Do you need a
cuppa?
Dr. Anushma Sharma
ST5 Paediatrics
Department of Community Paediatrics Salford
AIM
1. Present an interesting case
2. Discuss the outcome
3. Discuss the causes of the presenting symptoms
Admission 1

1 year old

Vomiting, loose stools, unwell

Tachycardiac, irrtable, breathless


Metabolic acidosis – pH 7.13, pCO2 2.2, BE -23 , Lac 27, Glu
5.3
Improved quickly within 12 hours with ventilatory support and
fluids + sodium bicarbonate correction

Metabolic disorder suspected

Investigations
ammonia
acyl carnitine
plasma amino acids
free fatty acids
urine organic and amino acids
LFT and renal funtions
salicylate levels
Admission 2

13 months

Had been well

Found unresponsive on bedroom floor at 0800

No hypoglycaemia

Severe metabolic acidosis pH 6.91, pCO2 2.96, Bicarb 4.3, BE 27.9, lactate>30

Sent to PICU and recovered in 12 hours

Skin biopsy and toxicology investigations
Previously.....

Parents 18 years old, both unemployed, separated

H/o domestic violence

Good pregnancy

NVD

No significant neonatal diagnoses

Satisfactory growth and development



Previously............
7 weeks old
Unwitnessed fall from sofa while being watched by mother's
friend

Attended A+E promptly

Parietal skull fracture

Discharged back to mother after child protection investigations

11th admission

Recent Burn????
Toxicology
Urine positive for Glycolate
Antifreeze= Ethylene Glycol
Colourless
Odourless
Very sweet
Present in Radiator fluid, Deicer, Wind screen wash, Window
cleaning fluid
Fake vodka health warning in UK
The Guardian, Saturday 31 December 2011
Counterfeit vodka seized by council trading
standard teams. Photograph: Nottinghamshire
County Council/PA
Ethylene Glycol Toxicity
Toxic dose requiring medical trematment is 0.1ml/kg body
weight or 4 ml for 20 Kg child
Lethal dose in humans is 1.4ml/kg or 56 ml for a 20 kg
child
Ethylene glycol does not evaporate so inhalational
exposure is unlikely
Ethylene glycol is not absorbed through skin so dermal
exposure is also uncommon
Outcome
Forensic samples obtained
Police investigations started and mother was taken in custody
BC and sister 10 months old in foster care
Metabolism
Ethyl alcohol
Fomipezole
NPIS annual Report 2010-2011
➲
➲
Prospective audit
Toxic alcohol and glycol cases reported through telephone
enquiries to the NPIS in 2010
➲ Aim:
1. To provide information on the frequency, current
management and outcomes of systemic toxic alcohol
poisoning.
2. To provide information on which to base the planning of
clinical services for this type of poisoning, including
appropriate availability of assays and antidotes.
Results
➲
➲
488 individual exposures
250 in non hospital sourced
➲
➲
➲
89 (18%) cases less than 5 years old
238 in hospital sources
182 potentially systemic exposures
➲
➲
➲
99 (20%) reqiured treartment with antidotes
33 haemodialysis, heamofiltration
At least 2 severe cases each week nationally
➲
Main difficulty in management is unavailability of lab assay
and inadequate stock of antidote
Summary
➲
Glycol and Toxic alcohol toxicity though less common in
UK is a significant differntial diagnosis to consider
especially in cases of disproportionate metabolic acidosis
➲
It is important to plan and consider how we can treat such
a case in our unit, especially when most of us donot stock
any of the antidotes
Questions?