History: A 19-year-old female presents to your emergency department after
ingesting a large amount of rubbing alcohol following a fight with her
boyfriend. She appears very sleepy and complains of generalized
weakness. She now denies suicidal ideation and has no plan to injure
herself. She denies any co-ingestion and the paramedics found no other
pills or substances in the house.
PMH: None.
SH: No previous suicide attempts or history of depression.
Physical Examination:
T: 99.4°F HR: 78 bpm RR: 18 breaths per minute BP: 90/60 mm Hg
General: Lethargic.
HEENT: Acetone odor on the breath, otherwise normal.
Pulmonary: Clear to auscultation.
CV: Regular rate and rhythm without murmur, capillary refill 4 seconds.
Neurologic: GCS 14. Cranial nerves II-XII intact. Ataxia is present. All deep tendon
reflexes are depressed. Strength is 3/5 all flexors and extensors of
bilateral upper and lower extremities.
QUESTIONS CASE STUDY # 6
1. What substance did the patient ingest?
2. What are the usual signs of acute toxicity?
3. What initial therapy should be instituted?
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Isopropyl Alcohol Ingestion: Clinical Presentation and Initial Management
This case study examines the acute toxicity of isopropyl alcohol ingestion and outlines the appropriate initial management strategies. The patient’s presentation, clinical signs, and treatment approach are analysed based on current medical knowledge and best practices.
Substance Ingested
The patient ingested rubbing alcohol, which typically contains isopropyl alcohol (isopropanol) as its main active ingredient. Isopropyl alcohol is a common household antiseptic and disinfectant that can cause significant toxicity when ingested in large quantities (Slaughter et al., 2019).
Signs of Acute Toxicity
Acute isopropyl alcohol intoxication manifests through a range of clinical signs and symptoms. The patient’s presentation aligns with typical features of isopropanol poisoning:
1. Central nervous system depression: The patient appears lethargic and has a decreased Glasgow Coma Scale (GCS) score of 14, indicating mild impairment of consciousness.
2. Gastrointestinal effects: While not explicitly mentioned in this case, nausea, vomiting, and abdominal pain are common early symptoms.
3. Cardiovascular effects: The patient exhibits hypotension (90/60 mm Hg) and prolonged capillary refill time (4 seconds), suggesting compromised peripheral perfusion.
4. Neurological impairment: Ataxia and depressed deep tendon reflexes are present, along with generalised weakness and reduced muscle strength.
5. Metabolic disturbances: The acetone odour on the patient’s breath indicates the metabolism of isopropanol to acetone, a characteristic finding in isopropyl alcohol poisoning (Kraut and Kurtz, 2020).
Additional signs not observed in this case but potentially present in severe intoxications include hypothermia, respiratory depression, and in rare cases, haemorrhagic gastritis.
Initial Therapy
The initial management of isopropyl alcohol intoxication focuses on supportive care and prevention of further absorption. The following interventions should be instituted:
1. Airway protection and oxygenation: While the patient’s respiratory rate is currently adequate, close monitoring is essential due to the risk of respiratory depression. Supplemental oxygen should be provided if needed.
2. Fluid resuscitation: Intravenous fluid administration is crucial to address hypotension and improve peripheral perfusion. Isotonic crystalloids should be used, with careful monitoring of fluid status and urine output (Gussow, 2019).
3. Gastric decontamination: Although controversial, activated charcoal administration may be considered if the patient presents within one hour of ingestion and has an intact gag reflex. However, its efficacy in isopropanol poisoning is limited.
4. Electrolyte and acid-base monitoring: Regular assessment of serum electrolytes, blood glucose, and acid-base status is important, as metabolic disturbances may occur.
5. Supportive care: Close neurological monitoring, temperature regulation, and management of any gastrointestinal symptoms are essential components of care.
6. Psychiatric evaluation: Once the patient is medically stable, a comprehensive psychiatric assessment should be conducted to address the underlying factors contributing to the ingestion and to develop an appropriate mental health management plan.
7. Antidote consideration: Unlike ethylene glycol or methanol poisoning, there is no specific antidote for isopropyl alcohol intoxication. Fomepizole or ethanol, which inhibit alcohol dehydrogenase, are not indicated as they may prolong the presence of isopropanol in the body (Slaughter et al., 2019).
8. Haemodialysis: In severe cases with significant central nervous system depression, persistent hypotension, or refractory metabolic acidosis, haemodialysis may be considered to enhance isopropanol and acetone elimination (Kraut and Kurtz, 2020).
The management of isopropyl alcohol ingestion requires a multidisciplinary approach, involving emergency medicine, toxicology, and psychiatry. Prompt recognition of the clinical features and implementation of appropriate supportive measures are crucial for optimising patient outcomes.
References
Gussow, L., 2019. Toxicology Rounds: Isopropyl Alcohol: Low Toxicity, High Risk. Emergency Medicine News, 41(4), pp.12-13.
Kraut, J.A. and Kurtz, I., 2020. Toxic alcohol ingestions: clinical features, diagnosis, and management. Clinical Journal of the American Society of Nephrology, 15(2), pp.290-303.
Slaughter, R.J., Mason, R.W., Beasley, D.M., Vale, J.A. and Schep, L.J., 2019. Isopropanol poisoning. Clinical toxicology, 57(11), pp.1067-1075.
