Toxicology Case

Presentation
Paria Wilson M.D.
Pediatric Emergency Medicine Fellow

23 month old
Altered Mental Status
Previously healthy kid
Brought in my EMS as a trauma stat page
Had been home with dad while mom was at work
History earlier in the day of falling and hitting his head but
was watching TV afterwards
Mom had told EMS that when she got home he was dazed
and out of it
He just kept staggering and falling back

Social History
Home with no steps in it
No one in the family takes any medications
Tylenol is in the house on top of the fridge
No alcohol in the house
Mom and dad hand off the kids as each goes to work

Physical Exam
VS: BP 102/50 HR 103 T 36.2 (R) RR 20 100% on RA
GEN: very sleepy, difficult to arouse, no noxious smells, initial
GCS 9 (spontaneously opens eyes intermittently, localizes
pain, no verbal response)
HEENT: No head trauma noted, pupils 3mm->1mm
bilaterally, TMs normal
CV: regular rate, no murmurs, 2+ pulses
PULM: lungs clear bilaterally
ABD: soft, nontender, not distended
SKIN: old bruise to L eyelid, no rashes

Further History
EMS informed us that when they arrived he was
unresponsive but maintaining his airway
He was given one dose of Naloxone en route to the ED with
no improvement in symptoms
Glucose en route: 70s

What are we thinking?

No signs of trauma on his body other than the old bruise
Blood gas: 7.37/32.2/-7
Electrolytes: normal, but AG 18
Glucose: 92
CBC: normal
Liver function tests: normal
Head CT: normal

So basicallywe got
nothing

Toxicology saves the day!

APAP level: <2 mcg/ml
Salicylate level: <1.7 mg/dL
UDS: negative
Blood Ethanol Level: 201 mg/dL
Interestingly enough, on re-assessment he was noted to have
pinpoint pupils that responded to a dose of narcan
Narcan was repeated 4 more times (0.1mg/kg) with improvement
in mental status and pupil size
It was determined that narcan was underdosed by squad
(0.03mg/kg)
He was admitted on a narcan gtt to the PICU

(Lamminpaa, 1994)

Acute Ethanol Toxicity

Studying the effects of alcohol in children is obviously not
ethical and therefore difficult to determine
We rely on case reports to inform us on lethal doses and side
effects
Hollstedt (1977): reported death due to a BAC of less
300mg/dL in children
Dickerman (1968): 4 year old female with BAC of 740mg/dL
survived
In 1986, Litowitz reported that the lethal dose in children is
3g/kg, compared to 5-8g/kg in adults

(Lamminpaa, 1994)

Acute Ethanol Toxicity

The Preschool Years
Multiple reports exist stating that elimination of Ethanol in
adolescents is similar to adults
In children <5 years of age, immaturity of the hepatic alcohol
dehydrogenase activity limits their ability to metabolize
alcohol
BAC is dependent on total body water,
of which toddlers have
more of

(Lamminpaa, 1994)

Acute Ethanol Toxicity

Signs
Multiple case reports exist regarding hypoglycemia related to
ethanol ingestion in young children
Length of preceding fasting plays a role in this
Related to inhibition of hepatic gluconeogenesis

Metabolic Acidosis (our child had a base deficit of -7 and an

AG)
Respiratory Depression as a direct effect of alcohol on the
respiratory center
Mild hypokalemia has been reported

(Lamminpaa, 1994)

Acute Ethanol Toxicity

Symptoms
Odor of ethanol on the breath
Vomiting is the most common symptom, reported in up to
70% of patients
Major risk of hypothermia from peripheral vasodilation and
CNS depression
Hypotension
Coma occurs at a lower BAC in children than in adults

(Hussain, Rawal, & Henry, 1998)

Acute Ethanol Toxicity

Treatment
Since the hepatic enzymes are either not working or saturated,
we rely on excretion via first order kinetics to clear the ethanol
Tx with IV glucose has been reported to decrease the
occurrence of vomiting and decrease serum lactate
concentration
Address hypothermia
Hemodialysis in severe intoxication
Clearance is estimated at 30mg/dL/hour
Case report of a 3 year old with BAC 369mg/dL who improved
after gastric decontamination

(Engel & Spiller, 2010)

So why is this important?

Kids are not only getting into their parents beers, they are
also drinking hand sanitizer!
Active ingredient in Purell: 62% Ethanol, Isopropanol <10%
Case Report: 4 year old with AMS, ataxia, periodic
unresponsiveness, hypoxia, hypothermia, hypokalemia
Serum Ethanol level: 243mg/dL
She must have ingested about 1.5-2oz

Never became hypoglycemic

Intubated and sedated with etomidate, suc
Discharged home the next day

(Rayar & Ratnapalan, 2013)

What else around the house has

ethanol?
Medicinal: Tylenol liquid (7%), Benadryl (14%), Nyquil (10%),
Robitussin (3.5%)
Cosmetics: Hair color, mascara, hairspray, sunblock (>50%),
cologne (60-100%),
Hygiene Products: Listerine (20-30%), Old Spice classic stick
(60-100%), Axe body spray (40-65%)
Cleaning: Dial hand sani (62%), Oust air sanitizer (60-70%),
Lysol disinfectant spray (55-60%), Swiffer Wet Jet (1-4%)
Calls to poison center in 2010 for Children <5 years:
165,719 cosmetic and personal care substances
116, 203 household cleaning substances

In Summary
Ethanol has different signs and symptoms based on its
metabolism and the age group of the child
It exists in many products that are around us on a daily basis
Think of obtaining a blood alcohol level on a comatose young
child with no source of injury

Questions?