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Agency for Toxic Substances and Disease Registry Case Studies in Environmental Medicine (CSEM) Ethylene Glycol and Propylene Glycol Toxicity Course: WB 4342 CE Original Date: March 20, 2020 CE Expiration Date: March 20, 2022 Key • Ethylene glycol ingestion first affects the central Concepts nervous system (CNS). After a characteristic latent period, toxic metabolites might produce signs of inebriation followed by serious illness and even death. • No studies were located regarding a link between ethylene glycol exposure and cancer or reproductive or developmental hazards in humans. • Propylene glycol is much less toxic than ethylene glycol. About This This educational case study is one in a series of self- and Other instructional modules designed to increase the primary Case Studies care provider’s knowledge of hazardous substances in the in environment. The modules also promote adoption of Environment medical practices that aid in the evaluation and care of al Medicine potentially exposed patients. You can access the complete series of Case Studies in Environmental Medicine on the Agency for Toxic Substances and Disease Registry (ATSDR) website at URL: https://www.atsdr.cdc.gov/emes/health_professionals/ind ex.html. A downloadable PDF version of this educational series and other environmental medicine materials provides content in an electronic, printable format, especially for those who might lack adequate Internet service. Page 1 of 124 Acknowledgments We gratefully acknowledge the work of the medical writers, editors, and reviewers in producing this educational resource. Listed below are the contributors to this version of the Case Study in Environmental Medicine. Please Note: Each content expert for this case study has indicated that he or she has no conflict of interest to disclose that would bias the case study content. ATSDR Authors: Dianyi Yu, MD ATSDR Planners: Charlton Coles, PhD; Sharon L. Hall, PhD; Delene Roberts MSMHC; Julia Smith, MPH, CHES; Germania Pinheiro MD, MSc, PhD; Dianyi Yu, MD Peer Reviewers: Obaid Faroon, DVM, PhD, and Ki Moon Bang, PhD, MPH ATSDR Commenters: Alaina Steck, MD How to Apply for In order to receive continuing education (CE) for and Receive WB4342 - ATSDR CSEM: Ethylene Glycol/Propylene Continuing Glycol Toxicity please visit TCEO and follow these 9 Education Credit Simple Steps before March 20, 2020. Including the Assessment and Complete the activity Posttest Complete the Evaluation at www.cdc.gov/GetCE Pass the posttest at ___80___% at www.cdc.gov/GetCE To receive free continuing education, please visit the CSEM Ethylene Glycol/Propylene Glycol Toxicity registration page Page 2 of 124 Accrediting Credits Offered Organization The Centers for Disease Control and Prevention is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. CME The Centers for Disease Control and Prevention designates this enduring activity for a maximum of 1.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. CNE The Centers for Disease Control and Prevention designates this activity for 1.6 nursing contact hours. CEU The Centers for Disease Control and Prevention is authorized by IACET to offer 0.2 CEU's for this program. CECH Sponsored by the Centers for Disease Control and Prevention, a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is designated for Certified Health Education Specialists (CHES®) and/or Master Certified Health Education Specialists (MCHES®) to receive up to 1.5 total Category I continuing education contact hours. Maximum advanced level continuing education contact hours available are 0. Continuing Competency credits available are 1.5 . CDC provider number 98614. Page 3 of 124 CPH The Centers for Disease Control and Prevention is a pre-approved provider of Certified in Public Health (CPH) recertification credits and is authorized to offer 2.0 CPH recertification credits for this program. Disclaimer and Disclaimer Disclosure What we know about treating patients potentially exposed to hazardous substances in the environment is constantly evolving and is often uncertain. In developing its educational products, the Agency for Toxic Substances and Disease Registry (ATSDR) has worked hard to ensure the accuracy and the currency of the presented information. However, ATSDR makes no claim that the environmental medicine and health education resources discussed in these products comprehensively address all possible situations related to various substances. These products are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients potentially exposed to hazardous substances. The products are not a substitute for a healthcare provider's professional judgment. Please interpret the environmental medicine and the health education resources in light of specific information regarding the patient and in conjunction with other medical authorities. Use of trade names in ATSDR products is for identification purposes only and does not imply endorsement by the ATSDR or the U.S. Department of Health and Human Services. Disclosure In compliance with continuing education requirements, all presenters must disclose any financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. Page 4 of 124 CDC, our planners, content experts, and their spouses/partners wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. Planners have reviewed content to ensure there is no bias. Content will not include any discussion of the unlabeled use of a product or a product under investigational use. CDC did not accept commercial support for this continuing education activity. U.S. Department of Health and Human Services Agency for Toxic Substances and Disease Registry Division of Toxicology and Human Health Sciences Environmental Medicine Branch Page 5 of 124 Table of Contents How to Use This Course ......................................................................... 7 What Is Ethylene Glycol? ..................................................................... 13 Where Is Ethylene Glycol Found? .......................................................... 23 What Are Routes of Exposure to Ethylene Glycol? ................................... 26 Who is at Risk of Exposure to Ethylene Glycol?.......................................30 What Are U.S. Regulations and Guidelines for Ethylene Glycol Exposure?... 36 What Is the Biological Fate of Ethylene Glycol? ....................................... 39 What Are the Toxicological Effects of Ethylene Glycol Poisoning? .............. 43 Clinical Assessment—History and Physical Examination ........................... 56 Clinical Assessment—Laboratory Tests .................................................. 69 How Should Patients Exposed to Ethylene Glycol Be Treated and Managed? 7979 What Is Propylene Glycol? ................................................................... 87 What Instructions Should You Give to Patients Regarding Ethylene Glycol/Propylene Glycol Exposure? ........................................................ 98 Sources of Additional Information ....................................................... 100 Posttest ........................................................................................... 107 Literature Cited ............................................................................... 112 Page 6 of 124 How to Use This Course Introduction Case Studies in Environmental Medicine’s goal is to increase the primary care provider’s knowledge of hazardous substances in the environment and to help in evaluation and treating of potentially exposed patients. This case study focuses on ethylene glycol and propylene glycol toxicity. Availability Two versions of the Ethylene Glycol/Propylene Glycol Toxicity CSEM are available. • The HTML version (To be added after clearance during Web production) provides content through the Internet. • The downloadable PDF version (To be added after clearance during web production) provides content in an electronic, printable format, especially for those who might lack adequate Internet service. • The HTML version offers interactive exercises and prescriptive feedback to the user. Instructions Follow these steps to make the most effective use of this course: • Take the Initial Check to assess your current knowledge about ethylene glycol and propylene glycol toxicity. • Read the title, learning objectives, text, and key points in each section. • Complete the progress check exercises at the end of each section and check your answers. • Complete and submit your assessment and posttest response online if you want continuing education credit. You can print continuing education certificates immediately after course completion. Page 7 of 124 Instructional This course is designed to help you learn efficiently. Format Topics are clearly labeled; you can
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