound CNS and respiratory depression

›Avoid unless required for agitation management in intubated patient

Hemodialysis

›Indications for hemodialysis

›Serum isopropanol >= 83 mmol/L (500 mg/dL)

›Threshold based on expert consensus

›Accelerates elimination of isopropanol and acetone

›Hemodynamic instability refractory to supportive care

›Cardiovascular compromise despite vasopressors

›Anticipated prolonged course

›Renal failure impairing elimination

›Chronic kidney disease with rising levels

›Acute kidney injury in context of toxicity

›Hemodialysis practicalities

›Isopropanol effectively removed by hemodialysis

›Low molecular weight and water solubility

›Half-life reduced from approximately 3 to 7 hours to 1.5 hours during dialysis

›Acetone also removed

›Accelerates resolution of osmol gap

›Continuous renal replacement therapy as alternative

›Less efficient but option when hemodynamically unstable

›Consult nephrology for modality selection

›Rebound levels may occur after session completion

›Redistribution from tissues

›Repeat serum levels post-dialysis

Hemorrhagic gastritis management

›GI bleed management

›Proton pump inhibitor therapy

›Pantoprazole 80 mg IV bolus followed by 8 mg/hour infusion

›Switch to oral PPI when tolerating intake

›GI consultation for hematemesis or significant GI bleeding

›Endoscopy timing guided by hemodynamic stability

›Transfuse packed red blood cells for hemoglobin < 70 g/L

›NPO if significant GI bleeding

›IV fluids for hydration

›Serial hemoglobin monitoring every 4 to 6 hours

Pancreatitis management

›Acute pancreatitis supportive care

›Aggressive IV fluid resuscitation

›Lactated Ringer's preferred over normal saline

›250 to 500 mL/hour initial rate titrated to urine output > 0.5 mL/kg/hour

›NPO until nausea and vomiting resolve

›Advance diet as tolerated

›Early enteral feeding if prolonged course

›Analgesia

›Hydromorphone 0.2 to 1 mg IV every 3 to 4 hours as needed

›Use cautiously given CNS depression risk

09Special Populations/sp64

Pregnancy

›Pregnancy-specific considerations

›Isopropanol crosses placenta

›Fetal CNS depression risk

›Teratogenicity not well established but avoidance critical

›Altered pharmacokinetics in pregnancy

›Increased plasma volume may alter distribution

›Renal blood flow increased may accelerate elimination

›Management priorities

›Maternal stabilization is primary priority

›Fetal monitoring when viable gestation

›Obstetrics consultation for all pregnant patients

›Imaging and treatment adjustments

›Radiation exposure minimization

›Chest X-ray with abdominal shielding when indicated

›Limit CT to essential imaging

›Antiemetic safety

›Ondansetron: generally used; avoid first trimester if possible

›Metoclopramide: acceptable in pregnancy

›Hemodialysis in pregnancy

›Appropriate when indications met

›Fetal monitoring during procedure

Geriatric

›Older adult specific risks

›Altered pharmacokinetics

›Decreased total body water increases distribution volume-related peak levels

›Reduced hepatic and renal clearance prolongs half-life

›Increased CNS sensitivity

10Background/b61

Epidemiology

›Frequency and patterns

›Most commonly ingested toxic alcohol worldwide

›Found in rubbing alcohol, hand sanitizers, household cleaners, solvents

›Widely available and inexpensive

›Exposure demographics

›Accidental ingestion predominant in children under 6 years

›Intentional ingestion in adults: ethanol substitute or self-harm

›Mortality profile

›Deaths rare with prompt supportive care

›Isopropanol toxicity significantly less fatal than methanol or ethylene glycol

›Healthcare burden

›Common presentation to emergency departments

›Poison control centers receive thousands of calls annually

›Majority managed in ED without ICU admission

›Coingestion complicates outcomes

›Sedatives, other toxic alcohols, medications

›Increases morbidity and diagnostic complexity

Pathophysiology

›Metabolism pathway

›Primary metabolism via alcohol dehydrogenase

›Isopropanol converted to acetone (not an organic acid)

›Acetone has CNS depressant properties

›Half-life isopropanol approximately 3 to 7 hours

›Why no anion-gap metabolic acidosis

›Acetone is not an organic acid (unlike formate or glycolate from other toxic alcohols)

›No accumulation of acid anions

›Key differentiator from methanol and ethylene glycol

11Patient Discharge Instructions/pdi27

copy discharge instructions

›Isopropanol poisoning home care instructions

›Rest and hydration for 24 to 48 hours

›Oral fluids as tolerated

›Avoid alcohol and sedatives

›No driving, operating machinery, or making important decisions for 24 hours

›Persistent impairment possible after apparent recovery

›Complete any prescribed medications

›Follow discharge medication instructions exactly

›Warning signs to return to emergency immediately

›Return if confusion, extreme drowsiness, or difficulty waking

›Return if vomiting blood or black tarry stools

›Return if severe abdominal pain develops or worsens

›Return if breathing feels difficult or slowed

›Return if unable to keep any fluids down

›For intentional ingestion follow-up

›Mental health follow-up appointment scheduled before leaving hospital

›Crisis resources provided

›National Suicide Prevention Lifeline 988

›Local crisis centre contact information

›Safe storage of household chemicals discussed

›Lock away rubbing alcohol, hand sanitizers, cleaning products

›Reduce access to potential ingestion agents

›Safe product storage at home

›All isopropanol-containing products stored out of reach of children

›Locked storage strongly recommended

›Do not store rubbing alcohol or hand sanitizer in unlabeled or food containers

›Dispose of unused or expired products safely

12References/r15

Guidelines and key sources

›Toxicology guidelines and reviews

›Kraut JA, Mullins ME. Toxic Alcohols. New England Journal of Medicine 2018; 378(3):270-280

›Comprehensive review including isopropanol diagnostic and management algorithm

›Barceloux DG et al. American Academy of Clinical Toxicology Practice Guidelines on the treatment of isopropanol, methanol and ethylene glycol poisoning. Journal of Toxicology: Clinical Toxicology 2002

›UpToDate: Isopropyl alcohol poisoning (current version)

›Poison control and emergency medicine references

›American Association of Poison Control Centers national data reports

›Annually published exposure statistics

›Isopropanol among most frequent toxic alcohol exposures

›ACEP Clinical Policy on evaluation and management of patients with altered mental status

›Level B: osmol gap measurement in toxic alcohol exposure suspected

›Diagnostic standards

›ICD-10 T51.2 toxic effects of isopropanol

›SNOMED CT: isopropanol poisoning disorder

›Osmol gap reference ranges from clinical laboratory standards

Evidence & Review

Evidence & Review