Severe ethanol intoxication in an adolescent

Severe Ethanol Intoxication in an Adolescent DAVID L. MORGAN, MD, MS,* MARK H. DURSO, PHARMD,I":I: BRIAN K. RICH, BS,* THOMAS L. KURT, MD, MPHt§ A 15-year-old boy presented to the emergency department with status epilepticus and a blood ethanol concentrationof 757 mg/dL. Mechanical ventilation and substantial amounts of benzodiazepines were required. His hospital coursewas complicated by aspiration pneumonia, but he had no episodes of hypoglycemia. He received 2.8 hours of hemodialysis, which increased the rate of ethanol elimination, but there is no evidence that hemodialysis improved his clinical outcome. To our knowledge, this is the highest blood ethanol level reported in a child or adolescent who survived. (Am J Emerg Med 1995;13:416-418. Copyright© 1995 by W.B. Saunders Company) S e v e r e e t h a n o l i n t o x i c a t i o n m a y c a u s e d e a t h b y respiratory d e p r e s s i o n , h y p o g l y c e m i a , or h y p o t h e r m i a . ~ M o s t rep o r t s of v e r y high b l o o d e t h a n o l c o n c e n t r a t i o n s ( g r e a t e r t h a n 500 m g / d L ) p e r t a i n to adult patients. 2-6 A l t h o u g h some of t h e s e adults h a d mild s y m p t o m s of e t h a n o l toxicity a n d required only s u p p o r t i v e t r e a t m e n t , 2'3'5 signs of s e v e r e intoxication m a y o c c u r in c h i l d r e n 7 a n d a d o l e s c e n t s 8"9 with m u c h lower blood ethanol concentrations. A MEDLINE search for r e p o r t s o f b l o o d e t h a n o l levels > 5 0 0 m g / d L in p a t i e n t s y o u n g e r t h a n 18 y e a r s s h o w e d only 3 d e s c r i p t i o n s o f y o u n g c h i l d r e n 1°-~2 a n d n o c a s e r e p o r t s of a d o l e s c e n t s .

CASE REPORT A 15-year-old Hispanic boy with no significant medical history presented to the emergency department (ED) in status epilepticus. He had left school with friends to drink alcohol about 3 hours earlier. After drinking an unknown amount of beer and vodka, he fell to the ground in a generalized tonic-clonic seizure. He continued to have intermittent seizure activity without regaining consciousness while being transported to the ED by friends. On arrival to the ED at 1:35 pm, his breathing was extremely labored, and vomitus with an alcohol odor was coming from his mouth and nose. He was immediately endotracheally intubated for airway protection, and received supportive ventilation. There was no gag reflex, no response to noxious stimuli, no pupillary response, and decreased rectal tone. Breath sounds were coarse bilaterally. His blood pressure was 125/51 mm Hg, heart rate was 96 beats/min, tympanic temperature was 35.9°C, and he weighed 66 kg. He had several generalized tonic-clonic seizures in the ED and was treated with a total of 14 mg lorazepam and 1,000 mg phenytoin. He con-

From the *Division of Emergency Medicine and the -I-Department of Internal Medicine, University of Texas Southwestern Medical School, :[:Parkland Memorial Hospital, and §North Texas Poison Center, Dallas, TX. Manuscript received July 14, 1994; revision accepted August 26, 1994. Address reprint requests to Dr Morgan, Division of Emergency Medicine, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75235-8579. Key Words: Adolescent, ethanol, alcohol, dialysis, seizure, hemodialysis, toxicology, intoxication. Copyright © 1995 by W.B. Saunders Company 0735-6757/95/1304-000955.00/0 416

tinued to have some small facial focal seizures over the next several hours. Gastric lavage was performed until clear aspirate was obtained. Initial laboratory studies obtained a few minutes after presentation included an ethanol level of 757 mg/dL and serum osmolality of 482 mOsm/kg. A urine toxicology screen was negative for phencyclidine, cannabinoids, benzodiazepines, barbiturates, opiates, cocaine, and amphetamines. There was no detectable acetaminophen, salicylates, or ethylene glycol in his serum. White blood cell count was 18,3000/t~L with 53% polymorphic neutrophils, 42% lymphocytes, 2% monocytes, and 2% eosinophils. Hemoglobin was 14.7 g/dL, hematocrit was 42.6%, and platelets were 317,000/p.L. His mean corpuscular volume was 84.4, prothrombin time 12.1 seconds, and partial thromboplastin time 23.8 seconds. Sodium was 136 mEq/ L; potassium, 4.1 mEq/L; chloride, 103 mEq/L; bicarbonate, 21 mEq/L; glucose, 155 mg/dL; creatinine, 0.9 mg/dL; calcium, 8.1 mg/dL; magnesium, 2.0 mEq/L; phosphate, 3.1 mg/dL; total bilirubin, 0.5 mg/dL; alkaline phosphatase, 87 U/L; aspartate aminotransferase, 21 U/L; and gamma-glutamyl transferase, 21 U/L. Arterial blood gases obtained immediately after intubation and on 100% Flo2 were as follows: pH, 7.29; Po 2, 172 mm Hg; and Pco2, 43 mm Hg. Initial chest radiograph was suggestive of bilateral aspiration pneumonitis. Computerized tomography showed no intracranial abnormalities. An electroencephalogram showed no epileptiform activity and was consistent with sedative medication effects or a profound metabolic encephalopathy. The patient remained comatose for the first 7 hours after presentation, and had no additional generalized seizures. Because of the marked hyperosmolar state, continuing coma, multiple seizures, and extremely high blood ethanol concentration, it was believed that hemodialysis might benefit the patient. Before starting hemodialysis, the patient's ethanol level and serum osmolality had decreased to 407 mg/dL (Figure 1) and 410 mOsm/kg, respectively. After 1 hour of dialysis, the patient was noted to have spontaneous movements and responded to painful stimuli. At the conclusion of 2.8 hours of dialysis, he was moving all extremities and attempting to sit up in bed. He also had corneal, gag, and cough reflexes. His ethanol level and serum osmolality were 139 mg/dL and 321 mOsm/kg, respectively. Three and a half hours later, his ethanol level was 84 mg/dL (Figure 1) and serum osmolality was 303 mOsm/kg. He had no episodes of hypoglycemia and no additional seizure activity. He remained agitated and combative, requiring more than 100 mg of lorazepam over the first 24 hours. On the second hospital day, a continuous lorazepam infusion was started and required rapid titration to a rate of 8 mg/h. In the first 5.5 days of his hospitalization, he required a total lorazepam dosage of 935 mg. Additional haloperidol and morphine were also required to sedate him. He developed a fever on the third day, and a chest radiograph showed bilateral infiltrates. He was treated with antibiotics, and assisted controlled ventilation was continued with the Fzo 2 slowly decreased over time. The patient was extubated on his 7th hospital day 10 hours after the lorazepam was discontinued. He remembered drinking three "fifths" of vodka, a 12-pack of beer, and several margaritas on the day of admission. He admitted to drinking alcohol occasionally for the past 2 years. On the 1 lth hospital day, he was afebrile, had no neurological deficits, and was discharged. He was seen two months later in the neurology clinic, and was doing well with no obvious sequelae.

MORGAN ET AL • SEVERE ETHANOL INTOXICATION

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FIGURE 1. Bloodethanol concentration.

DISCUSSION There are many reports of adult patients who survived with blood ethanol levels >757 m g / d L . 2'3'5'6 However, the highest blood ethanol level reported in a patient younger than 18 years old who survived was 740 mg/dL in a 4-yearold girl. 1° Another 3.5-year-old child had a blood ethanol level of 640 mg/dL. 11 Both of these children were treated with peritoneal dialysis, which slightly enhanced ethanol elimination. A 1.5-year-old boy who survived an ethanol level of 575 mg/dL required endotracheal intubation but did not receive dialysis. 12 The physiological rate of ethanol elimination has been traditionally described as a zero-order process. 13 That is, the blood ethanol level decreases by a constant amount (12 to 39 mg/dL 14'15) each hour. This constant amount varies according to a g e , 14 past alcohol u s e , 16 gender, 16J7 stomach contents,18 and other factors.19 However, investigators recently have reported that ethanol elimination in some individuals follows a logarithmic decline (first-order kinetics) or a complex partial logarithmic decline. 2°-22 In these patients, the blood ethanol concentration decreases faster at higher levels than at lower blood levels. There is also evidence that ethanol elimination does not follow zero-order kinetics at very high levels. 6 Between the blood ethanol concentrations of 757 to 407 mg/dL, our patient eliminated ethanol with an overall rate of 51.4 mg/dL/h (Table 1). At this elimination

TABLE1. Blood Ethanol Levels Interval Predialysis

Dialysis

Postdialysis

Time (h)

Ethanol level (mg/dL)

0 3.7 5.5 6.5 7.5 9.2 9.5 9.8 10.8 11.7 13.3

757 508 439 407 336 179 171 139 136 120 84

Elimination Rate (mg/dL/h)

53.8

84.5

20.8

rate, our patient had to ingest (not including the amount vomited) a calculated amount of 948 mL of 80-proof (40%) ethanol 1.25 hours earlier to reach a blood ethanol level of 757 mg/dL. There have been many therapies suggested to increase the elimination of ethanol during acute intoxication. Activated charcoal, 23 fructose, z4 or gastric lavage 25 do not significantly decrease the blood ethanol level for most patients. Dialysis for severe ethanol intoxication was first suggested in 1960, and hemodialysis was reported to be four times faster than the physiological elimination of ethanol. 26 Since then, many patients with ethan01 intoxication have undergone peritoneal d i a l y s i s 6"1°']1'27 and hemodialysis. 28 However, the clinical benefit of dialysis for these patients has not been established. During hemodialysis, the estimated average physiological elimination rate of ethanol for our patient was probably about 30 mg/dL/h based on the rates before and after dialysis (Table 1). Therefore, the elimination rate of 84.5 mg/dL/h during dialysis represents a rate nearly three times greater than the estimated physiological rate. Had dialysis not been used and had the physiological elimination rate been 30 mg/ dL/h during this time, the blood ethanol level would have decreased to 139 mg/dL in 8.9 hours (compared to the 3.3 hours using dialysis). It is impossible to determine whether the estimated 5.6 hours of lower blood ethanol concentration provided by hemodialysis significantly improved the clinical outcome of this patient. Our patient required very large amounts of benzodiazepines for sedation in the intensive care unit. The reason for this is not clear. He may have developed tolerance to them if he regularly used large amounts of ethanol or benzodiazepines before admission. There was no laboratory evidence that he was a chronic user of large amounts of ethanol or benzodiazepines, and he had only begun drinking alcohol 2 years earlier. Most children and adolescents with ethanol intoxication and blood ethanol levels <500 mg/dL can be treated without dialysis. 7-9J4'29'3° Many of these patients will be comatose and may require mechanical ventilation. Ethanol intoxication may cause death by respiratory failure or hypoglycemia. These effects can be seen with relatively low blood ethanol concentrations, especially in younger children. A 4-year-old child died with a blood ethanol level of only 31 mg/dL after drinking mouthwash and developing hypoglycemia.31 Vomiting, seizures, hypothermia, and metabolic acidosis are also frequently observed in children and adolescents with acute ethanol intoxication. 9 It is unclear whether these seizures are caused by hypoglycemia, hypoxia, or the direct toxic effects of ethanol. 9"29Our patient continued to have seizures in the ED without hypoglycemia and with adequate oxygenation.

CONCLUSION Optimal treatment for severe ethanol intoxication consists of aggressive supportive care with attention to ventilation, adequate perfusion, avoiding hypothermia, monitoring serum electrolytes, and frequent blood glucose determinations with rapid treatment of hypoglycemia if detected. Although it has not been proven to improve the clinical outcome of those patients with severe symptoms of ethanol intoxication

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AMERICAN JOURNAL OF EMERGENCY MEDICINE • Volume 13, Number 4 • July 1995

and high blood ethanol concentrations, dialysis does enhance the elimination of ethanol from the blood. The unproven potential benefit of dialysis for severe ethanol intoxication needs to be weighed against the known complications of acute hemodialysis. Additional studies are needed to determine if hemodialysis, in addition to reducing the blood ethanol level, actually improves the outcome of patients with severe ethanol intoxication.

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