Executive Summary of Methanol Poisoning - 03
Executive Summary of Methanol Poisoning - 03
MedicalEducation
ClinicalGuidelinefor
Treatmentof
Methanol Poisoning
SubstanceAbusePreventionandTreatmentOffice
BureauofPsychosocialHealthandAddiction
DeputyforHealth
MinistryofHealthand
MedicalEducation
ClinicalGuidelinefor
Treatmentof
Methanol Poisoning
SubstanceAbusePreventionandTreatmentOffice
BureauofPsychosocialHealthandAddiction
DeputyforHealth
CharacteristicsofDocument
Title
Aim
TargetAudience
Guideline
Development
Group
Editor
AlirezaNoroozi
Edition
FirstEdition
PublicationDate
Summer2009
TargetAudience
ClinicalToxicologyFellowship,ShahidBeheshtiMedicalUniversity(SBMU)
Psychiatrist,HeadofSubstanceAbusePreventionandTreatmentOffice(SAPTO)
3
SubspecialistofClinicalToxicology,MashhadUniversityofMedicalSciences(MUMS)
4
Psychiatrist,DirectorGeneralofBureauofPsychosocialHealthandAddiction
5
ProfessorandToxicologySpecialist,TehranUniversityofMedicalSciences(TUMS)
6
Psychiatrist,OfficerofTreatment,SubstanceAbusePreventionandTreatmentOffice
(SAPTO)
7
ToxicologySpecialist,ShahidBeheshtiMedicalUniversity(SBMU)
2
Contact
GuidelineDevelopmentGroup
HosseinHassanianMoghaddam
ClinicalToxicologyFellowship,ShahidBeheshtiMedicalUniversity(SBMU)
AlirezaNoroozi
Psychiatrist,HeadofSubstanceAbusePreventionandTreatmentOffice
(SAPTO)
MahdiBalaliMood
SubspecialistofClinicalToxicology,MashhadUniversityofMedicalSciences
(MUMS)
MohammadBagherSaberiZafarghandi
Psychiatrist,DirectorGeneralofBureauofPsychosocialHealthand
Addiction
MohammadAbdollahi
ProfessorandToxicologySpecialist,TehranUniversityofMedicalSciences
(TUMS)
MahsaGilanipour
Psychiatrist,OfficerofTreatment,SubstanceAbusePreventionand
TreatmentOffice(SAPTO)
ShahinShadnia
ToxicologySpecialist,ShahidBeheshtiMedicalUniversity(SBMU)
ExecutiveSummary
This is an executive summary for Clinical Guideline for Treatment of
MethanolPoisoningthathasbeenproducedforuseasaquickreference
incriticalsituations.Tostudyinmoredetails,refertothefullguidelineon
methanolpoisoning.Toreportmassepidemicsofmethanolpoisoningand
to get any technical support contact Bureau of Psychosocial Health and
Addiction Tel. No 02166707063. For emergency consultation please
contactwithDrugandPoisonInformationCenterTel.No02155422020
or09646(24hoursservice)[email protected].
Duetotheepidemicofmethanolpoisoningindifferentcitiesofthe
country,allhealthprofessionalsshouldbefamiliarwithprinciplesof
diagnosisandtreatmentofmethanolpoisoning.Ontimediagnosis,
propercasefindingandstandardtreatmenthaveanessentialroleto
reduce mortality and morbidity of methanol poisoning, particularly
blindnessandotherphysicalandpsychologicaldisabilities.
Absorption,DistributionandMetabolism
Methanolasanalcoholisrapidlyabsorbedthroughgastrointestinaltract,
so the average absorption half life is 5 minutes and reaches maximum
serum concentration within 30 60 minutes and well dissolves in body
water. Methanol is not toxic by itself, but its metabolites are toxic.
Methanol metabolized in different phases mainly in the liver. The initial
enzymeinitsmetabolismisalcoholdehydrogease.
ClinicalManifestations
Blurredvisionwithunalteredconsciousnessisastrongsuspiciousfor
methanolpoisoning.
Importantdifferentialdiagnosis
Animportantpointinmanagementoftoxicalcohols,particularlymethanol
poisoning, is proper and early diagnosis. Since emergency estimation of
serummethanolconcentrationisnotavailableinmostpartsofthecountry,
clinicaldifferentialdiagnosisisveryimportant.
Drunkennessandvasodilatation:Inethanolpoisoning,thepatientis
drunk with flashing, talkative and aggression, whereas in toxic
alcohols,nosignofdrunkisobservedandastateofshockwithchill
andcoldextremitiesarenoted.
Smellofalcohol:Smellofalcoholislessnotedintoxicalcoholsthan
inethanolintoxication.
Tachypneaandacademia:Acidemiaisofgoodlaboratoryfindingin
differential diagnosis of toxic alcohol and the nontoxics. The body
respondtoacidemiaistachypneaandhyperventilation.However,in
Serumalcoholslevels:Estimationofserumalcohollevelisprobably
important in early hours of intoxication, but practically is less
important as the time passes (hours after) and even may be
confusing. Since the toxic metabolites are responsible for the
complications, the time that patient refer to the clinic, methanol
concentration may be decreased and the toxic metabolites have
beenincreased.Inaddition,impropersamplingsuchasusingalcohol
asaskindisinfectantmayshowfalseincreaseinalcohollevel.
Treatment
Incaseofmethanolintoxication,tofindotherpatientsorvictims
activelyandidentificationoftheoriginviathepatientsisvery
important,whichrequirealsointersectoralcooperations.
Methanol
Ethanolor
Fomepizole
Folinicacid
andFolicAcid
ADH:alcoholdehydrogenaseFDH:formaldehydedehydrogenaseFTHFS:10formyl
tetrahyrofolatesynthetase
ApproachtoMethanolPoisoningEpidemics
TableAIndicationsofethanolandfomepizolformethanolpoisoning
Criteria
Serummethanolconcentrationof>20mg/dLor
Historyoftoxicdoseofmethanolingestionandosmolal
gap>10mOs/kgH2Oor
Historyorhighsuspicious*ofmethanolpoisoningincase
thatpatientadmitwithin72hoursofingestionandhad
twooffollowing:
A.arterialpH<7.3
B.Serumbicarbonate<20mEq/L.
C.Osmolgap>10mOsm/kgH2O
*Theauthorsofthismonographrecommendthatincaseofmethanol
poisoningepidemic,inanyclinicalsuspicious,treatmentshouldbeinitiated.
TableBAlgorithmofMethanolPoisoningTreatment
Suspectedorconfirmedmethanolpoisoningcase
Reconsiderdiagnosis
andreassess.
No
DoespatientmeetcriteriainTableA?
Findothercasesactively*
Yes
Administer1ml/kgoffivefolddilutedalcohol 96 asloadingdoseand0.16ml/kg/has
maintenancedoseorallyorbyNGTOR
Fomepizole15mg/kgloadingdoseand10mg/kgmaintenanceevery12hrsupto4doseand
then15mg/kgevery12hrsAND
AdministerFolicAcidorFolinicAcid1mg/kgupuntil50mgevery46hours,IVinD5Wduring
3060minutes
IFMethanolserumconcentrationcouldnotbedetectedorosmolalgap<10mOsm/kgH2O,
avoidethanol/fomepizoltreatment.
No
PH<7.3
Bicarbonatenot
necessary
Yes
Administerbicarbonateto
correctPHto>7.3
PH<7.3resistanttopreliminarytreatmentsor
Visualsigns/symptomsor
Deterioratingvitalsignsdespiteintensive
supportivecareor
Renalfailureor
Electrolytedisturbancesresistanttousual
treatmentsor
Lossofconsciousnessor
Methanolserumconcentration50mg/dl**
No
ContinuetreatmentaccordingtoTableAuntil
ethanol/fomepizoleindicationwouldbecorrected
Hemodialysi
Yes
Continue untilcorrectionof
hemodialysisindication
*Theaimofcasefindingistoaccessatriskpatientswhodidnotrefertoahospital.This
could be performed via consultation with patient or the relatives confidentially. The
patientsandtheirrelativesshouldbeeducatedabouttheriskofmethanolpoisoning,and
askthemtohelpinfindingnewpossiblepatientswhomighthaveingestedtoxicalcohol.
Every suspected or confirmed methanol poisoning case should be reported to the
Universitypatientsreferralcommittee.
**Although serum methanol concentration higher than 25 mg/dL in ethanol treated
patentsisanindicationforhemodialysis,thefomepizoltreatedpatientscouldbedelayed
forhemodialysis.However,itmayprolonghospitalization.
Thisalgorithmisageneralguidefortreatment.However,itisuptothephysicianincharge
todecideforthetreatmentbasedonhis/herclinicaljudgment.