Treatment of Ethylene Glycol Poisoning with Documented Plasma Concentration >20 mg/dL or Osmol Gap Elevation
This protocol addresses ethylene glycol poisoning confirmed by direct laboratory measurement or by a combination of metabolic and clinical criteria. It covers the antidote-centred approach indicated when specific diagnostic thresholds are met.
Clinical Scenario
This protocol applies when any one of the following is present:
- Documented plasma ethylene glycol concentration >20 mg/dL
- Documented recent history of ingesting toxic amounts of ethylene glycol with serum osmol gap >10 mosm/L
- Strong clinical suspicion of ethylene glycol poisoning with at least two of: arterial pH <7.3; serum bicarbonate <20 mEq/L; osmol gap >10 mosm/L; urinary oxalate crystals
The patient must have no hypersensitivity to fomepizole. Fomepizole is the preferred antidote over ethanol — particularly when there is altered consciousness, co-ingestion of CNS depressants, active hepatic disease, or a critically ill presentation with unexplained anion-gap metabolic acidosis.
Treatment Overview
Management centres on prompt intravenous antidote therapy, alongside concurrent supportive measures that address metabolic correction and symptomatic management in selected patients.
The complete regimen — drug, dosing sequence, continuation criteria, and full supportive care algorithm — is available in the full structured protocol.
Clinical Goals
Serum ethylene glycol undetectable or <20 mg/dL, patient asymptomatic, and normal arterial pH.
References
DOI: 10.1081/clt-100102445
- Documented plasma ethylene glycol concentration >20 mg/dL.
- Documented recent (hours) history of ingesting toxic amounts of ethylene glycol and osmol gap >10 mosm/L.
- History or strong clinical suspicion of ethylene glycol poisoning and at least two of the following criteria: A. Arterial pH <7.3. B. Serum bicarbonate <20 mEq/L. C. Osmol gap >10 mosm/L. D. Urinary oxalate crystals present.
- The administration of fomepizole to patients with ethylene glycol poisoning is preferred to the use of ethanol in the following situations: ingestion of multiple substances with CNS depressant activity; any alteration of consciousness; the lack of intensive care beds; critically ill patient with an anion gap–metabolic acidosis of unknown etiology and potential exposure to ethylene glycol; the lack of laboratory support to monitor ethanol administration; and the presence of contraindications to the use of ethanol.
- Fomepizole should not be administered to patients with known hypersensitivity reactions to fomepizole or to other pyrazole compounds.
- Consider gastric aspiration and lavage if <1 h after ingestion.
- Activated charcoal if mixed ingestion.
- Correct pH <7.3 with intravenous bicarbonate.
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