20.Sep.2018-Expires: 7 days - Do not archive

Ethylene Glycol

Ethylene Glycol
20.Sep.2018-Expires: 7 days - Do not archive

DESCRIPTION

SUBSTANCE NAME

Ethylene Glycol
 

SUBSTANCE CLASS

Glycol
 

PHYSICOCHEMICAL PROPERTIES

Colorless, odorless, sweet-tasting, hygroscopic liquid
 
Molecular Weight
62.07 62.07% degrees C[1]
Melting Point
-13 -13% degrees C[1]
Specific Gravity (water = 1)
1.1274 1.1274% degrees C[1]
Flash Point
115 115% degrees C[1]
Solubility
Water: miscible[1]
Ethanol: miscible[1]
Glycerol: miscible[1]
Acetic acid: miscible[1]
Acetone: miscible[1]
Ether: slightly soluble[1]
Benzene: insoluble[1]
Chlorinated hydrocarbons: insoluble[1]
Petroleum ether: insoluble[1]
Oils: insoluble[1]
 

USES

Ethylene glycol is predominantly used as a deicer or antifreeze in cooling systems. It is also used in hydraulic brake fluids, as a solvent, a chemical intermediate, and as an industrial humectant. It may also be used as a glycerin substitute in commercial products including paints, detergents, and cosmetics.
 

INTERVENTION CRITERIA

Intervention Level

Child

Medical assessment and observation in an emergency department is recommended for:
- Ingestions greater than a witnessed lick or exploratory taste (e.g. a small sip) of ethylene glycol
- Ingestions where the dose is unknown
- Symptomatic ingestions
- All eye exposures (if symptomatic following flushing)
- Significantly symptomatic patients (more than mild irritation) following skin or inhalation exposure
 

Adult

Medical assessment and observation in an emergency department is recommended for:
- Ingestions of greater than 10 mL of ethylene glycol
- Ingestions where the dose is unknown
- Exposures with intent to self-harm
- Symptomatic ingestions
- All eye exposures (if symptomatic following flushing)
- Significantly symptomatic patients (more than mild irritation) following skin or inhalation exposure
 

Observation Period

Observation at Home

If the patient does not require medical observation they can be monitored at home for 8 hours in the care of a reliable observer.
 
The patient should be medically assessed if any symptoms develop, including:
Nausea
Vomiting
Drowsiness
Slurred speech
Stumbling or difficulty in moving
Confusion
Decreased urine output
 

Medical Observation

If medical observation is required the patient should be monitored until 8 hours post-exposure for the onset or worsening of symptoms. Patients co-ingesting ethanol should be monitored until 12 hours.
 
If the patient is asymptomatic at the end of the observation period, their venous bicarbonate concentration is greater or equal to 20 mmol/L (mEq/L) and their serum (or breath) ethanol concentration is zero (in adults), and any investigations have been carried out, they may be:
Discharged into the care of a reliable observer, or
Referred for psychological assessment if the overdose or exposure was with intent to self-harm
 

Investigations

Patients, particularly children, presenting within an hour of suspected ethylene glycol ingestion may not have any abnormal surrogate markers of ingestion. In these instances, close observation and serial monitoring of acid-base and renal function status should be performed. Any development of early metabolic acidosis would be highly suggestive of recent ethylene glycol exposure.
 
Serum ethylene glycol concentration (where available in a practical time frame i.e.: 1 to 2 hours)
Serum ethanol concentration (required for osmolar gap calculation)
Osmolar gap (elevated in early stages of poisoning)
Serum electrolytes including:
Calcium
Chloride (required for anion gap calculation)
Potassium
Anion gap (elevated in later stages of poisoning)
Arterial pH
Serum bicarbonate
Urinalysis including:
Proteinuria
Hematuria
Examination under UV light (Wood’s lamp) for fluorescence (present in many antifreeze solutions and with urinary elimination the urine will fluoresce when expose to UV light). A negative result does not completely rule out ethylene glycol exposure.
Microscopic examination for crystalluria (calcium oxalate crystals)
 
If a serum ethylene glycol concentration measurement is not available a presumptive diagnosis of poisoning may be based on:
 
either
 
A history or suspicion of ethylene glycol ingestion plus any 2 of the following;[2][3]
Arterial pH < 7.3
Serum bicarbonate < 20 mmol/L (20 mEq/L)
Osmolar gap > 10 mOsm/L
Presence of urinary oxalate crystals
 
or
 
A history or suspicion of ethylene glycol ingestion within the last 1 hour and osmolar gap > 10 mOsm/L
 
A serum ethylene glycol is the preferred investigation, but is commonly not readily available at most institutions. A significant ethylene glycol ingestion may be inferred from an increased osmolar gap (in the early stages of intoxication) indicating a solute (glycol) load. However, a negative test result cannot rule out the uncommon case of ethylene glycol exposure with a normal osmolar gap. Once the glycol is metabolized the osmolar gap will drop and may be replaced by an increased anion gap, indicating an increased organic acid (glycol metabolite) load, with an accompanying metabolic acidosis.
 
Presence in the urine of either fluorescein or calcium oxalate crystals indicates ethylene glycol exposure, but their absence does not exclude this poisoning. Calcium oxalate crystals may not be present until the later stages of intoxications. Fluorescein is rapidly eliminated by the kidneys and may have already been excreted prior to presentation. Also, the ingested ethylene glycol may not contain fluorescein. Care must be exercised when checking for fluorescence as plastic containers may exhibit some degree of fluorescence under a UV light. A glass container is preferable and previous experience with visualizing fluorescein containing urine is useful.
 

Admission Criteria

Admission to an intensive care environment is recommended when:
Ethylene glycol concentrations are > 8.1 mmol/L (50 mg/dL)
Those receiving ethanol therapy
Following symptoms occur
Coma
Seizures
Kidney injury
Hypotension
 
Ensure the receiving hospital is able to provide:
The specific antidotes (Ethanol or Fomepizole)
Advanced care/ICU facilities, and
Hemodialysis
 

TREATMENT

TREATMENT SUMMARY

Initial management includes airway protection, administration of IV fluids, treating any seizures with a benzodiazepine, and correcting hypoglycemia (unless rapid glucose screen indicates otherwise); concurrently administer thiamine and multivitamins if alcoholism is suspected. Nasogastric aspiration may be performed within 1 to 2 hours of ingestion provided the airways are protected. Ethanol and fomepizole are effective antidotes and should be administered to patients with an elevated osmolar gap and anion gap acidosis.[3] Hemodialysis is effective in excreting glycols and their toxic metabolites and should be considered in acute renal failure or severe metabolic acidosis. Doses of ethanol and fomepizole need to be increased during hemodialysis.[4][5]
 
Acidosis should be managed with generous sodium bicarbonate to return base excess to normal within 12 to 24 hours. Large quantities may be required, and iatrogenic hypernatremia may occur. Hypocalcemia should only be reversed if cardiac dysrhythmia occurs (particularly QT prolongation), or seizures prove unresponsive to management. Hypoglycemia, hyperkalemia, and hypomagnesemia should be corrected. Calcium oxalate crystals may form in any organ with resultant multiorgan dysfunction/failure. The kidneys are often afflicted, resulting in acute kidney injury. There is also a risk of acute respiratory distress syndrome, and fluid balance will require careful (possibly invasive) monitoring. Stupor or coma indicates metabolic encephalopathy or cerebral edema.[6] Cranial nerve palsies may occur some 4 to 18 days following ingestion and usually spontaneously resolve over weeks to months without specific therapy.[7][8][9]
 
ICU admission is recommended in patients with coma, seizures, renal failure, hypotension, ethylene glycol concentration > 8.1 mmol/L (50 mg/dL), or receiving ethanol therapy.
 
Eye exposures require a 15 minute flush with saline and if more than mild, resolving symptoms are present following irrigation, a full ophthalmologic examination should be undertaken, including slit lamp examination and fluorescein staining. If there is evidence of injury an ophthalmologist should be consulted. Treatment should follow standard protocols for the management of eye irritation.
 
Emergency Stabilization
Ensure adequate cardiorespiratory function
Hypotension
Seizure
Hypoglycemia
Emergency monitoring
Decontamination
Ingestion
Nasogastric aspiration
Eye
Irrigate immediately
Inhalation
Fresh air, oxygen
Skin
Irrigate
Antidote(s)
Ethanol
Fomepizole
Pyridoxine
Thiamine
Enhanced Elimination
Hemodialysis
Urinary alkalinization
Supportive Care
Monitoring
Metabolic
Metabolic acidosis
Renal
Acute renal failure
Fluid and electrolytes
Hypocalcemia
Hypomagnesemia
Hyperkalemia
Neurologic
CNS depression
Seizure
Neurotoxicity
Cardiovascular
Hypotension
Hepatic
Hepatotoxicity
Respiratory
Acute respiratory distress syndrome (ARDS)
Pulmonary edema
 

EMERGENCY STABILIZATION

Ensure Adequate Cardiopulmonary Function

Airway

Ensure the airway is protected (intubation may be required), and administer oxygen. Establish secure intra-venous access.
 

Hypotension

Hypotension may be significant due to gastrointestinal fluid loss, and in such cases fluid replacement should be aggressive where possible, having regard to renal function.
 
Immediately establish secure intravenous access.
 
CHILD
Where the systolic blood pressure is below normal blood pressure ranges for the age group:[10]
 
Age (years)
Normal Systolic Blood Pressure (mm Hg)
< 1
70 to 90
1 to 2
80 to 95
2 to 5
80 to 100
5 to 12
90 to 110
> 12
100 to 120
 
Administer normal (0.9%) saline
10 mL/kg IV over 5 to 10 minutes
 
If the systolic blood pressure does not return to the normal range, give a further 10 mL/kg body weight normal saline over 5 to 10 minutes. If intravenous access cannot be obtained consider intra-osseus access.
 
ADULT
Administer a bolus of normal saline if systolic blood pressure is less than 100 mmHg.
 
Normal (0.9%) saline dose:
10 mL/kg IV over 5 to 10 minutes
 
If the systolic blood pressure does not return to the normal range, give a further 10 mL/kg body weight normal saline over 5 to 10 minutes.
 

Seizure

Most toxic seizures are short-lived and often do not require intervention.[11]
 
Administer a benzodiazepine as first-line treatment to patients with seizure activity.[11]
 
Blood glucose concentration should be promptly determined. If the result indicates hypoglycemia, or is unobtainable, 50% dextrose should be administered IV (preceded by thiamine in adults).
 
Seizures due to ethylene glycol intoxication may prove unresponsive to standard management unless hypocalcemia is corrected.

Hypoglycemia

IV dextrose is indicated (even if blood glucose cannot be quickly measured) in patients with altered mental status, unusual behavior, coma, or seizures. Hypoglycemic patients may present with focal neurological deficits.[12] However, these may also be due to cerebral ischemia. As administration of dextrose may exacerbate ischemic injury,[13] it is important to verify hypoglycemia with blood glucose measurement prior to use - unless this would lead to unacceptable delay in administration.
 
Thiamine
Must be administered to adult patients considered alcoholic or malnourished.[3][14]
 
Thiamine dose
 
ADULT
100 mg IV
 

Emergency Monitoring

ECG
Blood pressure
Respiratory rate
Oxygen saturation
Electrolytes including:
Calcium
Magnesium
Chloride (for calculation of anion gap)
Potassium
Serum ethylene glycol concentration (if available)
Anion gap (elevated later in poisoning)
Serum ethanol concentration (used in calculation of osmolar gap)
Osmolar gap (elevated early in poisoning)
Arterial blood gases including:
Arterial pH
Bicarbonate
 

DECONTAMINATION

Ingestion

Nasogastric Aspiration

Nasogastric aspiration is recommended if the quantity of liquid ingested is both systemically toxic and in sufficient volume to aspirate. As this procedure may increase the risk of vomiting and pulmonary aspiration, the airway must be protected in all patients. Accurate placement of the nasogastric tube must also be ensured in all patients.
 
Nasogastric aspiration is recommended if the patient has presented early (within 1 to 2 hours) following ingestion of ethylene glycol.

Single Dose Activated Charcoal

Activated charcoal is not considered an effective decontaminant for this ingestion as ethylene glycol is rapidly absorbed from the gastrointestinal tract and has poor binding affinity for activated charcoal. Unless there is concern for coingestants, there is little benefit from activated charcoal administration in ethylene glycol ingestions.

Eye

Remove contact lenses. Irrigate immediately with water or saline for at least 15 minutes. If the eye is contaminated with solid particles, the eyelid should be completely everted and any solid material removed as quickly as possible whilst continuing to irrigate. A topical anesthetic may be necessary in some patients, especially children, to enable the patient to open the lids sufficiently for effective irrigation.
 
If, following irrigation, any of the following are apparent:
Ocular pain (other than mild and resolving)
Erythema (other than mild and resolving)
Decreased visual acuity
Ocular discharge/crusting
 
The patient should receive a full ophthalmologic examination, including slit lamp examination and fluorescein staining. If there is evidence of injury an ophthalmologist should be consulted.
 

Inhalation

Remove the patient from the exposure. If respiratory symptoms such as shortness of breath are present, administer oxygen and provide additional support if necessary.
 

Skin

Remove any contaminated clothing or jewelery. Wash the affected area thoroughly with soap and water until all of the contaminant is removed.
 

ANTIDOTE(S)

Appropriate use of antidotes in glycol poisoning is essential. Ethanol has long been regarded as an effective intervention, is cheap and available but requires longer periods of monitoring due to the risk of ethanol intoxication. Fomepizole has proven efficacy,[15] but suffers the disadvantage of expense. Both effectively act (via different mechanisms) by inhibiting the role of alcohol dehydrogenase in ethylene glycol metabolism, thus reducing the metabolic conversion of glycol to toxic metabolites (acids).
 
Thiamine and pyridoxine may be indicated as therapeutic adjuncts. Theoretically, they act as cofactors in the formation of non-toxic metabolites of ethylene glycol. No data exists to support this assumption, but they may benefit those with a history of ethanol abuse or inadequate nutrition (e.g. vitamin deficient patients).[3]
 
Ethanol
Fomepizole
Pyridoxine
Thiamine
 

Ethanol

Indications

Ethanol is indicated if:[3]
- Reliable history of ingestion of a toxic quantity of ethylene glycol; or
- Plasma ethylene glycol concentration is greater than 3.2 mmol/L (20 mg/dL) or;
- Recent ingestion of greater than 0.2 mL/kg ethylene glycol and presence of osmolar gap of greater than 10 mosm/L or;
- History or clinical suspicion of ethylene glycol poisoning and at least two of the following:
Arterial pH < 7.3
Serum bicarbonate < 20 mmol/L (20 mEq/L)
Osmolar gap > 10 mosm/L
Presence of urinary oxalate crystals
 

Dose and Administration

For acceptable efficacy, the blood ethanol concentration should be maintained between 22 and 33 mmol/L (100 to 150 mg/dL).[3] To achieve this both a loading dose and maintenance infusion are required. Either 100% ethanol diluted for intravenous use may be infused, or liquor (e.g. vodka, gin) may be administered orally.
 
Prior to use of ethanol therapy a blood ethanol determination should be made to identify if the patient has an existing ethanol concentration requiring a modification of the loading dose. Monitoring in an intensive care setting is required during administration.
 
As ethanol may depress respiration, mechanical hyperventilation is recommended in those with reduced level of consciousness.[16]
 
Loading Dose
Oral Ethanol Loading Dose
 
To calculate the loading dose of oral ethanol from common concentrations in spirits use the appropriate calculation below. The dose should be administered as a 20% or less solution (e.g. diluted with water or fruit juice).
 
Ethanol %
Dose (mL)
37/37.5%
body weight x 2.5
40%
body weight x 2.3
42%
body weight x 2.2
45%
body weight x 2.04
 
If the concentration of spirits does not match those in the above table the dose can be calculated by clicking here.
 
Note: The term "proof" describing alcohol content of beverages should be halved to obtain the proper % v/v value (e.g. 60 proof = 30% v/v ethanol).
 
 
Intravenous Ethanol Loading Dose
 
Concentrated ethanol solutions need to be diluted to prevent vascular damage, and reduce fluid load in pediatric patients or those suffering from cerebral edema. To convert concentrated ethanol formulations to 5 or 10% click here.
 
To reach the desired blood ethanol concentration of 22 to 33 mmol/L (100 to 150 mg/dL) administer:
5% v/v ethanol:
15 to 22.5 mL/kg over 30 minutes
10% v/v ethanol:
7.5 to 11.25 mL/kg over 30 minutes.
 
If you have w/v formulations please click here to convert to v/v
 
Maintenance Dose
Oral Ethanol Maintenance Dose
 
Ethanol %
Children (mL/h)
Adults (non-alcoholics) (mL/h)
Adults (alcoholics) (mL/h)
37%
0.61 x body weight
0.41 x body weight
0.82 x body weight
40%
0.57 x body weight
0.38 x body weight
0.76 x body weight
42%
0.54 x body weight
0.36 x body weight
0.72 x body weight
45%
0.5 x body weight
0.33 x body weight
0.67 x body weight
 
This should be administered as a 20% or less solution (e.g. diluted with water or fruit juice).
 
If the concentration of spirits does not match those in the above table the dose can be calculated by clicking here.
 
Intravenous Ethanol Maintenance Dose
 
Concentrated ethanol solutions need to be diluted to prevent vascular damage, and reduce fluid load in pediatric patients or those suffering from cerebral edema. To convert concentrated ethanol formulations to 5 or 10% click here.
 
5% v/v solution:
CHILD
4.5 mL/kg/h
ADULT
Non-alcoholic:
2.25 to 3 mL/kg/h
Alcoholic:
4.5 to 6 mL/kg/h
 
10 % v/v solution:
CHILD
2.25 mL/kg/h
ADULT
Non-alcoholic:
1.125 to 1.5 mL/kg/h
Alcoholic:
2.25 to 3 mL/kg/h
 
If you have w/v formulations please click here to convert to v/v.
 

Antidote Endpoint

Ethanol administration may be discontinued if ethylene glycol concentrations can no longer be detected or are less than 3.2 mmol/L (20 mg/dL) with a normalized arterial pH - this is likely to take 2 to 3 days given ethylene glycol's typical elimination half-life of around 17 hours in the presence of ethanol.[3]
 

Precautions

Hypoglycemia may occur, especially in children.[17] Once an infusion has been commenced blood glucose concentrations must be determined on a frequent basis (every 20 to 60 minutes). It may be necessary to add dextrose to intravenous solutions, or give glucose if ethanol is being administered orally.
 
It is recommended that patients receiving ethanol therapy be monitored in an intensive care setting and any decline in respiratory drive countered with hyperventilation.[16]
 

Fomepizole

While availability is limited by purchase price, fomepizole appears preferable to ethanol. It is more particularly indicated in those with altered mental status, patients suffering hepatic disease, or those critically ill but lacking confirmation of poisoning. Its administration to pediatric patients avoids the disadvantages of ethanol (e.g. inebriation, hypoglycemia).[3]
 

Indications

Fomepizole is indicated if:[3]
 
- Plasma ethylene glycol concentration greater than 3.2 mmol/L (20 mg/dL) or;
- Recent ingestion of greater than 0.2 mL/kg ethylene glycol and presence of osmolar gap greater than 10 mosm/L or;
- History or clinical suspicion of ethylene glycol poisoning and at least two of the following
Arterial pH < 7.3
Serum bicarbonate < 20 mmol/L (20 mEq/L)
Osmolar gap > 10 mosm/L
Presence of urinary oxalate crystals
 
Particular indications:[3]
- Altered mental status
- Hepatic disease
- Critically ill patients lacking confirmation of ethylene glycol toxicity
- Pediatric patients (avoids the inebriation and hypoglycemia that may occur with ethanol administration)
 

Dose and Administration

Child
There are no specific dosing recommendations for fomepizole in pediatric patients. Consultation with a medical toxicologist or a Poisons Center for dosing is recommended
 
Adult
Loading dose[4]
 
- 15 mg/kg diluted in 100 mL of normal saline or 5% dextrose in water and administered by IV infusion over 30 minutes
 
Maintenance doses[4]
 
- 10 mg/kg should be administered every 12 hours for 4 doses, then;
- 15 mg/kg every 12 hours thereafter if indicated
 
Maintenance fomepizole should be administered in the same fashion as the loading dose. Dosing requirements will change if hemodialysis is required – as outlined in the enhanced elimination section.
 

Antidote Endpoint

Fomepizole may be discontinued when ethylene glycol plasma concentrations are either undetectable, or below 3.2 mmol/L (20 mg/dL) in an asymptomatic patient with a normal pH.[4]
 

Adverse Effects

Abdominal pain, skin rash, nausea, headache, dizziness, and drowsiness have been reported following fomepizole use.[4]
 

Pyridoxine (Vitamin B6)

Pyridoxine acts as a co-factor in the conversion of glyoxylic acid to the non-toxic metabolite glycine. While the clinical benefit of pyridoxine administration for the treatment of ethylene glycol poisoning has not been demonstrated in healthy individuals, it is recommended for use in malnourished or alcoholic patients who may have vitamin deficiencies.[3]
 

Dose and Administration

The formulation should be diluted at least 1 to 5.
 
ADULT
- 50 to 100 mg pyridoxine given as an IV infusion over 15 to 30 minutes every six hours
- Continue for two days[18]
 

Precautions

Profound peripheral neuropathy may occur after very large single doses[19] or a series of doses (for example a total of > 2 g/kg pyridoxine over a three day period).[20] The sensory (if not motor) disturbances are potentially irreversible.[21]
 

Thiamine

Thiamine acts as a co-factor in the conversion of glyoxylic acid to the non-toxic metabolite alpha-hydroxy-beta-ketoadipate. While the clinical benefit of thiamine administration for the treatment of ethylene glycol poisoning has not been demonstrated in healthy individuals, it is recommended for use in malnourished or alcoholic patients who may have vitamin deficiencies.[3]
 

Dose and Administration

ADULT
- Administer 100 mg IV or IM thiamine every six hours
- Continue for two days[18]
 

ENHANCED ELIMINATION

Hemodialysis

Hemodialysis is a highly effective method to enhance excretion of glycols and their toxic metabolites, reducing duration of antidote use and enhancing patient outcome. The approximately 6-hour elimination half-life of ethylene glycol may be reduced to 3 to 3.5 hours or 2.5 hours with ethanol administration.[22][23][24] In severe poisonings it can be life-saving. If dialysis is prolonged monitor for and treat hypophosphatemia.
 
Hemodialysis is indicated where:[3]
Clinical signs are deteriorating despite intensive supportive care or;
Metabolic acidosis with pH < 7.25 unresponsive to therapy or;
Acute kidney injury or;
Serum ethylene glycol concentration > 8.1 mmol/L (50 mg/dL) in those not receiving fomepizole therapy.
 
Ethanol Maintenance
 
This therapy should continue during hemodialysis. As ethanol is dialysed, infusions must be increased (approximately doubled, possibly tripled) or 95% ethanol added to the dialysate. Further infusion rates must be guided by regular measurement of serum ethanol concentration.
 
Hemodialysis should be continued in those receiving ethanol until:
Measured serum ethylene glycol concentration is < 1.6 mmol/L (< 10 mg/dL), and renal function is restored, and acidosis resolved,[5]
or
Osmolar gap, anion gap, electrolyte concentrations, acid-base, and renal function have normalized.
 
To reduce risk of recurrence of toxicity (due to redistribution or continued absorption) consideration should be given to continuation of ethanol treatment for 24 hours after completion of hemodialysis.[5]
 
Fomepizole Maintenance
 
The dose of fomepizole must be increased during hemodialysis to compensate for losses from the procedure. If the dialysis is started six or more hours after the last administration, the next scheduled dose should be given at the commencement of the procedure. All patients should then receive four hourly administrations for the duration of the treatment.[4]
 
Hemodialysis should be continued in those receiving fomepizole until:[25][4]
 
Acid-base and renal function have normalized;
Signs of systemic toxicity have disappeared, and;
Serum ethylene glycol concentration are 3.2 mmol/L (20 mg/dL) or less.
 
While the procedure is preferably terminated under these conditions it has been reported as safe with ethylene glycol concentrations above 8.1 mmol/L (50 mg/dL) when associated with fomepizole therapy.[26]
 
Fomepizole treated patients should continue this therapy following hemodialysis. If a dose has been administered within the last hour a further is not required. Those not having received a dose within 1 to 3 hours should be administered half their next scheduled dose at the completion of dialysis; while those who have not received fomepizole for more than 3 hours should receive their full dose. All should maintain 12 hourly dosing thereafter during the monitoring period.[4]
 
Post-hemodialysis monitoring
 
Glycols may redistribute following cessation of hemodialysis causing re-intoxication requiring repeat hemodialysis.[27] Serum osmolar gap, anion gap, acid-base status, electrolytes, and renal function should be monitored (2 to 4 hourly) for the next 24 hours.[3]
 
Patients may suffer acute renal failure as a result of their poisoning and require hemodialysis for some weeks. It is usual (but not inevitable) that full renal function will return.
 

Urinary Alkalinization

The renal clearance of the acidic metabolites of glycols (such as glycolic acid, a toxic metabolite of ethylene glycol), may be increased by aggressive treatment of metabolic acidosis with sodium bicarbonate due to “ion-trapping” within the kidney.[22]
 

SUPPORTIVE CARE

Monitoring

Level of consciousness
Blood pressure
Heart rate
Respiratory rate
Respiratory function
ECG
Plasma glucose
Liver function
Electrolytes including:
Calcium
Magnesium
Chloride (for calculation of anion gap)
Potassium
Anion gap (will be increased in later stages of poisoning)
Serum ethanol concentration (ethanol may influence antidote dose)
Serum ethylene glycol concentration (if available)
Osmolar gap (will be increased in early stages of poisoning)
Blood urea nitrogen (urea)
Serum creatinine
Urine output
Proteinuria
Hematuria
Arterial blood gas
Plasma lactate
Head CT (if neurological abnormality)
 

Metabolic

Metabolic Acidosis

Increased anion gap metabolic acidosis results from the metabolism of ethylene glycol to acidic metabolites, predominantly glycolic acid. It is widely accepted that early and aggressive treatment of acid-base abnormality (pH < 7.3) with potentially large quantities of sodium bicarbonate is life-saving following ethylene glycol intoxication (beware of the potential for hypernatremia).[28] Bicarbonate may also enhance renal excretion of toxic metabolites by renal “ion trapping”,[22] but may contribute to hypocalcemia. It is recommended that base excess be raised to normal within 12 to 24 hours however much bicarbonate that requires.[29] In severe acidosis, use of an antidote to halt production of acidic metabolites, and aggressive hemodialysis are necessary. Iatrogenic hypernatremia may occur following large doses of sodium bicarbonate.
 
Monitor:
Arterial blood gases (pH, bicarbonate, pCO2, pO2)
Plasma lactate
Base excess
 
Follow standard protocols for the management of metabolic acidosis.
 
Early use of hemodialysis must be considered, and should be used where cardiorespiratory support and sodium bicarbonate are insufficient to control acidosis.

Renal

Acute Renal Failure

Renal failure may occur due to the toxic metabolites of ethylene glycol crystallizing in the presence of calcium and being deposited in the kidneys. Acute tubular necrosis, cortical edema, and other direct toxicity is possible.[30][31] Signs and symptoms of renal insufficiency predominate at 2 to 3 days post ingestion.[32][33][34] Alkalinize the urine and ensure adequate output.[22] Hemodialysis is indicated in the presence of renal failure.[3]
 
Patients should be monitored for the onset of renal failure:
Urine output
Serum creatinine
Blood urea nitrogen (urea)
Proteinuria
Hematuria
Loin pain may occur
 
Manage following standard treatment protocols for acute renal failure.
 

Fluid and Electrolytes

Hypocalcemia

Calcium is recommended for patients continuing to seize despite standard anticonvulsant management, or in the presence of cardiac dysrhythmia – particularly prolonged QT interval. (Available ionized calcium will rise with increasing acidosis [due to release from plasma proteins] and fall with return to normal serum pH). Prophylactic calcium or treatment of asymptomatic hypocalcemia is not recommended due to the risk of further precipitation of calcium oxalate in the tissues.[3]
 
Monitor for onset of hypocalcemia with:
Observation for signs and symptoms of hypocalcemia
Serum ionized calcium
Serum electrolytes (hypomagnesemia and hyperkalemia are often also present)
 

Hypomagnesemia

Magnesium is a cofactor with thiamine in the metabolic detoxification of ethylene glycol metabolites. Serum magnesium concentrations should be monitored and hypomagnesemia corrected.[18]
 
Monitor:
Serum magnesium
Nausea and vomiting
Lethargy, weakness, fatigue
Tremor
Hyperreflexia
 
Manage hypomagnesemia following standard protocols.
 

Hyperkalemia

Hyperkalemia can occur in association with metabolic acidosis due to the formation of acidic metabolites. IV ethanol and bicarbonate are necessary to correct potassium concentrations.[29]
 
Observe for:
Abdominal pain/diarrhea
Weakness
Ascending paralysis
Respiratory failure
Monitor:
ECG changes suggestive of hyperkalemia include
Peaked T waves (tenting)
Flattened P waves
Prolonged PR interval (first-degree heart block)
Widened QRS complex
Deepened S waves and merging S and T waves
Idioventricular rhythm
Sine-wave formation
VF and cardiac arrest
Arterial blood gases
Serum potassium
 
Administer calcium gluconate as outlined in the antidote section. If this is not successful, follow standard protocols for the management of hyperkalemia.
 

Neurologic

CNS Depression

Drowsiness, ataxia, slurred speech, and stupor are common early signs of ethylene glycol intoxication.[30] Ethylene glycol metabolites, namely glycoaldehyde, glycolic acid, and glyoxylic acid, may contribute to CNS depression.[3]
 
Closely monitor level of consciousness.
 
Follow standard protocols for the management of depressed level of consciousness.
 

Seizures

Seizure activity unresponsive to standard management is typically indicative of hypocalcemia, particularly in the presence of calcium oxalate crystalluria, or following administration of sodium bicarbonate (which can lower ionized serum calcium). Calcium is recommended for patients continuing to seize despite standard anticonvulsant management.[3] Seizure-related hypoxic encephalopathy may also occur.[18]
 
Observe the patient closely for onset of seizure activity.
 

Neurotoxicity

Cranial nerve defects occur in the subacute phase of ethylene glycol toxicity. This may occur within 5 to 20 days and may persist for weeks or months.[9][7] The exact mechanism in ethylene glycol poisoning is unknown.[7]
 
Closely monitor patients for onset of neurotoxicity.
 
Follow standard protocols for the management of neurotoxicity.
 

Cardiovascular

Hypotension

Profound hypotension has been reported due to critical circulatory failure.[35] The exact mechanism is unknown.
 
Monitor:
Heart rate/rhythm
Blood pressure
ECG
 
Follow standard management protocols for hypotension.
 

Hepatic

Hepatotoxicity

Acute liver dysfunction may develop with significant toxicity. Elevated ALT and bilirubinemia has been reported.[36][37]
 
Hepatic monitoring should include:
Alanine aminotransferase (ALT)
Aspartate aminotransferase (AST)
International normalized ratio (INR)
Serum bilirubin
Plasma glucose
 
Follow standard protocols for the management of acute hepatotoxicity.
 

Respiratory

Acute Respiratory Distress Syndrome

Acute respiratory distress syndrome has been reported in the presence of normal cardiac function. The exact mechanism is unknown, however, it is speculated that it may be due to direct toxic effect from ethylene glycol metabolites. Respiratory support with mechanical ventilation and positive end-expiratory pressure may be required.[38]
 
Monitoring for acute respiratory distress syndrome should include:
Oxygen saturation
Arterial blood gases
FiO2 (mechanically ventilated patients)
Chest auscultation
Lung function tests
Chest X-ray (may be normal early, and not correlate well with clinical effects)
Heart rate
Blood pressure
Circulatory status (consider invasive hemodynamic monitoring)
ECG
Urine output
Fluid balance
Serum electrolytes
Level of consciousness
 

Pulmonary Edema

Pulmonary edema may occur in severe ethylene glycol poisoning. Death can occur within 24 to 72 hours. The exact mechanism is unknown.[30]
 
Pulmonary edema may manifest with desaturation and pulmonary crepitations. Occasionally frothy, pink sputum may be apparent.
 
Monitoring for this condition should include:
Chest auscultation
Oxygen saturations
Arterial blood gases
Chest x ray
 
Treat using standard treatment protocols for pulmonary edema.
 

DISCHARGE CRITERIA

All asymptomatic patients should be observed until appropriate investigations have been carried out, venous bicarbonate level is greater or equal to 20 mmol/L (mEq/L), and serum (or breath) ethanol concentration is zero in adults. If treatment is not required they may be:
- Discharged into the care of a reliable observer, or
- Referred for psychological assessment (if the overdose was intentional)
 
Symptomatic patients may be considered for discharge once venous bicarbonate concentration is greater or equal to 20 mmol/L (mEq/L), serum (or breath) ethanol concentration is zero in adults, toxic sequelae have resolved, and ethylene glycol serum concentrations have declined to below 3.2 mmol/L (20 mg/dL). In some cases, patients may exhibit transient renal failure, requiring continuing dialysis. Furthermore, ongoing cranial nerve palsies may occur, but typically resolve within weeks to months. Rehabilitation may be required during this time.
 

FOLLOW UP

Standard protocols should be used for follow-up of patients suffering renal failure or CNS effects. Psychiatric intervention may be necessary depending on the circumstances of the exposure.

PROGNOSIS

Those patients surviving an initial severe acidosis may face oliguric renal failure and require regular hemodialysis for weeks to months.[18][29] Fortunately, recovery is expected and very few cases lead to permanent renal failure. The return of renal function is usually signified by an increase in urine output and concomitant decrease in serum creatinine.
 
Those who develop severe CNS manifestations, including seizures and coma, can recover full neurologic function. Cranial nerve palsies may occur in nerves II, V, VII, VIII, IX, and XII, typically resolving over weeks to months[9] though ongoing mild defects may persist.[7]
 

SIGNS AND SYMPTOMS

Symptoms following ethylene glycol ingestion can be divided into three acute stages and one subacute phase.[34][32][7][39] The severity of these stages and their progression from one to the other often depends on the amount ingested. Death can occur in any of the acute stages but most commonly the second stage.[18] Ethanol co-ingestion can delay the onset of toxic effects.[35] Seizures, hyperkalemia, low pH, decreased base excess, and coma usually indicate a poor prognosis.[29]
 
Initial symptoms of ethylene glycol ingestion are due to the direct toxicity of ethylene glycol. CNS effects predominate and include inebriation (without the alcohol odor on the breath), gastrointestinal upset, and drowsiness. Mild metabolic acidosis may occur. Hypercalcemia and calcium oxalate crystalluria may present at this stage or in subsequent stages or not at all. In severe cases, coma, and seizures may develop.[36][34][32][40][41][42][43][32][44]
 
In subsequent phases of intoxication, the various metabolites of ethylene glycol are responsible for the presenting abnormalities, which in the second phase of poisoning include, metabolic acidosis and cardiopulmonary symptoms 12 to 24 hours post ingestion.[26][34][32][42] The anion and osmolar gaps are usually increased, but may be within normal parameters in some patients.[33][39][42] In significant poisonings, severe metabolic acidosis with compensatory hyperventilation or Kussmaul respirations can develop.[7][30][45] Tachycardia, mild hypertension, pulmonary edema, and congestive heart failure are all believed to be due to the deposition of calcium oxalate crystals within the vascular tree, myocardium, and the lung parenchyma.[32][46][47]
 
The renal phase of intoxication, beginning 24 to 48 hours after ingestion, is marked by oliguria, acute tubular necrosis, renal failure, and occasionally bone marrow suppression.[43][30][36] Hematuria and proteinuria are also possible.[36][48] In severe poisonings, renal failure may appear early and progress to anuria.[43][3] Renal symptoms may last up to 45 days or more.[18] Acute renal failure may prove permanent in a minority of cases.[35] Subacute cranial nerve palsies usually occur within 5 to 20 days and may persist for weeks to months.[9][7]
 
Inhalation of ethylene glycol can cause upper respiratory tract irritation. Systemic effects are not expected unless it has been heated or aerosolized.[49]
 
Eye exposure to vapors or direct contact with the liquid may lead to eye irritation;[50] significant eye injury would not be expected.
 
Brief or occasional skin exposure is unlikely to cause harm to the skin but prolonged or repeated exposure may lead to significant irritation and sensitivity.[51] Skin absorption is limited, and systemic effects are unlikely to develop.[52]
 

Routes of Exposure

Symptoms predominantly occur following ingestion of ethylene glycol. However, toxicity is also possible via dermal, intravenous, and intramuscular routes.

Onset/Duration of Symptoms

There are three acute stages[32][44][33] and one subacute stage[9][53][54][55][39][7] that may occur following ethylene glycol ingestion. Most deaths are reported in stage II but can occur at any of the stages.[56] The severity of these stages and their progression from one to the other often depends on the amount ingested.
 
Stage I: Neurological Phase
0.5 to 12 hours post-ingestion
Inebriation
Nausea
Vomiting/hematemesis
Metabolic acidosis/elevated anion gap/elevates osmolar gap
Hypocalcemia
Calcium oxalate crystalluria
CNS depression
Coma
Stage II: Cardiopulmonary Phase
12 to 24 hours post-ingestion
Hypertension
Tachycardia
Tachypnea
Severe metabolic acidosis
Pulmonary edema
Congestive heart failure
Stage III: Renal Phase
24 to 72 hours post-ingestion
Proteinuria
Oliguria
Anuria
Acute tubular necrosis
Renal failure
Subacute Stage
Onset several (5 to 20) days after ingestion
Cranial nerve neuropathies
 

Severity of Poisoning

Mild Ethylene Glycol ToxicityModerate Ethylene Glycol ToxicitySevere Ethylene Glycol Toxicity
Nausea
Vomiting
Ataxia
Slurred speech
Confusion
Drowsiness
Mild metabolic acidosis
Tachycardia
Hypertension
Mydriasis
Hypocalcemia
Calcium oxalate crystalluria
Oliguria
Hematuria
Proteinuria
Pulmonary edema
Anuria
Hyperventilation/Kussmaul respirations
Hyperkalemia
Elevated anion and osmolar gaps
Severe metabolic acidosis
Seizures
Acute renal failure
Multiple organ failure
Cranial nerve defects
Coma
Death
 

ACUTE EFFECTS (ROUTE OF EXPOSURE)

Inhalation

Exposures via inhalation are rare due to the low vapor pressure of ethylene glycol at normal temperatures. However, when heated or aerosolized, exposures may occur. Upper respiratory tract irritation and cough have been reported.[49] Chronic inhalation has caused nystagmus, periods of unconsciousness, and lymphocytosis.[57]
 

Skin

Ethylene glycol is slightly irritating to the skin.[58][59] Repeated skin exposures may result in sensitivity including erythema and edema.[51] Dermal absorption is limited; acute contact is unlikely to produce systemic effects.[52]
 

Eye

There are limited human reports involving eye exposures to ethylene glycol. However, in animal studies, direct eye contact may result in immediate eye irritation with temporary conjunctival inflammation and swelling. Significant corneal damage would not be expected.[50]
 

ACUTE EFFECTS (ORGAN SYSTEM)

Neurologic

Slurred speech[60][30][9][7][62]
CNS depression[34][18]
Disorientation[62][36][60]
Agitation[64]
Dizziness[7][36]
Strabismus[36][34]
Headache[36][53]
Dysarthria[67]
Hyporeflexia[36][68]
Myoclonus[64]
Myoclonic jerks[36]
Hypotonia[45][69]
Dysthymia[60][9]
Absent reflexes (deep tendon and plantar)[31][69]
Acute Parkinson's syndrome[60][34]
Bradykinesia
Cogwheel rigidity
Defects of cranial nerves V, VII, VIII, IX, X[9][7][55][54][39][64][30][53]
Dysphagia[60][7][55][9]
Hearing loss[55][39]
Ophthalmoplegia[9][36]
Strabismus[36][34]
Facial weakness/diplegia[9][54][39][7][9]
Anisocoria (unequal pupil diameters)[70][9]
Absent gag reflex[55][9]
Permanent deficit in gross and fine motor skill[33]
Cerebral edema[66]
Encephalopathy[18][31]
Quadriparesis[43]
Seizures[36][30][40][63][33][43][31][66][34][37][29][71]
 

Metabolic

Hyperthermia[36][48][73]
Hypothermia[40][37]
Hypoglycemia[40][45]
 
NB. A normal anion or osmolar gap does not rule out ethylene glycol ingestion.[39][33]
 

Renal

Respiratory

Kussmaul respirations[7][33][40][36][45][68][30][43]
Wheeze[42][70]
Bradypnea[65][42]
Hypoxia[73]
Pneumonia[36][35]
Adult respiratory distress syndrome[38]
Non-cardiogenic pulmonary edema[35][64][36]
 

Cardiovascular

Fluid and Electrolytes

Hyponatremia[64]
Hypernatremia[43]
Hypobicarbonemia[69]
 

Gastrointestinal

Hematemesis[34]
Sialorrhea[60]
Abdominal pain[36][64][7][48][39]
 

Ocular

Decreased visual acuity[75][53]
Blurred or edematous optic discs[36][75][53][9]
Miosis[45]
 

Musculoskeletal

Myalgia (muscle pain)[30][36]
Increased creatine kinase (CK)[30][73]
Rhabdomyolysis[68]
 

Hepatic

Elevated ALT[37]
Bilirubinemia[36]
 

Hematologic

Leukocytosis[45][34][43][66]
Anemia[72][36]
Thrombocytopenia[72]
Methemoglobinemia[48]
Bone marrow arrest[43]
Disseminated intravascular coagulation[37]
 

CHRONIC EFFECTS

General Effects

Chronic exposures to ethylene glycol vapor may result in nystagmus, unconsciousness, and lymphocytosis.[57]
 

TOXICITY

TOXIC MECHANISM

The major toxic agent in ethylene glycol poisoning is not the parent compound, but the metabolites produced by the action of alcohol dehydrogenase (ADH) on the parent compound.[76]
 
Ethylene glycol is rapidly metabolized via ADH into glycoaldehyde, which is rapidly converted into glycolic acid by aldehyde dehydrogenase. The rate-limiting step in the metabolism of ethylene glycol is the formation of glyoxylic acid from glycolic acid via lactic dehydrogenase or glycolic acid dehydrogenase. Glyoxylic acid can be either metabolized into non-toxic alpha-hydroxy-beta ketoadipate and glycine via thiamine and pyridoxine respectively, or into oxalate.[27][18]
 
The etiology and pathophysiology of the CNS, metabolic, cardiopulmonary, and renal toxicity are primarily due to the formation and accumulation of toxic intermediary metabolites, especially glycolic acid (produces metabolic acidosis)[46] and to a lesser but histologically important extent, oxalate production, and excretion.[47][46][32] Calcium oxalate crystals may form in tissues, in particular the renal tubules, lungs, and the meninges of the brain, and excreted in the urine.[46][32]
 

HUMAN

Acute

The toxic dose is variable in humans. Death has occurred with just 30 mL of the concentrate in adults,[59] with survival occurring with ingestions of 3 and 4 litres.[65][41][77]
 
Ethylene glycol concentrations are often not a predictor of toxicity due to metabolism to more toxic metabolites. Patients with hyperkalemia, acidosis, seizures, and/or coma are at a high risk of death.[29] Co-ingestion of ethanol may delay toxic effects.[35]
 
Medical assessment is warranted for any ingestion of pure ethylene glycol greater than a witnessed lick or taste in a child or more than a 'swallow' (10 to 30 mL) in an adult. For ingestions of lower concentration products (<20%), any ingestion greater than 0.1 mL/kg of pure substance equivalent warrants referral.[78]
 

Case Studies

Child
100 mL ethylene glycol(ingested)
2 year male: initially vomited and found unconscious the following morning. On arrival was semi-conscious, hyperventilation, tachycardia, and hypotension. Hematemesis, oliguria, hematuria, albuminuria, decreased serum bicarbonate, metabolic acidosis, and elevated BUN occurred. Later developed seizures and had athetoid movements
Supportive care, including IV calcium gluconate, ethanol infusion, frusemide, peritoneal dialysis, diazepam, and phenobarbitone[34]
Recovered after 17 days[34]
Unknown amount of antifreeze(ingested)
6 year female: presented with metabolic acidosis, responsive to pain only, tachycardia, tachypnea, hypertension, emesis, and crystalluria. Elevated anion gap, lactate, sodium, chloride, and glucose were present. Nystagmus developed following fomepizole administration. Polyuria developed at 18 hours. Serum ethylene glycol concentration was 13 mg/dL 3 hours post-admission.
Supportive care, including oxygen, IV saline, sodium bicarbonate, IV cefotaxime, pyridoxine, thiamine, fomepizole, hemodialysis, and electrolyte supplementation[79]
Recovered and discharged after 2 days[79]
 
Adult
29.5 mL Antifreeze(ingested)
17 year male: dizziness, incoordination, confusion, dysuria, nausea, abdominal pain, emesis, tenderness in upper right quadrant, and calcium oxalate crystals in urine. Impaired renal function with elevated BUN developed on day 3. On day 7 developed azotemia, acidosis, and anemia
Supportive care[36]
Recovered and discharged after 7 days[36]
~30 mL Ethylene glycol(ingested)
33 year male: inebriation, slurred speech, hallucinations, vomiting, unconscious, pale, cyanosis, miosis and failed to react to light, hypotension, nystagmus, fever, and anuria
Supportive care, including blood transfusion, nicetamide, sympatol, and strophantin[59]
Fatal after 48 to 60 hours[59]
~30 mL Ethylene glycol(ingested)
42 year male: vomiting, pupils failed to react to light, anuria, coma, Kussmaul respiration, hypotension, and absent reflexes
Supportive care[59]
Fatal after 144 hours[59]
59 mL Ethylene glycol(ingested)
17 year male: disorientation, unable to ambulate, urinary incontinence, and calcium oxalate crystals in urine. On day 3 developed elevated BUN
Supportive care[36]
Recovered and discharge after 9 days[36]
100 mL antifreeze solution(ingested)
13 year old female: within 30 minutes developed tachycardia, hypertension, and elevated pO2. Ataxia and dysarthria also developed. Urinalysis revealed calcium oxalate crystals. Serum ethylene glycol concentration was 103 mg/dL
Supportive care, including IV ethanol, orotracheal intubation, and IV fomepizole[61]
recovered and discharged after three days[61]
88 to 118 mL Ethylene glycol(ingested)
17 year female: Within 36 hours presented with confusion, seizures, semi-comatose state, vomiting, metabolic acidosis, and hyperkalemia. Later developed cyanosis, hypotension, mild tachycardia, tachypnea with Kussmaul respirations, myoclonic jerks, mydriasis and pupils unreactive to light, papilledema, hypoactive deep tendon reflexes, and pulmonary edema
Supportive care, including oxygen, IV dextrose, hemodialysis, ascorbic acid, and methylene blue[36]
Fatal after 47 hours[36]
118 mL Ethylene glycol(ingested)
17 year male: Within 48 hours developed fatigue, headache, blurred vision, nausea, confusion, ocular palsy, anuria, bilateral ophthalmoplegia, and hypertension. Later developed bronchopneumonia, renal failure, and calcium oxalate crystals deposits
Supportive care, including lumbar puncture, potassium, sorbitol, and hemodialysis[36]
Fatal after 17 days[36]
150 mL ethylene glycol windscreen wash solution(ingested)
69 year male: GCS of 6, sluggish pupils, reduced muscle tone, tachypnea, severe metabolic acidosis, elevated BUN, elevated creatinine, increased anion and osmolar gap, anuria, and supraventricular tachycardia. Serum ethylene glycol concentration was 100 mg/dL
Supportive care, including intubation, ventilation, IV fluids, sodium bicarbonate, IV ethanol, IV fomepizole, hemofiltration, and amiodarone[69]
Recovered and discharged on day 30.[69]
450 mL antifreeze solution(ingested)
60 year old male: coma, Kussmaul respirations, hypotension, hypothermia, hyperglycemia, metabolic acidosis, hyperventilation, hypertension, hypocalcemia, calcium oxalate crystals in urine, aspiration, anuria, elevated creatinine, and seizure
Supportive care, including IV saline and glucose, sodium bicarbonate, oxygen, resuscitation, intubation, ventilation, insulin, dobutamine, crystalloid & colloids, epinephrine (adrenaline), norepinephrine (noradrenaline), calcium chloride, mannitol, frusemide, ethanol infusion, hemofiltration, diazepam, and phenytoin[40]
Fatal[40]
1,000 mL antifreeze solution(ingested)
48 year male: dysarthria, emesis, hypertension, tachypnea, hypoxia, and increased anion gap. Serum ethylene glycol concentration was 700 mg/dL
Supportive care, including oxygen and fomepizole[67]
Recovered and discharged after 4 days[67]
3,000 mL antifreeze solution(ingested)
36 year male: nausea, vomiting, increased drowsiness, somnolence and became progressively lethargic and bradypneic. Increased anion gap and osmolar gap developed. Urinalysis revealed moderate calcium oxalate crystals. Mild pulmonary edema and non-oliguric acute kidney failure developed after 72 hours. Serum ethylene glycol concentration was 1,889 mg/dL
Decontamination and supportive care, including gastric lavage with activated charcoal and magnesium citrate, IV administration thiamine, pyridoxine, magnesium sulfate, sodium bicarbonate, ethanol infusion, and hemodialysis[65]
Recovered and discharged after 3 days[65]
3,785 mL antifreeze and an unknown amount of ethanol(ingested)
33 year male: mildly intoxicated. Serum ethylene glycol concentration was 706 mg/dL
Supportive care, including fomepizole[77]
Recovered and discharged after 4 days[77]
~4,500 mL antifreeze solution(ingested)
58 year old male: confusion, metabolic acidosis with increased anion and osmolar gap, decreased BUN, and calcium oxalate crystals in urine. Serum ethylene glycol concentration was 791 mg/dL
Supportive care, including activated charcoal, IV ethanol, intubation, and hemodialysis[41]
Recovered after 3 to 5 days[41]
 

ANIMAL

Acute

Ethylene glycol poisoning in animals is relatively common as it has a sweet taste and looks like water. Relatively low amounts of water drained from radiators containing ethylene glycol may cause toxicity.
 
Symptoms in animals are similar to those seen in humans and follow similar stages of toxicity, although excluding the fourth neurological stage in humans. Symptoms in cats and dogs include ataxia, vomiting, diarrhea, disorientation, bradycardia, hypothermia, metabolic acidosis, acute kidney injury or acute renal failure, and diuresis.[80] In birds, ataxia, weakness, depression, and flaccid paralysis can occur. Calcium oxalate deposits in the renal tubules have also been noted.[81][82]
 
In dogs, peak plasma ethylene glycol concentrations occur 2 hours post-ingestion.[80] Peak glycolic acid plasma levels occur at 4 hours.[80]
 
The sooner antidotal therapy is commenced, the better the outcome.[83] Cats have the best chance of survival following a lethal dose if the antidote is started within 3 hours of ingestion,[84] whereas dogs can have the antidote started within 6 to 8 hours of ingestion.[80] Recovery may take 3 to 5 days.[84] The antidote is only effective at blocking ethylene glycol metabolism, therefore, there is no benefit of administering it if the ethylene glycol is already metabolized or if the animal has renal failure. Prognosis is poor if the animal presents in the final stage of poisoning, with symptoms of renal failure or coma.[83] Hemodialysis can be considered in severe cases.[85]
 
Ethylene Glycol:
LD50 Oral, Rat
4,000 to 10,020 mg/kg4,000 to 10,020 mg/kg/[86][1]
LD50 Oral, Mouse
5,500 to 8,350 mg/kg5,500 to 8,350 mg/kg/[86]
LD50 Oral, Guinea pig
6,610 mg/kg6,610 mg/kg/[1]
LD50 IP, Rat
5,010 mg/kg5,010 mg/kg/[86]
LD50 IP, Mouse
5,614 mg/kg5,614 mg/kg/[86]
LD50 SC, Rat
2,800 mg/kg2,800 mg/kg/[86]
LD50 IV, Rat
3,260 mg/kg3,260 mg/kg/[86]

BIOLOGICAL LEVELS - TOXIC

SI Unit Conversion

To convert an ethylene glycol concentration expressed in mg/dL into mmol/L:
Multiply the mg/dL by 0.1611
 
To convert an ethylene glycol concentration expressed in mmol/L into mg/dL:
Multiply the mmol/L by 6.2070
 
Units: 1 dL = 0.1 L
1 ug/L = 0.1 ug/dL
1 ug/dL = 10 ug/L
 

Toxic Plasma Level

Plasma Ethylene Glycol Concentration
 
Serum ethylene glycol concentrations at admission are not predictive of outcome. Low pH and low base excess, indicative of toxic metabolites, do predict outcome.[29]
 
Initial ethylene glycol concentration greater than 20 mg/dL may result in toxic effects.[18]
 
Initial ethylene glycol concentration greater than 30 mg/dL has the potential to be fatal.[18]
 
Patients presenting with established signs of acute ethylene glycol toxicity may have relatively low or undetectable serum concentrations of ethylene glycol. It is rapidly metabolized to the toxic metabolites responsible for the development of clinical and biochemical signs of poisoning.
 
Correlation Of Toxic Concentration And Effect
 
< 20 mg/dL Low Concentration
Nausea
Vomiting
Inebriation
20 to 30 mg/dL Moderate Concentration
Mild anion gap metabolic acidosis
Elevated osmolar gap (absence does not rule out toxicity)
Tachycardia
Hypertension
> 30 mg/dL High Concentration
Severe metabolic acidosis
Hyperventilation
Seizure
Multiple organ failure
Death
 
Ethylene Glycol Toxic Plasma Concentrations
 
103 mg/dL (1 hour post ingestion)
After approximately 120 mL of antifreeze orally, a 13 year old female had ataxia, dysarthria, and calcium oxalate crystals in urine[61]
700 mg/dL (time of ingestion unknown)
After approximately 1,000 mL of antifreeze orally, a 48 year old male had dysarthria, emesis, and metabolic acidosis with a
high anion gap[67]
888 mg/dL (3 hours post ingestion)
After an unknown amount of ethylene glycol was ingested a 28 year old male was comatose with hyperventilation, calcium oxalate crystals in urine, and acute renal failure[18]
1,889 mg/dL (5 hours post ingestion)
After approximately 3,000 mL of antifreeze orally, a 36 year old male had nausea, emesis, lethargy, bradypnea, metabolic
acidosis, calcium oxalate crystals in urine, and acute kidney failure[65]
 

Osmolar Gap

The osmolar gap represents the difference between the measured osmolality (osmoles per kilogram solvent) and calculated osmolarity (osmoles per liter of solution).[87][3] When positive, it may indicate the presence of low molecular weight compounds such as alcohols and glycols. A normal osmolar gap does not reliably rule out the presence of a toxic alcohol in the blood stream.
 
OSMOLALITY
 
Serum osmolality is generally in the range 270 to 290 mOsm/kg H2O, and should be measured by freezing point depression.[41]
 
OSMOLARITY
 
The osmolarity may be calculated using SI units or using Mass (traditional) units.
 
Osmolarity Calculation Using SI Units
 
Osmolarity = 2 x sodium[mmol/L] + glucose[mmol/L] + urea[mmol/L] + ethanol[mmol/L]
 
Urea = BUN (blood urea nitrogen)
Include ethanol if found on serum measurement
 
Osmolarity Calculation Using Mass (traditional) Units[88]
 
Osmolarity = (2 x sodium[mEq/L]) + (glucose[mg/dL] /18) + (BUN[mg/dL]/2.8) + (ethanol[mg/dL]/4.6)
 
All units should be expressed as mg/L
 
BUN = urea
Include ethanol if found on serum measurement
 
These equations should also include other compounds such as ethanol or mannitol, if present. This calculation should be undertaken in the earlier phases of intoxication prior to the metabolic removal of alcohols and glycols.
 
OSMOLAR GAP CALCULATION
 
Osmolar gap = Osmolality - Osmolarity
 
The mean normal osmolar gap has been determined to be approximately < 10 or 15 mOsm/kg H2O (though this range will vary between laboratories).[41] However, there exists considerable variation in osmolar gaps between individuals. Hence, a ‘normal’ osmolar gap does not rule out the presence of an alcohol or glycol.[88] The osmolar gap is most useful in suggesting the presence of suspected glycol or alcohol ingestion when it is significantly elevated (usually > 20 to 30 mOsm/kg).
 

Anion Gap

The anion gap represents the difference between the sum of measured cations and the sum of measured anions. An elevated anion gap indicates the presence of unmeasured organic acids (including products of the metabolism of alcohols or glycols).
 
ANION GAP CALCULATION[89]
 
Anion gap = [([sodium]) – ([bicarbonate] + [chloride])]
 
Potassium is normally omitted from the calculation because its range is relatively small and constant.
 
All units should be expressed as mmol/L.
 
A “normal” anion gap may be considered within the range 3 to 11.[89]
 

REPRODUCTION

PREGNANCY

There are limited studies of ethylene glycol in pregnant women. A 26 week pregnant patient who ingested ethylene glycol underwent a cesarean section due to fetal asphyxia. Following birth the neonate was intubated and required artificial lung ventilation. The child had metabolic acidosis and was treated with forced diuresis and replacement transfusion. The baby was extubated at 2 weeks and discharged after 3.5 months with no significant neurological complications.[71] Pregnant female workers potentially exposed to industrial mixtures containing ethylene glycol ethers had increased risk of spontaneous abortion and subfertility.[90]
 
In animal studies the metabolite glycolic acid is responsible for developmental toxicity in rats rather than ethylene glycol itself.[91] Low level exposures of ethylene glycol do not saturate glycolic acid metabolism so have a low risk of development effects.[92] Both ethylene glycol and glycolic acid decreased fetal body weights and axial skeleton malformations in rats.[91]
 
Ethylene glycol has been shown to be teratogenic in animals. Teratogenicity was observed in the absence of maternal toxicity in both rats and mice. Effects in mice include reduced number of live pups, decreased pup weight, and skeletal malformations (fused ribs, abnormally-shaped or missing vertebrae, and twisting of the spine).[93] Similar effects were noted in rats receiving doses of 2,500 to 5,000 mg/kg/day.[94][93] At these doses, severe malformations including craniofacial abnormalities, neural tube defects (anencephaly, meningomyelocele), and visceral malformations were observed.[93]
 

LACTATION

It is unknown whether this compound is excreted in human breast milk.
 

KINETICS

ABSORPTION

Oral Absorption
Rapid
Onset of Action
CNS effects may occur within 30 minutes[32]
Time to Peak Plasma Levels
1 to 4 hours[44]
 

DISTRIBUTION

Volume of Distribution
  1. During hemodialysis: 0.5 to 0.67 L/kg[41][24]
 

METABOLISM

Metabolism
  1. Hepatic[2]
Metabolites
  1. Glycoaldehyde[44]
  2. Glycolic acid[44][76]
  3. Glyoxylic acid[44]
  4. Oxalate[44]
Major Metabolic Pathways
Parent:
  1. Via alcohol dehydrogenase to glycoaldehyde[44][2]
Glycoaldehyde :
  1. Metabolized to glycolic acid with subsequent conversion to glyoxylic acid and oxalate[44][2]
 

ELIMINATION

Excretion
Urine
  1. 20% excreted unchanged in urine[2][3]
Half-life
Overdose
  1. Ethylene glycol: 3 to 3.79 hours[23][41]
  2. Ethylene glycol with ethanol: 17 to 18 hours[23][41]
  3. Ethylene glycol with ethanol and dialysis: 2.5 to 3.5 hours[23][41]
  4. Ethylene glycol with 4-methylpyrazole: 11.5 to 14.75 hours[95]
Clearance Rate
  1. 210 mL/min[23]
Potential for Accumulation
  1. Calcium oxalate crystals can accumulate in the kidney leading to renal damage and renal failure[44]
 

IDENTIFICATION

OTHER NAME(S)

Common Names

1,2-Ethaandiol1,2-Ethandiol1,2-Ethanediol
2-HydroxyethanolAntifreezeAthylenglykol
CoolantDeicerEG
EtandiolEthane-1,2-diolEthylene alcohol
Ethylene dihydrateEthylene glycolEthylenglycol
EtilenglicolEtilenglikolEtilenoglicol
EtyleeniglykoliGlicole etilenicoGlikol etylenowy
GlycolGlycol alcoholGlycolmonomer
Lutrol-9M.E.GMonoethylene glycol
Radiator fluidRampUcar 17
 

Chemical Name

Ethylene Glycol:
1,2-Ethanediol
 

CODES

CAS NUMBER

Ethylene Glycol:
107-21-1
 

MOLECULAR FORMULA

Ethylene Glycol:
C2H6O2
 

REFERENCES

 
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