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Methanol and Ethylene Glycol Intoxication

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Methanol and Ethylene Glycol Intoxication Methanol and Ethylene Glycol Intoxication a,b, James A. Kruse, MD, FCCM * KEYWORDS Methanol Ethylene glycol Intoxication Ingestion KEY POINTS More than 9000 cases of methanol and ethylene glycol ingestion were reported to the American Association of Poison Control Centers in 2010. Accidental or intentional ingestion of substances containing these agents can result in death, and some survivors are left with blindness, renal dysfunction, and chronic brain injury. Even in large ingestions, a favorable outcome is possible if the patient arrives at the hospital early enough and the poisoning is identified and appropriately treated in a timely manner. The word alcohol is commonly used to specifically refer to ethyl alcohol or ethanol. However, in chemical terms, alcohol can refer to any hydroxyl derivative of a hydro- carbon. By extension, the suffix “-ol” is used in chemical nomenclature to designate any of various alcohols. Ethanol (CH3-CH2-OH) is derived from the 2-carbon hydro- carbon ethane (CH3-CH3) and is sometimes called grain alcohol because it can be produced by fermentation from various grains. It is the alcohol found in beer, wine, and distilled spirits such as whiskey. The simplest alcohol is methanol or methyl alcohol (Table 1),1–9 derived from the 1-carbon hydrocarbon known as methane (CH4). Methanol is also known as wood alcohol because it can be produced by the destructive distillation of wood.2 The worldwide demand for methanol is about 50 billion kg annually.10 Methanol has many uses as a laboratory and industrial solvent and as a synthetic precursor. As a precursor, methanol is used in the production of certain plastics, synthetic textiles, and paints. Methanol also finds use as a fuel and antifreeze. It has been used, mainly in the past, as an antifreeze in automotive cooling systems.6 Methanol is a constituent of certain other automotive fluids and household products (Box 1).2,5 Two of particular note because of their availability at the residential level are many formulations of a College of Physicians and Surgeons, Columbia University, 116 Broadway, New York, NY 10027, USA; b Critical Care Services, Bassett Medical Center, One Atwell Road, Cooperstown, NY 13326, USA * Bassett Medical Center, One Atwell Road, Cooperstown, NY 13326. E-mail address: [email protected] Crit Care Clin 28 (2012) 661–711 http://dx.doi.org/10.1016/j.ccc.2012.07.002 criticalcare.theclinics.com 0749-0704/12/$ – see front matter Ó 2012 Elsevier Inc. All rights reserved. Downloaded from ClinicalKey.com at Inova Fairfax Hospital - JCon June 27, 2016. For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved. 662 Kruse Table 1 Properties of methanol and ethylene glycol Methanol Ethylene Glycol Molecular formula CH4OC2H6O2 Structural formula CH3-OH HO-CH2-CH2-OH Molecular mass (daltons) 32 62 Appearance Clear, colorless Clear, colorless Physical state Mobile liquid Slightly viscous liquid Aqueous solubility Miscible Miscible Odor description Slightly alcoholic Practically odorless Odor threshold (mg/m3) 13.1 62.5 Taste description Alcoholic Sweet Density (g/cm3) 0.79 1.11 Vapor pressure at 20C (torr) 96 0.06 Flammability Highly Slightly Flash point (C) 12 116 Boiling point (C) 65 198 Freezing point (C) À98 À13 Freezing point, 50% solution (C)a À55 À35 a Aqueous solution, by weight.1 Data from Refs.1–9 and other sources. automotive windshield washer fluid, and a gelled formulation of methanol marketed in small cans for use as a food warmer under chaffing dishes (eg, Sterno brand, The Sterno Group, LLC Des Plaines, IL). Methanol is also found in many commercially available paint products, including various solvents and thinners. Another major use of methanol is as a denaturant. Although ethanol has industrial uses other than in alcoholic beverages, potable ethanol-containing products, even if not intended for ingestion, are still subject to excise taxation and other governmental regulations. These taxes and restrictions are legally avoidable if the product contains a stipulated denaturant specifically to render the admixture unfit for human consump- tion. The resulting product is called denatured ethanol, or more commonly, denatured alcohol.2 The US Code of Federal Regulations specifies many permissible denaturants and formulas, but a common one uses methanol, typically constituting 4% or 5% of the admixture.14 Some alcoholics have been known to intentionally consume products containing denatured alcohol as a substitute for ethanol-containing beverages.15,16 Certain countries have banned the use of methanol as a denaturant because of the health hazard posed by this practice.17 Methanol poisoning is most often caused by ingestions involving commercially available methanol-containing products, or from attempts to concoct alcoholic bever- ages from these products. Although methanol is found in small amounts in certain fruits and vegetables, and it is a metabolic product of the artificial sweetener aspar- tame, the quantities available from these sources do not pose a health hazard.18,19 Similarly, small amounts of methanol are present as minor congeners in some legiti- mate fermented alcoholic beverages.20,21 The human toxicity of various alcohols depends on the specific chemical nature of the particular alcohol. The inebriating and sedative-hypnotic effects of ethanol are well known. Methanol can have similar effects, but it can also lead to substantial acute Downloaded from ClinicalKey.com at Inova Fairfax Hospital - JCon June 27, 2016. For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved. Methanol and Ethylene Glycol Intoxication 663 Box 1 Products that may contain methanol Denatured alcohol Windshield washer fluids Windshield deicers Automotive antifreezea Carburetor cleaners Gasohol (gasoline blends) Race car fuels Fuel cell fuels Dry gas Model airplane fuel Portable torch fuel Chafing-dish and camp-stove fuels Various cleaning fluids Embalming fluids Octane booster in gasoline Nonbeverage alcoholb Surrogate alcoholc Lacquer and paint thinners Shellac thinners Wood stains Paints and varnishes Shellacs Dye-based wood stains Furniture refinishers Paint and varnish removers Dewaxing preparations Glass cleaners Hobby and craft adhesives Pipe sweeteners Copy machine fluids a Uncommon constituent of modern commercially available antifreeze products intended for automotive cooling systems, compared with ethylene glycol-based and propylene glycol- based formulations. b Any alcohol not intended for human consumption. c Illegally produced or homemade alcohol. Data from Refs.2,5,7,11–13 and other sources. Downloaded from ClinicalKey.com at Inova Fairfax Hospital - JCon June 27, 2016. For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved. 664 Kruse toxicity or death if ingested in small amounts. Propyl alcohol, derived from the 3-carbon hydrocarbon propane, has 2 isomers: normal or n-propanol (CH3-CH2- CH2-OH) and isopropanol (CH3-CHOH-CH3). The latter is commonly available in many rubbing alcohol formulations. Compared with methanol, isopropanol is less toxic and there are important differences in their toxicity.11,12 Isopropanol ingestion is discussed elsewhere in this issue by Cartwright and colleagues. Hydrocarbons containing 2 hydroxyl groups are called glycols. The glycol derived from ethane is called ethylene glycol (see Table 1). The estimated worldwide produc- tion of ethylene glycol exceeds 23 billion kg annually.9 Ethylene glycol is used as the main ingredient in the most commonly available automotive antifreeze prod- ucts.1,2,6,9,22 Automotive antifreeze formulations may contain various additives such as anticorrosives, lubricants, antifoaming agents, and dyes. Sodium fluorescein, a compound that exhibits fluorescence on exposure to ultraviolet (UV) illumination, is commonly, but not universally, added to help identify automotive cooling system leaks.2,23 Denatonium benzoate (Bitrex, Macfarlan Smith, Edinburgh, Scotland), a lido- caine derivative with an intensely disagreeable taste, is added to some antifreeze formulations and other products as an aversive agent to discourage accidental or intentional ingestion.24 The same bittering agent is legally allowable in many countries, including the United States, as a denaturant (hence the generic name of the compound).14 Some jurisdictions, including some states within the United States, require the addition of a bitterant in automotive antifreeze products, although a before-and-after study found no change in the frequency, severity, or rate of hospi- talizations for antifreeze ingestions in children less than 5 years of age in areas where such statutes were enacted.25 Ethylene glycol is also found in various solvents and paint formulations, and other industrial and consumer products (Box 2).2,5,7,11–13 The largest industrial use is as a synthetic precursor. For example, polyethylene terephthalate, the polymer used to make plastic carbonated beverage bottles and other containers, is produced from ethylene glycol, as is the familiar synthetic textile known as polyester (eg, Dacron brand).2 Although these secondary products are made from ethylene glycol, they are distinct molecular entities that do not pose any direct toxic hazard. However, ethylene glycol itself, like methanol, can result in life-threatening poisoning if ingested. The usefulness of ethylene glycol as an antifreeze derives from its low molecular mass, miscibility
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