Ethylene glycol exposure

An evidence-based consensus guideline for out-of-hospital management

E. Martin Caravati, Andrew R. Erdman, Gwenn Christianson, Anthony S. Manogeerra, Lisa L. Booze, Alan D. Woolf, Kent R. Olson, Peter Chyka, Elizabeth J. Scharman, Paul M. Wax, Daniel C. Keyes, William G. Troutman

Research output: Contribution to journalReview article

33 Citations (Scopus)

Abstract

In 2002, poison centers in the US reported 5816 human exposures to ethylene glycol. A guideline that effectively determines the threshold dose for emergency department referral and need for pre-hospital decontamination could potentially avoid unnecessary emergency department visits, reduce health care costs, optimize patient outcome, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with a suspected exposure to ethylene glycol by 1) describing the process by which the exposure might be evaluated, 2) identifying the key decision elements in managing the case, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care, considering all of the circumstances involved. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) A patient with exposure due to suspected self-harm, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the dose reported (Grade D). 2) Patients with inhalation exposures will not develop systemic toxicity and can be managed out-of-hospital if asymptomatic (Grade B). Patients with clinically significant mucous membrane irritation should be referred for evaluation (Grade D). 3) Decontamination of dermal exposures should include routine cleansing with mild soap and water. Removal of contact lenses and immediate irrigation with room temperature tap water is recommended for ocular exposures. All patients with symptoms of eye injury should be referred for an ophthalmologic exam (Grade D). 4) Patients with symptoms of ethylene glycol poisoning should be referred immediately for evaluation regardless of the reported dose (Grade C). 5) The absence of symptoms shortly after ingestion does not exclude a potentially toxic dose and should not be used as a triage criterion (Grade C). 6) Adults who ingest a "swallow" (10-30 mL), children who ingest more than a witnessed taste or lick, or if the amount is unknown of most ethylene glycol products should be referred immediately for evaluation. The potential toxic volume of dilute solutions (e.g., concentration <20%) is larger and can be estimated by a formula in the text (Grade C). 7) A witnessed taste or lick only by a child, or an adult who unintentionally drinks and then expectorates the product without swallowing, does not need referral (Grade C). 8) Referral is not needed if it has been >24 hours since a potentially toxic unintentional exposure, the patient has been asymptomatic, and no alcohol was co-ingested (Grade D). 9) Gastrointestinal decontamination with ipecac syrup, gastric lavage or activated charcoal is not recommended. Transportation to an emergency department should not be delayed for any decontamination procedures (Grade D). 10) Patients meeting referral criteria should be evaluated at a hospital emergency department rather than a clinic. A facility that can quickly obtain an ethylene glycol serum concentration and has alcohol or fomepizole therapy available is preferred. This referral should be guided by local poison center procedures and community resources (Grade D). 11) The administration of alcohol, fomepizole, thiamine, or pyridoxine is not recommended in the out-of-hospital setting (Grade D).

Original languageEnglish (US)
Pages (from-to)327-345
Number of pages19
JournalClinical Toxicology
Volume43
Issue number5
DOIs
StatePublished - Oct 17 2005

Fingerprint

Ethylene Glycol
Poisons
Decontamination
Guidelines
Hospital Emergency Service
Alcohols
Ipecac
Contact lenses
Referral and Consultation
Triage
Pyridoxine
Soaps (detergents)
Water
Charcoal
Thiamine
Health care
Irrigation
Toxicity
Gastric Lavage
Health

All Science Journal Classification (ASJC) codes

  • Toxicology
  • Health, Toxicology and Mutagenesis

Cite this

Caravati, E. M., Erdman, A. R., Christianson, G., Manogeerra, A. S., Booze, L. L., Woolf, A. D., ... Troutman, W. G. (2005). Ethylene glycol exposure: An evidence-based consensus guideline for out-of-hospital management. Clinical Toxicology, 43(5), 327-345. https://doi.org/10.1080/07313820500184971

Ethylene glycol exposure : An evidence-based consensus guideline for out-of-hospital management. / Caravati, E. Martin; Erdman, Andrew R.; Christianson, Gwenn; Manogeerra, Anthony S.; Booze, Lisa L.; Woolf, Alan D.; Olson, Kent R.; Chyka, Peter; Scharman, Elizabeth J.; Wax, Paul M.; Keyes, Daniel C.; Troutman, William G.

In: Clinical Toxicology, Vol. 43, No. 5, 17.10.2005, p. 327-345.

Research output: Contribution to journalReview article

Caravati, EM, Erdman, AR, Christianson, G, Manogeerra, AS, Booze, LL, Woolf, AD, Olson, KR, Chyka, P, Scharman, EJ, Wax, PM, Keyes, DC & Troutman, WG 2005, 'Ethylene glycol exposure: An evidence-based consensus guideline for out-of-hospital management', Clinical Toxicology, vol. 43, no. 5, pp. 327-345. https://doi.org/10.1080/07313820500184971
Caravati EM, Erdman AR, Christianson G, Manogeerra AS, Booze LL, Woolf AD et al. Ethylene glycol exposure: An evidence-based consensus guideline for out-of-hospital management. Clinical Toxicology. 2005 Oct 17;43(5):327-345. https://doi.org/10.1080/07313820500184971
Caravati, E. Martin ; Erdman, Andrew R. ; Christianson, Gwenn ; Manogeerra, Anthony S. ; Booze, Lisa L. ; Woolf, Alan D. ; Olson, Kent R. ; Chyka, Peter ; Scharman, Elizabeth J. ; Wax, Paul M. ; Keyes, Daniel C. ; Troutman, William G. / Ethylene glycol exposure : An evidence-based consensus guideline for out-of-hospital management. In: Clinical Toxicology. 2005 ; Vol. 43, No. 5. pp. 327-345.
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AU - Manogeerra, Anthony S.

AU - Booze, Lisa L.

AU - Woolf, Alan D.

AU - Olson, Kent R.

AU - Chyka, Peter

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N2 - In 2002, poison centers in the US reported 5816 human exposures to ethylene glycol. A guideline that effectively determines the threshold dose for emergency department referral and need for pre-hospital decontamination could potentially avoid unnecessary emergency department visits, reduce health care costs, optimize patient outcome, and reduce life disruption for patients and caregivers. An evidence-based expert consensus process was used to create this guideline. Relevant articles were abstracted by a trained physician researcher. The first draft of the guideline was created by the primary author. The entire panel discussed and refined the guideline before distribution to secondary reviewers for comment. The panel then made changes based on the secondary review comments. The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with a suspected exposure to ethylene glycol by 1) describing the process by which the exposure might be evaluated, 2) identifying the key decision elements in managing the case, 3) providing clear and practical recommendations that reflect the current state of knowledge, and 4) identifying needs for research. This guideline is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care, considering all of the circumstances involved. Recommendations are in chronological order of likely clinical use. The grade of recommendation is in parentheses. 1) A patient with exposure due to suspected self-harm, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the dose reported (Grade D). 2) Patients with inhalation exposures will not develop systemic toxicity and can be managed out-of-hospital if asymptomatic (Grade B). Patients with clinically significant mucous membrane irritation should be referred for evaluation (Grade D). 3) Decontamination of dermal exposures should include routine cleansing with mild soap and water. Removal of contact lenses and immediate irrigation with room temperature tap water is recommended for ocular exposures. All patients with symptoms of eye injury should be referred for an ophthalmologic exam (Grade D). 4) Patients with symptoms of ethylene glycol poisoning should be referred immediately for evaluation regardless of the reported dose (Grade C). 5) The absence of symptoms shortly after ingestion does not exclude a potentially toxic dose and should not be used as a triage criterion (Grade C). 6) Adults who ingest a "swallow" (10-30 mL), children who ingest more than a witnessed taste or lick, or if the amount is unknown of most ethylene glycol products should be referred immediately for evaluation. The potential toxic volume of dilute solutions (e.g., concentration <20%) is larger and can be estimated by a formula in the text (Grade C). 7) A witnessed taste or lick only by a child, or an adult who unintentionally drinks and then expectorates the product without swallowing, does not need referral (Grade C). 8) Referral is not needed if it has been >24 hours since a potentially toxic unintentional exposure, the patient has been asymptomatic, and no alcohol was co-ingested (Grade D). 9) Gastrointestinal decontamination with ipecac syrup, gastric lavage or activated charcoal is not recommended. Transportation to an emergency department should not be delayed for any decontamination procedures (Grade D). 10) Patients meeting referral criteria should be evaluated at a hospital emergency department rather than a clinic. A facility that can quickly obtain an ethylene glycol serum concentration and has alcohol or fomepizole therapy available is preferred. This referral should be guided by local poison center procedures and community resources (Grade D). 11) The administration of alcohol, fomepizole, thiamine, or pyridoxine is not recommended in the out-of-hospital setting (Grade D).

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