Summary

Ethylene glycol poisoning is managed with rapid supportive care, antidote administration (preferably fomepizole), correction of acidosis, and consideration for hemodialysis in severe cases.

At-a-glance

Intervention	Details
Airway, breathing, circulation	Ensure airway protection, breathing, and circulation; intubate if mental status is compromised or risk of aspiration exists 1
Antidote	Fomepizole is the antidote of choice as a competitive inhibitor for alcohol dehydrogenase. If unavailable, ethanol is an acceptable alternative 12
Correction of Acidosis	Administer sodium bicarbonate in patients with significant metabolic acidosis to help stabilize pH while avoiding further acidemia during intubation 2
Hemodialysis	Indications include an ethylene glycol level >8 mmol/L (50 mg/dL), pH <7.25, renal failure, or persistent osmolar gap >10; used for definitive removal of ethylene glycol and its toxic metabolites 12

Treatment Protocol

1. Initial Stabilization:

   • Assess and secure the airway, breathing, and circulation.
   • Provide supportive care, including IV fluids and correction of electrolyte abnormalities.

2. Antidote Administration:

   • Fomepizole: Administer as early as possible to prevent the formation of toxic metabolites by inhibiting alcohol dehydrogenase.
   • Ethanol: In centers where fomepizole is not available, ethanol can be used either orally or intravenously; dosing must achieve therapeutic blood levels (100–150 mg/dL) ¹.

3. Acidosis Correction:

   • Use sodium bicarbonate to correct metabolic acidosis. Bolus dosing (1–2 mmol/kg) followed by additional doses as needed while awaiting definitive therapy.

4. Enhanced Elimination (Hemodialysis):

   • Initiate hemodialysis when indicated by:
     • Ethylene glycol level >8 mmol/L (or >50 mg/dL)
     • Severe acidosis (pH <7.25)
     • Evidence of acute renal failure
     • Large ingestion with persistently elevated osmolar gap (>10)
   • Dialysis effectively reduces the half-life of ethylene glycol and clears its toxic metabolites. Continue dialysis until the ethylene glycol level is <3.2 mmol/L (20 mg/dL), the acidosis has corrected, and the osmolar gap normalizes ¹².

5. Ongoing Monitoring and Support:

   • Frequent reassessment of acid-base status, electrolytes, renal function, and ethylene glycol levels.
   • Monitor for complications such as seizures (manage with IV benzodiazepines) or cardiovascular instability.

This multi-pronged approach—supportive care, antidote administration, correction of acidosis, and hemodialysis when indicated—is the cornerstone of managing ethylene glycol poisoning in the emergency setting ¹².