Lab Case 165 – Interpretation

A 30 year old NIDDM is brought to your ED after being found with altered mental state following an argument with his partner.

He is unwell, has compensated shock requiring emergent management

Compensated HAGMA,   No NAGMA

Mild renal impairment


Very high lactate

All suggest toxic alcohol (ethylene glycol) – check osmolar gap

  • there is a conversion to add BAL to AG

Resusc RSI DEAD approach

Resusc – fluid, intubate with care (HCO3 pre, hyperventilate)

Investigation – BSL, ECG, BAL

Decon – no role for AC


  • temporising alcohol (vodka shots)
  • dialysis
  • Fomepazole not available in Australia

Disposition – ICU

In ethylene glycol toxicity, pyridoxine (100mg IV Q6H) and thiamine (100mg IV Q6H) increase the metabolism of glycolic and glycoxlic acid to the less toxic metabolites glycine and alpha-hydroxy-beta-ketoadipate.

The indications to commence antidotal therapy are:

  • Serum concentration of methanol / ethylene glycol > 20 mg/dL
  • Confirmed or suspected methanol / ethylene glycol ingestion and two of the following:
  • Osmolar gap > 10 mOsm
  • Arterial pH < 7.3
  • Bicarbonate < 20 mmol/L
  • Presence of urinary oxalate crystals

The indications for haemodialysis in methanol / ethylene glycol poisoning are:

  • Metabolic acidosis (pH < 7.25-7.30)
  • Visual abnormalities
  • Renal failure
  • Electrolyte abnormalities not responsive to conventional treatment
  • Haemodynamic instability refractory to ICU treatment
  • Serum concentration > 50mg/dL