Internal and Emergency Medicine

, Volume 13, Issue 3, pp 375–383 | Cite as

Toxic alcohol diagnosis and management: an emergency medicine review

  • Patrick Chow Yuen Ng
  • Brit J. Long
  • William Tyler DavisEmail author
  • Daniel J. Sessions
  • Alex Koyfman


Toxic alcohols are a group of substances containing a hydroxyl group not meant to be ingested. They are the cause of a significant number of accidental and non-accidental exposures. Toxic alcohol poisoning can be associated with a significant degree of morbidity and mortality if not promptly recognized and treated. This review describes the clinical presentation and an approach to the recognition and management for toxic alcohol poisoning. Toxic alcohols classically refer to a group of alcohols not meant for ingestion. Methanol, ethylene glycol, and isopropyl alcohol are readily available in common hardware and household materials. Toxic alcohols are ingested for a variety of reasons including accidental exposures, intentional inebriation, homicide and suicide. The patient with an altered mental status or concerning history warrants consideration of this potentially deadly ingestion. Treatment considerations include alcohol dehydrogenase blockade and hemodialysis. Toxic alcohol poisoning can be an elusive diagnosis. This review evaluates toxic alcohol poisoning signs and symptoms and an approach to diagnosis and management.


Fomepizole Alcohol Toxic alcohol Hemodialysis Methanol Isopropyl alcohol Ethylene glycol 



The authors thank Dr. Jeffrey Brent, MD, PhD, Distinguished Clinical Professor, Medicine-Clinical Pharmacology/Toxicology, University of Colorado School of Medicine, for valuable feedback in reviewing this manuscript. This manuscript did not utilize any grants, and it has not been presented in abstract form. This clinical review has not been published, it is not under consideration for publication elsewhere, its publication is approved by all authors and tacitly or explicitly by the responsible authorities where the work was carried out, and that, if accepted, it will not be published elsewhere in the same form, in English or in any other language, including electronically without the written consent of the copyright-holder. This review does not reflect the views or opinions of the US government, Department of Defense, US Army, US Air Force, or SAUSHEC EM Residency Program.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Statement of human and animal rights

 This is a clinical review that did not involve the care of humans or animals.

Informed consent

There is no requirement for informed consent with this review.


  1. 1.
    Wiener SW (2015) Toxic Alcohols. In: Hoffman RS, Howland M, Lewin NA et al (eds) Goldfrank’s toxicologic emergencies, 10th edn. McGraw-Hill, New YorkGoogle Scholar
  2. 2.
    Mowry JB, Spyker DA, Brooks DE et al (2016) 2015 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 33rd Annual Report. Clin Toxicol 54(10):924–1109CrossRefGoogle Scholar
  3. 3.
    Paasma R, Hovda KE, Jacobsen D (2009) Methanol poisoning and long term sequelae—a six years follow-up after a large methanol outbreak. BMC Clin Pharmacol 9:5CrossRefPubMedCentralPubMedGoogle Scholar
  4. 4.
    Moral AR, Cankayali I, Sergin D et al (2015) Neuromuscular functions on experimental acute methanol intoxication. Turk J Anaesthesiol Reanim. 43(5):337–343CrossRefPubMedCentralPubMedGoogle Scholar
  5. 5.
    Liesivuori J, Savolainen H (1991) Methanol and formic acid toxicity: biochemical mechanisms. Pharmacol Toxicol 69:157–163CrossRefPubMedGoogle Scholar
  6. 6.
    Maddry JK, Ng PC, Sessions D et al (2016) A prospective observation study of medical toxicology consultation in a U.S. Combat Theater. Mil Med 181(11):e1666–e1668CrossRefPubMedGoogle Scholar
  7. 7.
    Brent J, McMartin K, Phillips S et al (2001) Fomepizole for the treatment of methanol poisoning. N Engl J Med 344(6):424–429CrossRefPubMedGoogle Scholar
  8. 8.
    Cederbaum AI (2012) Alcohol metabolism. Clin Liver Dis 16(4):667–685CrossRefPubMedCentralPubMedGoogle Scholar
  9. 9.
    Peterova K, Brozova H, Klempir J et al (2018) Gait and balance impairment after acute methanol poisoning. Basic Clin Pharmacol Toxicol 122:176–182CrossRefPubMedGoogle Scholar
  10. 10.
    Desai T, Sudhalkar A, Vyas U et al (2013) Methanol poisoning: predictors of visual outcomes. JAMA Ophthalmol 131(3):358–364CrossRefPubMedGoogle Scholar
  11. 11.
    Liu B, Xue Z, Zhu X et al (2017) Long-term trends (1990–2014), health risks, and sources of atmospheric polycyclic aromatic hydrocarbons (PAHs) in the U.S. Environ Pollut 220(Pt B):1171–1179CrossRefPubMedGoogle Scholar
  12. 12.
    Spiteri A (2016) The blue patient. Emerg Med J 33(12):896CrossRefPubMedGoogle Scholar
  13. 13.
    Sakai N, Hirose Y, Sato N et al (2016) Late metabolic acidosis caused by renal tubular acidosis in acute salicylate poisoning. Intern Med 55(10):1315–1317CrossRefPubMedGoogle Scholar
  14. 14.
    Kanamori F, Kawabata T, Muraoka S et al (2016) Ruptured partially thrombosed anterior inferior cerebellar artery aneurysms: two case reports and review of literature. Nagoya J Med Sci 78(4):517–522PubMedCentralPubMedGoogle Scholar
  15. 15.
    Parola P, Paddoc CD, Raoult D (2005) Tick-borne rickettsioses around the world: emerging diseases challenging old concepts. Clin Microbiol Rev 18:719–756CrossRefPubMedCentralPubMedGoogle Scholar
  16. 16.
    Elsterova J, Palus M, Sirmarova J et al (2017) Tick-borne encephalitis virus neutralization by high dose intravenous immunoglobulin. Ticks Tic Borne Dis 8(2):253–258CrossRefGoogle Scholar
  17. 17.
    Hoiland RL, Bain AR, Rieger MG et al (2016) Hypoxemia, oxygen content, and the regulation of cerebral blood flow. Am J Physiol Regul Integr Comp Physiol 310(5):R398–R413CrossRefPubMedGoogle Scholar
  18. 18.
    Shah NM, Hussain S, Cooke M et al (2015) Wilderness medicine at high altitude: recent developments in the field. Open Acess J Sports Med 24(6):319–328CrossRefGoogle Scholar
  19. 19.
    Schmidt KJ, Doshi MR, Holzhausen JM et al (2016) Treatment of severe alcohol withdrawal. Ann Pharmacother 50(5):389–401CrossRefPubMedGoogle Scholar
  20. 20.
    Niaz K, Bahadar H, Maqbool F et al (2015) A review of environmental and occupational exposure to xylene and its health concerns. EXCLI J 23(14):1167–1186Google Scholar
  21. 21.
    Mygatt J, Amani M, Ng P et al (2017) Hydrocarbon enema: an unusual cause of chemical burn. J Burn Care Res 38:e872–e876CrossRefPubMedGoogle Scholar
  22. 22.
    Haddad FA, Nadelman RB (2003) Lyme disease and the heart. Front Biosci 1(8):s769–s782Google Scholar
  23. 23.
    Ben Khelil M, Chkirbene Y, Mlika M et al (2017) Penicillin-induced fulminant myocarditis: a case report and review of the literature. Am J Forensic Med Pathol 38(1):29–31PubMedGoogle Scholar
  24. 24.
    Kea B, Alligood T, Manning V et al (2016) A review of the relationship of atrial fibrillation and acute coronary syndrome. Curr Emerg Hosp Med Rep 4(3):107–118CrossRefPubMedCentralPubMedGoogle Scholar
  25. 25.
    Sinha SK, Sachan M, Goel A et al (2017) Efficacy and safety of thrombolytic therapy in acute submassive pulmonary embolism: follow-up study. J Clin Med Res 9(2):163–169CrossRefPubMedGoogle Scholar
  26. 26.
    Takagi H, Ando T, Umemoto T (2017) Worse late-phase survival after elective endovascular than open surgical repair for intact abdominal aortic aneurysm. Int J Cardiol 236:427–431CrossRefPubMedGoogle Scholar
  27. 27.
    Puga AE, Rodriguez SC, Panero BM et al (2016) Chronic type A aortic dissection and giant aortic root aneurysm after aortic valve replacment. Aorta 4(3):108–110CrossRefPubMedCentralPubMedGoogle Scholar
  28. 28.
    Pietrus M, Paprota P, Radziszewska R et al (2015) Carbon monoxide poisoning in pregnant woman. Przegl Lek 72(9):482–484PubMedGoogle Scholar
  29. 29.
    Gajda M, Kaminska G, Grzesiak I et al (2016) Melanoma as a surprising solution to the puzzle of intestinal obstruction. An Bras Dermatol 91(5 suppl 1):95–97CrossRefPubMedCentralPubMedGoogle Scholar
  30. 30.
    Mendez Y, Surani S, Varon J (2017) Diabetic ketoacidosis: treatment in the intensive care unit or general medical/surgical ward? World J Diabetes 8(2):40–44CrossRefPubMedCentralPubMedGoogle Scholar
  31. 31.
    Mangen MJ, Huijts SM, Bonten MJ et al (2017) The impact of community-acquired pneumonia on the health-related quality-of-life in elderly. BMC Infect Dis 17(1):208CrossRefPubMedCentralPubMedGoogle Scholar
  32. 32.
    Phelps HM, Kelleman MS, McCracken CE et al (2017) Application of pediatric appropriate use criteria for initial outpatient evaluation of syncope. Echocardiography 34(3):441–445CrossRefPubMedGoogle Scholar
  33. 33.
    Ataya A, Cope J, Alnuaimat H (2017) Pulmonary embolism in patients hospitalized for syncope. N Engl J Med 376(5):496–497PubMedGoogle Scholar
  34. 34.
    Kostic MA, Dart RC (2003) Rethinking the toxic methanol level. J Toxicol Clin Toxicol 41(6):793–800CrossRefPubMedGoogle Scholar
  35. 35.
    McMartin K, Jacobsen D, Hovda KE (2016) Antidotes for poisoning by alcohols that form toxic metabolites. Br J Clin Pharmacol 81(3):505–515CrossRefPubMedCentralPubMedGoogle Scholar
  36. 36.
    Buchanan JA, Alhelail M, Cetaruk EW et al (2010) Massive ethylene glycol ingestion treated with fomepizole alone—a viable therapeutic option. J Med Toxicol 6(2):131–134CrossRefPubMedCentralPubMedGoogle Scholar
  37. 37.
    Froberg K, Dorion RP, McMartin KE (2006) The role of calcium oxalate crystal deposition in cerebral vessels during ethylene glycol poisoning. Clin Toxicol 44(3):315–318CrossRefGoogle Scholar
  38. 38.
    Winter ML, Snodgrass WR (2007) Urine fluorescence in ethylene glycol poisoning. N Engl J Med 356(19):2006–2007CrossRefPubMedGoogle Scholar
  39. 39.
    Alzouebi M, Sarrigiannis PG, Hadjivassilou M (2008) Acute polyradiculoneuropathy with renal failure: mind the anion gap. J Neurol Neurosurg Psychiatry 79(7):842–844CrossRefPubMedGoogle Scholar
  40. 40.
    Gardner TB, Manning HL, Beelen AP et al (2004) Ethylene glycol toxicity associated with ischemia, perforation and colonic oxalate crystal deposition. J Clin Gastroenterol 38(5):435–439CrossRefPubMedGoogle Scholar
  41. 41.
    Delany C, Jay WM (2004) Papilledema and abducens nerve palsy following ethylene glycol ingestion. Semin Opthalmol 19(3–4):72–74CrossRefGoogle Scholar
  42. 42.
    Jacobsen D, McMartin KE (1986) Methanol and ethylene glycol poisonings. Mechanism of toxicity, clinical course, diagnosis and treatment. Med Toxicol 1(5):309–334CrossRefPubMedGoogle Scholar
  43. 43.
    Brent J (2001) Current management of ethylene glycol poisoning. Drugs 61(7):979–988CrossRefPubMedGoogle Scholar
  44. 44.
    Hodgman M, Marraffa JM, Wojcik S et al (2017) Serum calcium concentration in ethylene glycol poisoning. J Med Toxicol 13(2):153–157CrossRefPubMedGoogle Scholar
  45. 45.
    Wallace KL, Suchard JR, Curry SC et al (2001) Diagnostic use of physicians' detection of urine fluorescence in a simulated ingestion of sodium fluorscein-containing antifreeze. Ann Emerg Med 38(1):49–54CrossRefPubMedGoogle Scholar
  46. 46.
    Casavant MJ, Shan MN, Battels R (2001) Does fluorescent urine indicate antifreeze ingestion by children? Pedriatics 107(1):113–114CrossRefGoogle Scholar
  47. 47.
    Darchy B, Abruzzese L, Pitiot O et al (1999) Delayed admission for ethylene glycol poisoning: lack of elevated serum osmol gap. Intensive Care Med 25(8):859–861CrossRefPubMedGoogle Scholar
  48. 48.
    Head JM (2012) Ethylene glycol ingestion masked by concomitant ethanol intoxication. BMJ Case Rep. PubMedCentralPubMedGoogle Scholar
  49. 49.
    Jacobsen D (1999) New treatment for ethylene glycol poisoning. NEJM 340(11):879–881CrossRefPubMedGoogle Scholar
  50. 50.
    Stremski E, Hennes H (2000) Accidental isopropanol ingestion in children. Pediatr Emerg Care 16(4):238–240CrossRefPubMedGoogle Scholar
  51. 51.
    Zaman F, Pervez A, Abreo K (2002) Isopropyl alcohol intoxication: a diagnostic challenge. Am J Kidney Dis 40(3):E12CrossRefPubMedGoogle Scholar
  52. 52.
    Bessonneau V, Clement M, Thomas O (2010) Can intensive use of alcohol-based hand rubs lead to passive alcoholization? Int J Environ Res Public Health 7(8):3038–3050CrossRefPubMedCentralPubMedGoogle Scholar
  53. 53.
    Gormley NJ, Bronstein AC, Rasimas JJ et al (2012) The rising incidence of intentional ingestion of ethanol-containing hand sanitizers. Crit Care Med 40(1):290–294CrossRefPubMedCentralPubMedGoogle Scholar
  54. 54.
    Alexander CB, McBay AJ, Hudson RP (1982) Isopropanol and isopropanol deaths: ten year’s experience. J Forensic Sci 27(3):541–548CrossRefPubMedGoogle Scholar
  55. 55.
    Kraut JA, Kurtz I (2008) Toxic alcohol ingestions: clinical features, diagnosis and management. Clin J Am Soc Nephrol 3(1):208–225CrossRefPubMedGoogle Scholar
  56. 56.
    Pappas AA, Ackerman BH, Olsen KM et al (1991) Isopropanol ingestion: a report of six episodes with isopropanol and acetone serum concentration time data. J Toxicol Clin Toxicol 29(1):11–21CrossRefPubMedGoogle Scholar
  57. 57.
    Dyer S, Mycyk MB, Ahrens WR et al (2002) Hemorrhagic gastritis from topical isopropanol exposure. Ann Pharmacother 36(11):1733–1735CrossRefPubMedGoogle Scholar
  58. 58.
    Hawley PC, Falko JM (1982) “Pseudo” renal failure after isopropyl alcohol intoxication. South Med J 75(5):630–631CrossRefPubMedGoogle Scholar
  59. 59.
    Killeen C, Meehan T, Dohnal J et al (2011) Pseudorenal insufficiency with isopropyl alcohol ingestion. Am J Ther 18(4):e113–e116CrossRefPubMedGoogle Scholar
  60. 60.
    Adla MR, Gonzalez-Paoli JA, Rifkin SI (2009) Isopropyl alcohol ingestion presenting as pseudorenal failure due to acetone interference. South Med J 102(8):867–869CrossRefPubMedGoogle Scholar
  61. 61.
    Zakharov S, Pelclova D, Navratil T et al (2017) Efficiency of academia correction on intermittent versus continuous hemodialysis in acute methanol poisoning. Clin Toxicol (Phila) 55(2):123–132CrossRefGoogle Scholar
  62. 62.
    Velez JI, Shepard G, Lee YC et al (2007) Ethylene glycol ingestion treated only with fomepizole. J Med Toxicol 3(3):125–128CrossRefPubMedCentralPubMedGoogle Scholar
  63. 63.
    Jacobsen D, McMartin KE (1997) Antidotes for methanol and ethylene glycol poisoning. Clin Toxicol 35:127–143Google Scholar
  64. 64.
    Rietjens SJ, Lange DW, Meulenbelt J et al (2014) Ethylene glycol or methanol intoxication, which antidote should be used, fomepizole or ethanol? Neth J Med 72(2):73–79PubMedGoogle Scholar

Copyright information

© SIMI 2018

Authors and Affiliations

  • Patrick Chow Yuen Ng
    • 1
  • Brit J. Long
    • 1
  • William Tyler Davis
    • 1
    Email author
  • Daniel J. Sessions
    • 1
  • Alex Koyfman
    • 2
  1. 1.Department of Emergency MedicineSan Antonio Military Medical CenterFort Sam HoustonUSA
  2. 2.Department of Emergency MedicineThe University of Texas Southwestern Medical CenterDallasUSA

Personalised recommendations