Version July 2025
| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links). |
| Clinical features |
| Early toxicity: CNS sedation and inebriation similar to ethanol intoxication |
| Late toxicity: metabolic acidosis with elevated anion gap; compensatory tachypnea/hyperpnea; coma in severe cases, accompanied by ocular toxicity (methanol) or kidney failure (ethylene glycol) |
| Diagnostic testing |
| Arterial or venous blood gas (to determine extent of acidosis) |
| Basic chemistry (to determine anion gap and kidney function) |
| Serum osmolality (to help determine diagnosis) |
| Serum ethanol concentration (to help determine osmolal gap and assess for ADH inhibition) |
| Serum calcium concentration (to rule out ethylene-glycol associated hypocalcemia) |
| Serum methanol, ethylene glycol, and isopropanol concentrations (to establish diagnosis) |
| Urinalysis (for oxalate crystals) |
| Treatment |
| Secure airway as necessary in severely intoxicated patients (if profound metabolic acidosis exists or is suspected, minimize the apneic phase of RSI) |
| Treat hypotension with intravenous crystalloid, followed by standard vasopressors as necessary |
| Inhibit ADH with fomepizole 15 mg/kg IV loading dose, followed by 10 mg/kg every 12 hours for 4 doses then 15 mg/kg every 12 hours as needed* |
| If fomepizole is unavailable, inhibit ADH with ethanol (10% IV solution)¶ 10 mL/kg IV loading dose, followed by 1 mL/kg/hour titrated to serum ethanol concentration of 100 mg/dL* |
| For patients with moderate to severe metabolic acidosis (eg, blood pH <7.25, anion gap >24), administer sodium bicarbonate 1 to 2 mEq/kg IV bolus followed by continuous infusion (eg, 133 mEq sodium bicarbonate in 1 L D5W administered at 150 to 250 mL/hour) |
| For patients with known or suspected methanol poisoning, administer leucovorin or folic acid 50 mg IV every 6 hours |
| For patients with known or suspected ethylene glycol poisoning, administer thiamine 100 mg IV once daily and pyridoxine 100 mg IV once daily |
| Hemodialysis is indicated in severe toxicity, which we define as follows: |
| Elevated moderate-severe anion gap metabolic acidosis (eg, pH <7.25, anion gap >24), regardless of toxic alcohol concentration |
| Serum methanol concentration greater >50 mg/dL (15.6 mmol/L) |
| Serum ethylene glycol concentration >50 mg/dL (8.1 mmol/L) and presence of metabolic acidosis |
| Evidence of end-organ damage attributable to the toxic alcohol (eg, visual changes following methanol, kidney failure following ethylene glycol) |
ADH: alcohol dehydrogenase; CNS: central nervous system; D5W: 5% dextrose in water; RSI: rapid sequence intubation.
* For patients requiring hemodialysis, ADH inhibitor (ie, fomepizole, ethanol) dose adjustments are required. Refer to topic text for details.
¶ Refer to separate table for instructions on preparing a pharmaceutical-grade 10% ethanol solution for intravenous administration. Refer to topic text for instructions on dosing of ethanol orally.