POISON IN OUR POCKETS: MANAGEMENT OF LIFE-THREATENING ISOPROPANOL INTOXICATION

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Isopropanol is a readily available substance, which can cause disastrous consequences if ingested even in a relatively small amount. High degree of suspicion is required for identification. This issue has become more concerning in light of the increasing exposure to household disinfectants and cases of toxicity in the context of the Covid-19 pandemic. CASE PRESENTATION: A 70 year-old African American woman presented after being found difficult to arouse by her son. Her last known well was 1 hour prior to presentation. She was profoundly lethargic on arrival, hypotensive and having profuse hematemesis. She was intubated for airway protection. Her hypotension did not respond to intravenous fluid and required vasopressors to maintain a mean arterial pressure of 65 mmHg. She was found to have ketonuria and severely elevated osmolar gap with no acidosis. Her mental status continued to deteriorate and she became dependent on mechanical ventilation. After further probing, her son noted he had found an empty bottle of rubbing alcohol in her room. No evidence of co-ingestion of other toxic substances were found on laboratory evaluation. She was observed for 8 hours with no discernible improvement in her mental status or hemodynamics. Hemodialysis was initiated for isopropanol clearance. Within 1 hour the patient became alert and hemodynamically stable. She was extubated without incident and mental status returned to baseline. DISCUSSION: Isopropanol is one of the most ubiquitous toxic substances, especially in the midst of the Covid-19 pandemic. Unlike ethylene glycol and methanol, isopropanol is more toxic than its metabolites. It reaches peak serum levels within minutes of ingestion. The minimum documented lethal dose is estimated at 100 ml. Isopropanol intoxication presents non-specifically, usually manifesting as central nervous system impairment and gastrointestinal upset. Most ingestion only result in mild symptoms. Massive ingestion may result in hemorrhagic gastritis or circulatory collapse. Hypotension is associated with a near 50% mortality rate. Identification of isopropanol poisoning is challenging due to its non-specific symptoms and subtle laboratory abnormalities. An increased osmolal gap and positive ketonemia are frequently the only abnormalities observed. In life threatening cases hemodialysis has been utilized with some success as a rescue therapy. CONCLUSIONS: Isopropanol intoxication requires a high degree of clinical suspicion is required for early identification and intervention in life threatening cases. In doing so significant morbidity and mortality may be prevented. No antidotes or neutralizing agents are currently available. Further study is needed to determine which patients would benefit most from hemodialysis with isopropanol intoxication. REFERENCE #1: Abramson S, Singh AK. Treatment of the alcohol intoxications: ethylene glycol, methanol and isopropanol. Curr Opin Nephrol Hypertens. 2000 Nov;9(6):695-701. doi: 10.1097/00041552-200011000-00017. PMID: 11128434. REFERENCE #2: Slaughter RJ, Mason RW, Beasley DM, Vale JA, Schep LJ. Isopropanol poisoning. Clin Toxicol (Phila). 2014 Jun;52(5):470-8. doi: 10.3109/15563650.2014.914527. Epub 2014 May 9. PMID: 24815348. REFERENCE #3: King LH Jr, Bradley KP, Shires DL Jr. Hemodialysis for isopropyl alcohol poisoning. JAMA. 1970 Mar 16;211(11):1855. PMID: 5467117. DISCLOSURES: No relevant relationships by Philip Almalouf, source=Web Response No relevant relationships by Alexander Angelidis, source=Web Response No relevant relationships by Robert Petrossian, source=Web Response No relevant relationships by Farheen Surtie, source=Web Response