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tox.toxic-alcohols.core.v1

Toxic alcohols (methanol / ethylene glycol)

toxicologyacuteadultpediatricacuteinpatient
Start encounter →Print handoutPRODUCTION

Manifest is a batch-23 scaffold; full atoms/evidence/terminology not yet authored. No problem-package directory on disk for toxic alcohols. Regimen axes empty: fomepizole, ethanol drip, folate, thiamine, pyridoxine all need RxNav validation + seed entries before being added. Acid-base service (src/lib/systems/acid-base/acid-base.service.ts) is the runtime interpretation layer for HAGMA + osmolar-gap diagnosis. Calculator gap: dedicated osmolar-gap calculator (calc.osm_gap) is referenced clinically but not in clinical-tools-registry.ts; flag for INTEGRATED. PRODUCTION blockers: full atoms split, evidence PMIDs, terminology codes, RxNav-validated antidote regimen (fomepizole ± ethanol), dedicated tests. Deepened 2026-04-27: regimen ladder (fomepizole load → maintenance q12h × 4 → escalate → HD with q4h fomepizole redose) + folate (methanol) + thiamine+pyridoxine (EG) + ethanol-drip backup + NaHCO3 bridge, ED + ICU playbooks, 6 severity triggers (osmolar gap >25, level >50, pH <7.3, AKI, methanol visual, fomepizole unavailability), siblings: methanol/EG/isopropanol subtypes + salicylate + DKA. Fomepizole/ethanol/folate/thiamine/pyridoxine RxCUIs left undefined (not in seed).

Entry points (4)

  • symptom
    Reported ingestion of methanol (windshield wash, bootleg ethanol) or ethylene glycol (antifreeze) (AACT 2023)
    methanol_eg_ingestion_history
  • lab_abnormality
    Unexplained HAGMA (EXTRIP 2015)
    high_anion_gap_metabolic_acidosis
  • lab_abnormality
    Osmolar gap >10 (or >25 highly suspicious) (EXTRIP 2015)
    osmolar_gap_elevated
  • symptom
    Methanol vision changes / EG flank pain + oliguria (EXTRIP 2015)
    visual_changes_or_oliguria

Required inputs (19)

  • agerequired
    demographic • used at CONTEXT
    Pediatric ingestion thresholds; ED disposition (AACT 2023)
  • weight_kgrequired
    demographic • used at CONTEXT
    Fomepizole 15 mg/kg load + 10 mg/kg q12h x 4 doses (Brent NEJM 2001)
  • time_since_ingestion_hoursrequired
    history • used at CONTEXT
    Drives empiric fomepizole + HD timing (EXTRIP 2015)
  • product_formrequired
    history • used at CONTEXT
    Methanol vs EG vs other — isopropanol does not cause HAGMA (AACT 2023)
  • co_ingestion_ethanol
    history • used at CONTEXT
    Ethanol slows toxic metabolite formation; may delay presentation (AACT 2023)
  • sodiumrequired
    lab • used at INITIAL_WORKUP
    Calculated osmolality (2Na + glu/18 + BUN/2.8) (EXTRIP 2015)
  • glucoserequired
    lab • used at INITIAL_WORKUP
    Calculated osmolality + DKA differential (EXTRIP 2015)
  • bunrequired
    lab • used at INITIAL_WORKUP
    Calculated osmolality (EXTRIP 2015)
  • measured_osmolalityrequired
    lab • used at INITIAL_WORKUP
    Osmolar gap = measured - calculated (EXTRIP 2015)
  • arterial_phrequired
    lab • used at INITIAL_WORKUP
    pH <7.3 is HD criterion + severity marker (EXTRIP 2015)
  • bicarbonaterequired
    lab • used at INITIAL_WORKUP
    Anion gap calculation; HAGMA component (EXTRIP 2015)
  • chloriderequired
    lab • used at INITIAL_WORKUP
    Anion gap calculation (EXTRIP 2015)
  • lactaterequired
    lab • used at INITIAL_WORKUP
    EG + methanol -> lactic component; rules out other HAGMA (AACT 2023)
  • creatininerequired
    lab • used at INITIAL_WORKUP
    EG nephrotoxicity (calcium oxalate crystals); HD criterion (EXTRIP 2015)
  • methanol_level
    lab • used at INITIAL_WORKUP
    EXTRIP 2015 HD criterion: level >50 mg/dL or end-organ
  • ethylene_glycol_level
    lab • used at INITIAL_WORKUP
    EXTRIP 2015 HD criterion + diagnostic confirmation
  • urine_oxalate_crystals
    lab • used at BRANCHING_WORKUP
    Calcium oxalate crystals — EG-specific (AACT 2023)
  • ethanol_levelrequired
    lab • used at INITIAL_WORKUP
    Co-ingestion baseline; ethanol therapy plasma level if used (AACT 2023)
  • visual_disturbance
    symptom • used at CONTEXT
    Methanol — optic neuritis is an EXTRIP 2015 HD criterion

12-phase flow (12)

  1. 1FRAME
    Identify high-suspicion ingestion / unexplained HAGMA / osmolar gap; differentiate isopropanol — no HAGMA (AACT 2023)
    inputs: product_form
    advance: Toxic alcohol scope confirmed
  2. 2ENTRY
    Capture ingestion history or lab finding that triggered engine (AACT 2023)
    inputs: age, weight_kg
    advance: Trigger documented
  3. 3CONTEXT
    Time since ingestion, ethanol co-ingestion — delayed presentation (AACT 2023), visual symptoms — methanol (EXTRIP 2015), flank/oliguria — EG
    inputs: time_since_ingestion_hours, co_ingestion_ethanol, visual_disturbance
    advance: Risk modifiers documented
  4. 4RED_FLAGS
    Severe acidosis (pH <7.3), AKI, vision loss, AMS/seizure, level >50 mg/dL, refractory acidosis — all are EXTRIP 2015 HD triggers
    inputs: arterial_ph, creatinine
    advance: HD criteria evaluated; emergent dialysis initiated if any positive
  5. 5INITIAL_WORKUP
    CMP + ABG + lactate + measured osmolality + methanol/EG levels + ethanol + UA — oxalate crystals (EXTRIP 2015; AACT 2023)
    inputs: sodium, glucose, bun, measured_osmolality, arterial_ph, bicarbonate, chloride, lactate, creatinine, ethanol_level
    actions: toxic_alcohols, panel.abg, panel.renal
    advance: Osmolar gap + anion gap + acid-base picture interpreted
  6. 6BRANCHING_WORKUP
    If oxalate crystals -> EG; if optic neuritis -> methanol; if both gaps elevated -> empiric fomepizole pending levels (EXTRIP 2015; Brent NEJM 2001)
    inputs: urine_oxalate_crystals, methanol_level, ethylene_glycol_level
    advance: Specific toxin identified or empiric therapy started
  7. 7DIFFERENTIAL
    Rule out DKA, alcoholic ketoacidosis, salicylate, lactic acidosis, uremia, isopropanol — osmolar gap without HAGMA (AACT 2023)
    advance: Toxic alcohol differential refined
  8. 8RISK_STRATIFICATION
    Apply EXTRIP 2015 (Roberts Crit Care Med 2015) toxic alcohol criteria; severity (mild/moderate/severe); ICU admission decision
    inputs: arterial_ph, creatinine, measured_osmolality
    actions: calc.anion_gap, calc.winters, calc.ckd_epi_2021
    advance: EXTRIP status documented
  9. 9TREATMENT
    Empiric fomepizole 15 mg/kg IV load if osmolar gap >25 or known ingestion + acidosis (Brent NEJM 2001); ethanol drip alternative if no fomepizole; folate — methanol + thiamine + pyridoxine — EG; NaHCO3 for severe acidosis; HD per EXTRIP 2015
    inputs: weight_kg
    advance: Antidote administered + HD pathway active or excluded
  10. 10DISPOSITION
    ICU for any HD candidate or severe acidosis (EXTRIP 2015); transfer to dialysis-capable centre if needed; psych for intentional
    advance: Disposition assigned
  11. 11MONITORING
    q2h ABG/pH, q2h electrolytes, q4h methanol/EG levels through HD, UOP, neuro/visual exam, fomepizole redose q12h (EXTRIP 2015; AACT 2023)
    inputs: arterial_ph, bicarbonate, creatinine, methanol_level, ethylene_glycol_level
    actions: panel.abg, panel.renal
    advance: Levels falling, gap closing, pH normalizing
  12. 12FOLLOWUP
    Ophthalmology for methanol survivors (EXTRIP 2015); nephrology if AKI/HD; psych safety plan; PCP med review
    advance: Discharge plan + safety plan documented