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Toxicity of Alcohols Metabolic Activation

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Toxicity of Alcohols Metabolic Activation Toxicity of Alcohols Metabolic Activation A common pathway Methanol Toxicity and its Management A common industrial solvent: -used as antifreeze, screen wash and varnishes -Less potent in toxicity as compare to ethanol -Non-toxic in its parent from -requires metabolism for toxicity Methanol Toxicity SIGNS AND SYMPTOMS INITIAL INEBRIATION - ESPECIALLY IF ETHANOL COINGESTED AFTER 12 - 24 HOUR DELAY - PROGRESSION TO ACIDOSIS AND OTHER SIGNS AND SYMPTOMS MAY BE FURTHER DELAY WITH CONTINUED INGESTION OF ETHANOL SIGNS AND SYMPTOMS CNS - INEBRIATION ADVANCING TO COMA and CONVULSIONS RETINAL - BLURRED VISION, PHOTOPHOBIA, VISUAL ACUITY LOSS, DILATED NON-REACTIVE PUPILS, OPTIC NERVE HYPERAEMIC - BECOMING OEDEMATOUS GIT - NAUSEA, VOMITING CARDIAC - TACHYCARDIA, HYPERTENSION PROGRESSING TO HYPOTENSION AND CARDIOGENIC SHOCK RESPIRATORY - TACHYPNOEA Time course ◦ 12-24 hours after ingestion ◦ Interval is correlated with the volume ingested and the amount of ethanol concomitantly ingested ◦ Minimal lethal dose is 1 mg/kg of body weight. Neurologic manifestations ◦ Initial symptoms are similar to ethanol intoxication ◦ Headache, nausea, vomiting, or epigastric pain. ◦ Drowsiness may rapidly progress to obtundation and coma. ◦ Seizures ◦ Affect the basal ganglia, primarily the putamen Vision loss ◦ Flashes of light and blurring which may progress to scotomas & scintillations ◦ Diminished visual acuity which progress to scotomata & scintillations ◦ Frank blindness may respond to immediate therapy; however, complete loss of vision is a common sequela. Osmolar gap Osmolal Gap : Measured – Calculated Calculated Osmolality = (2xNa)+Urea+Glucose Initial Biochemistry @ ~10:00h Na 137 Alb 46 Glucose 6.0 pH 7.38 K 4.0 Prot 84 Ethanol < 2.2 H+ ion 42 Cl 101 Glob 38 Amylase 87 pCO2 5.7 HCO 27 ALP 81 pO2 12.2 3 Bili 20 Std.HCO 24.0 Urea 3.6 3 ALT 18 BE -0.8 Creat 102 GGT 23 (FiO2 21%) A.Gap 13 Osmo 335 (measured) Osmo (calculated) 284 Osmolal Gap = 51 Metabolism of Alcohols Ethanol Methanol Ethylene Glycol Alcohol Dehydrogenase Acetaldehyde Formaldehyde Glycoaldehyde (hangover, flushing) (blindness, cerebral (CNS effects) oedema) Aldehyde Dehydrogenase Acetic Acid Formic Acid Glycolic Acid (metabolic acidosis) (metabolic acidosis) CO2 + H20 Lactate dehydrogenase or glycolic acid oxidase Glycoxylate (lactic acidosis) Lactate dehydrogenase or aldehyde oxidase Oxalate (cerebral & renal damage, hypocalcaemia) Methanol half-life during ethanol administration MeOH t½ during: • EtOH monotherapy 43.1h (30.3-52.0) • EtOH & HD 3.5h dual therapy “EtOH monotherapy greatly increased MeOH t½” Palatnick et al. Methanol half-life during ethanol administration. Ann Emerg Med 1995; 26: 202-207 Treatment • If the clinical suspicion of methanol poisoning is high, treatment should not be delayed pending the reporting of a blood level Differential Diagnosis Ethylene glycol -Usually no visual symptoms -Oxalate crystals in the urine -CNS excitation -Increase in muscle enzymes -Hypocalcemia Isopropyl alcohol -Depressed central nervous system function -Unexplained osmolar gap -Does not cause severe -Acetonemia with a relatively low serum glucose Thus visual symptoms, acidosis, anion gap and unexplained osmolar forces will lead to the clinical diagnosis of methanol poisoning. INVESTIGATION BLOOD METHANOL LEVEL! ABC - METABOLIC ACIDOSIS OSMOLAL GAP - INCREASED (METHANOL) ANION GAP - INCREASED (FORMIC ACID, LACTIC ACID) BLOOD ETHANOL MAGNESIUM, AMYLASE, POTASSIUM Treatment • Emesis can be induced if the patient is not comatose not having seizures has not lost the gag reflex If contraindicated - endotracheally intubate and do gastric lavage Treatment • Three major modalities of treatment Diminishing metabolic degradation to toxic products (4-methyl pyrazole) Dialysis to enhance removal of methanol and its toxic products Alkalinization to counteract the metabolic acidosis. Ethanol • Has a higher enzyme affinity and is preferentially metabolized by alcohol dehydrogenase, so methanol is eliminated by nonmetabolic routes when ethanol is present • Concentrations of 100 to 200 mg/dl are optimal for saturating alcohol dehydrogenase • With the initiation of dialysis procedures, ethanol requires alterations of the dose Loading Dose and Infusion Rates Loading Dose During After Dialysis Dialysis Ethanol 42 gms 12-18 gms/hr 5-11 gms/hr Intravenous (10%) 530 ml 150-230 60-140 ml/hr 7.9gm/dl ml/hr Orally(43%) 125 ml 35-55 ml/hr 15-35 34gm/dl ml/hr TREATMENT ETHANOL (REDUCES FORMATION OF TOXIC METABOLITES) MAINTAIN BLOOD ETHANOL LEVEL OF 100 - 150 mg/dl LOADING DOSE BEWARE OF EXISTING ETHANOL LEVEL MAINTENANCE DOSE TITRATED AGAINST RATE OF ELIMINATION NON-ALCOHOLIC 15 - 20 mg/dl/h CHRONIC ALCOHOLIC 30 - 40 mg/dl/h CHILD 30 mg/dl/h Fomepizole Fomepizole/4-methylpyrazole Acts similarly to ethanol Stronger competitive inhibitor of ADH Does not cause hypoglycemia or sedation Relatively easier to administer Does not require monitoring of serum concentrations Clinical dose yet to be established: However, 20 mg/kg/d can beused in small series Folic Acid • Folate-dependent systems are probably responsible for the oxidation of formic acid • Folic acid can be given • Not tested in clinical studies. TREATMENT HAEMODIALYSIS METHANOL LOW MOLECULAR WEIGHT NOT PROTEIN BOUND LOW VOLUME OF DISTRIBUTION THEREFORE IDEAL FOR HAEMODIALYSIS Sodium Bicarbonate • Profound metabolic acidosis treated with bicarbonate therapy • Acidosis does not causes damage or alters the outcome of the visual disturbances. • Bicarbonate amount adjustment based upon cardiovascular status TREATMENT FOLINIC ACID/FOLIC ACID: -50 mg IV Every 4 hrs for 24 hrs, while formic acid may be forming and accumulating MAGNESIUM: -MgSO4 Titrated against Blood Mg levels METHYLATED SPIRITS METHYLATED SPIRITS: -5% METHANOL AND 95% ETHANOL Acute ingestion will represent Ethanol rather than Methanol METHANOL TOXICITYON IS CONCERNED WHEN METHYLATED SPIRSTS IS USED CHRONICALLY METHYLATED SPIRITS EXAMPLE: IF 250 ml METHYLATED SPIRITS INGESTED: BLOOD ETHANOL LEVEL = 450 mg/dl (LD50) BLOOD METHANOL LEVEL = 24 mg/dl Ethanol Ethanol Metabolism Samir Zakhari, Alcohol Research & Health: Vol. 29, No. 4, 2006 ALCOHOL ALCOPOPS 75% of High School Students report having tried alcohol at least once. 28% reported having an alcoholic beverage in the last month Male students more likely than female students to report episodic heavy drinking Effects of Alcohol • Heart/Blood Vessels –Short term •Perspiration increases and skin becomes flushed –Long Term •High blood pressure and damage to the heart muscle; blood vessels harden and become less flexible More Effects • Brain/Nervous System –Short Term • Speech is slurred and difficulty walking –Long Term • Brain cells are destroyed and unable to be replaced; damage to nerves in body resulting in numbness in hands and feet CNS Effect of ethanol Inhibits L-Type Ca++ Channels: Reducing CNS Excitability -effects on vassopressin release -reduced water reabsorption (alcohol induced diuresis) CNS Effect of ethanol …The Rest of Alcohol Effects • Liver –Short Term •Liver changes alcohol into water and carbon dioxide –Long Term •Liver is damaged possibly resulting in cirrhosis (scarring and destruction of the liver) Liver • Can only oxidize about 1 serving of alcohol an hour • NO WAY to speed up this process • Until liver has had time to oxidize all of the alcohol ingested, it keeps circulating through the bloodstream Liver Damage • FATTY LIVER –alcohol interferes with body’s ability to break down fats. •Excess fat blocks flow in liver resulting in reduced oxygen and cell death •can be REVERSED when drinking stops Liver Damage • CIRRHOSIS –scarring of the liver –no blood flow in scarred area –liver cannot function –symptoms: high blood pressure, abdominal swelling, jaundice –IRREVERSIBLE Healthy Liver Alcoholic Liver …The Rest of Alcohol Effects • Stomach/Pancreas –Short Term •Stomach acids increase, which often results in nausea and vomiting –Long Term •Irritation occurs in the stomach lining, causing open sores called ulcers; pancreas becomes inflamed Binge Drinking • 5 or more drinks in a sitting for men • 4 or more drinks in a sitting for women • May lead to Alcohol Poisoning • May lead to unplanned unprotected sex • May lead to drug use • Many high school/college students die from alcohol poisoning from binge drinking on the weekends. Dangers of Binge Drinking • Unintentional injuries (e.g. car crash, falls, burns, drowning). • Intentional injuries (e.g. firearm injuries, sexual assault, domestic violence). • Alcohol poisoning. • STD’s and/or Unintended pregnancy. • High blood pressure, stroke, and other cardiovascular diseases. • Liver Disease Factors affecting the amount of alcohol in a person’s blood • Gender • Metabolism • Amount of Alcohol (not # of drinks) • How much they weigh • How much time elapses after or between drinks Drinking and Driving • Drinking alcohol impairs vision, reaction time, and coordination. • DWI and DUI –leading cause of death among teens • Signs of intoxication can begin to appear as low as 0.02 • There is no acceptable BAC level for anyone under 21 SAFEST AMOUNT OF DRINKS = 0!!! This is at any age!!!! Alcohol Poisoning • Dangerous to just “sleep it off” • Signs –Mental confusion, stupor, coma, inability to be excited, vomiting, and seizures –Slow Respiration *Hypothermia *Dehydration *Irregular heartbeat –CALL 911 immediately if suspicious of poisoning Alcoholism • A disease in which a person has a physical or psychological dependence on drinks that contain alcohol. • Characterized as
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