Ethylene Glycol Exposure: an Evidence-Based Consensus Guideline for Out-of-Hospital Management

Figures & data

Table 1. Known outcome by reason for ingestion of ethylene glycol for all ages 2000–2002

Reason	No or minor effect (% of total)	Moderate, major, or death effect (% of total)	Total (%)
Unintentional	1912 (63)	129 (4)	2041 (67)
Intentional	286 (9)	715 (24)	1001 (33)
Total	2198 (72)	844 (28)	3042

Unintentional ingestions were 37 times more likely to have no effects or minor effects than intentional ingestions of ethylene glycol. Odds ratio = 37.1 (95% CI: 29.6, 46.4).

From Ref. 3.

Table 2. Summary of US Poison Control Center guidelines 2003

Poison Center	Recommend ipecac?	Recommend gastric lavage?	Recommend charcoal?	Observe at home dose	Referral (toxic) dose	Toxic serum ethylene glycol (mg/dL)
1	No	If < 1 hr after ingestion	No	Accidental taste or < mouthful	2 cc/kg or > mouthful	25
2				If estimated serum level < 20 mg/dL	Estimated serum level > 20 mg/dL	20
3	Yes, if < 20 minutes from ingestion	If < 1 hr				20
4						20
5		If < 1 hr		Adult ≤ mouthful of “50% diluted” product	Adult: > mouthful of > 50% solution.	20
					-All children
6		If < 2 hr	No		Treat ≥ 0.2 cc/kg 100%	20
7	For large ingestion if ED > 30 minutes away.			“iron-clad lick or taste,” < 0.5 mL total	-Adult: 15 cc of 100% solution or one mouthful
					-Child: 3–5 cc or > “taste”
8		Nasogastric suction if recent ingestion	“Consider”	Estimated peak serum level < 25 mg/dL	Estimated peak serum level ≥ 25 mg/dL	25
9				Ingests < 0.05 mL/kg	-All ingestions of ≥ 95% EG or ≥ 0.05 cc/kg	20
10	No	If < 1 hr	No			20
11		“Consider”		Taste or lick only	Full swallow	20
12	No	If < 2 hr	Yes, for co-ingestants		All ingestions ≥ 0.1 mL/kg	25
13	No		No	Witnessed taste only	> lick/taste in child or adult	20

Table 3. Reported cases of adult ethylene glycol toxicity with lack of CNS effects

Serum ethylene glycol (mg/dL)	CNS symptoms	Time since exposure	Serum HCO3 (mEq/L)
260	Unremarkable	> 12 hr	13
470	Nauseated	1 hr	17
6	Unremarkable	10 hr	16
13 (EtOH 160)	Unremarkable	1.5 hr	19
8 (EtOH 27)	Unremarkable	4 hr	17
343 (EtOH 84)	Unremarkable	4 hr	24
77 (EtOH 215)	Apprehensive	> 7 hr	25
9	Unremarkable	1.5 hr	23

From Ref. 13.

*EtOH = serum alcohol concentration (mg/dL).

Table 4. Ethylene glycol toxicity and CNS symptoms reported in children

Age	Reason	Serum ethylene glycol (mg/dL)	CNS symptoms	Time since exposure	Serum HCO3 (mEq/L)	Reference
8 mo	Malicious	68	Lethargy, weakness	24 hr?		25
8 mo	All unintentional	384	Lethargy	3 hr	17	57
3.5 yr		70	Irritable, ataxia	3 hr	16	26
2.5 yr		9	None	3 hr	15	26
6 yr		Not reported	None	8 hr	6	58
4 yr		Not reported	None	8 hr	10	58
22 mo		304	Dizzy, vomiting lethargy, or ataxia present among the group	Not reported	4	59
11 yr		133			12
7 yr		162			15

Figure 1. Dose-response for 19 patients less than 10 years of age who drank an ethylene glycol-contaminated soft drink mixture (9% ethylene glycol) 1. **Subjects complaining of fatigue or ataxia were considered symptomatic.

Table 5. Reported doses in acute ingestion of ethylene glycol by children

Product	Dose	% EG	Age	Mitigating factors	Effect	Symptom onset	Laboratory confirmation	Reference
Antifreeze	< 1 oz	Antifreeze-water mix (1:1)	4 yr	None	Moderate	17 hr	No	58
	2–3 oz	Antifreeze-water mix (1:1)	6 yr	None	Severe	17 hr	No	58
	30–100 mL	95%	4 patients 7–13 yr	None	Moderate to severe	Not reported	Yes	59
	< 120 mL	95%	8 mo	None	Moderate (dialysis)	3 hr	Yes	57
Radiator fluid	“one glass”	Antifreeze-water mix (unknown %)	3.5 yr	None	Moderate	4 hr	Yes	60
Ethylene glycol-contaminated beverage	None to > 1.5 cups	9%	19 children < 10 yr	None	Mild to moderate	“Hours”	No	1

*Mild = local symptoms only (e.g., GI or mild neurological effects); moderate = minimal acidosis or renal insufficiency; severe = coma, severe acidosis or renal failure (e.g., requiring dialysis).

^†Maximum time of onset, symptoms were present on admission but might have begun earlier.

Table 6. Minimum reported toxic doses in acute ethylene glycol ingestion by patients 10 years of age and older

Estimated dose	Product or % EG	Mitigating factors	Effect	Symptom onset	Laboratory confirmation	Reference
10 mL	Antifreeze	History not verified	Renal failure	NR	No	61
20 mL	Antifreeze	None	Moderate	NR	No	49
25 mL	Antifreeze	None	Moderate	NR	No	49
30 mL	Antifreeze	None	Moderate	NR	No	49
30 mL	Antifreeze	None	Severe	NR	No	49
30 mL	Antifreeze	None	Moderate	NR	No	21
30 mL	Antifreeze	None	Moderate	NR	No	21
30 mL	Antifreeze	None	Hematuria	NR	No	21
1 oz	Antifreeze in mixed drink	Possible alcohol co-ingestion	Moderate	Next morning	No	55
50 mL	Antifreeze	None	Death	NR	NT	49
60 mL	NR	None	Severe	< 68 hr	EG = 0	28
2 oz	Antifreeze in mixed drink	Possible alcohol co-ingestion	Moderate	Next morning	No	55
70–90 mL	95%	None	Severe	< 20 min	No	6
70–90 mL	95%	None	Severe	2 hr	No	6
75 mL	NR	None	Severe	2 days	No	54
100 mL	Antifreeze	Alcohol co-ingest	Death	1 hr	No	49
100 mL	NR	Alcohol co-ingest; alcoholic	Severe	< 15–24 hr	Yes	14
100–130 mL	Antifreeze	Alcohol co-ingest	Mild	NR	Yes	62
100–150 mL	NR	None	Severe	< few hr	No	63
3–4 oz	Antifreeze in mixed drink	Possible alcohol co-ingestion	Death	< 12 hr	No	55
4 oz	Antifreeze in mixed drink	Possible alcohol co-ingestion	Death	Next morning	No	55

NR=not reported.

*Mild=local symptoms only (e.g., GI); moderate=minimal systemic effects (e.g., acidosis, CNS changes, or renal insufficiency); severe=significant systemic effects (e.g., coma, severe acidosis or renal failure requiring dialysis).

^†Maximum time to onset, symptoms were present on admission and probably began earlier.

Table

Grade of recommendation	Level of evidence	Description of study design
A	1a	Systematic review (with homogeneity) of randomized clinical trials
	1b	Individual randomized clinical trials (with narrow confidence interval)
	1c	All or none (all patients died before the drug became available, but some now survive on it; or when some patients died before the drug became available, but none now die on it.)
B	2a	Systematic review (with homogeneity) of cohort studies
	2b	Individual cohort study (including low quality randomized clinical trial)
	2c	“Outcomes” research
	3a	Systemic review (with homogeneity) of case-control studies
	3b	Individual case-control study
C	4	Case series, single case reports (and poor quality cohort and case control studies)
D	5	Expert opinion without explicit critical appraisal or based on physiology or bench research
Z	6	Abstracts

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