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tox.toxic-alcohols.core.v1PRODUCTION
tox.toxic-alcohols.core.v1

Toxic alcohols (methanol / ethylene glycol)

toxicologyacuteadultpediatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Identify high-suspicion ingestion / unexplained HAGMA / osmolar gap; differentiate isopropanol — no HAGMA (AACT 2023)

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Advance rule
Set
Advance when

Toxic alcohol scope confirmed

Patient inputs (19)

Pediatric ingestion thresholds; ED disposition (AACT 2023)

Fomepizole 15 mg/kg load + 10 mg/kg q12h x 4 doses (Brent NEJM 2001)

Drives empiric fomepizole + HD timing (EXTRIP 2015)

Methanol vs EG vs other — isopropanol does not cause HAGMA (AACT 2023)

Calculated osmolality (2Na + glu/18 + BUN/2.8) (EXTRIP 2015)

Calculated osmolality + DKA differential (EXTRIP 2015)

Calculated osmolality (EXTRIP 2015)

Osmolar gap = measured - calculated (EXTRIP 2015)

pH <7.3 is HD criterion + severity marker (EXTRIP 2015)

Anion gap calculation; HAGMA component (EXTRIP 2015)

Anion gap calculation (EXTRIP 2015)

EG + methanol -> lactic component; rules out other HAGMA (AACT 2023)

EG nephrotoxicity (calcium oxalate crystals); HD criterion (EXTRIP 2015)

Co-ingestion baseline; ethanol therapy plasma level if used (AACT 2023)

Calcium oxalate crystals — EG-specific (AACT 2023)

Ethanol slows toxic metabolite formation; may delay presentation (AACT 2023)

Methanol — optic neuritis is an EXTRIP 2015 HD criterion

EXTRIP 2015 HD criterion: level >50 mg/dL or end-organ

EXTRIP 2015 HD criterion + diagnostic confirmation

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningmethanol_level_over_50_or_EG_level_over_50 (AACT 2023)
    Methanol level >50 mg/dL OR ethylene glycol level >50 mg/dL [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_acidosis_pH_under_7_3
    Arterial pH <7.3 in toxic alcohol context [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmethanol_visual_impairment
    Methanol ingestion + new visual symptoms (blurred vision, snowfield blindness, optic disk edema) [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereosmolar_gap_over_25_unexplained (AACT 2023)
    Osmolar gap >25 mOsm/kg with HAGMA, not explained by ethanol/mannitol/glycerol [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereAKI_or_oliguria
    Acute kidney injury (creatinine rise) OR oliguria in toxic alcohol context [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverecannot_tolerate_or_no_fomepizole
    Fomepizole unavailable, contraindicated, or patient cannot tolerate [EXTRIP 2015]
    Trigger could not be auto-evaluated — needs clinician judgement.

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RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

Methanol / Ethylene glycol — fomepizole-first antidote ladder + cofactors + HD (AACT 2023)
axis: toxic_alcohols_antidote_and_dialysisstep 1 - Step 1 — Fomepizole load (alcohol dehydrogenase blockade)
Selected step "Step 1 — Fomepizole load (alcohol dehydrogenase blockade)" — Suspected/confirmed methanol or EG ingestion: osmolar gap >25 OR known ingestion + acidosis OR confirmed level >20 mg/dL
  • fomepizole
    first line
    ADH_inhibitor_4MP
    15 mg/kg IV over 30 min • IV • load (single)
    triggers: osmolar_gap_over_25, methanol_or_EG_level_over_20, severe_unexplained_HAGMA_with_history, known_toxic_alcohol_ingestion
    Brent NEJM 2001 (Methylpyrazole for Toxic Alcohols Study Group) — fomepizole is preferred over ethanol drip (no CNS depression, no infusion adjustment, no ICU bed requirement)
    rxcui 15226

ed playbook — drug actions (5)

  1. 1. fomepizole_load
    15 mg/kg IV over 30 min • IV • load
    trigger: Osmolar gap >25 OR known ingestion + acidosis OR confirmed toxic alcohol level (EXTRIP 2015)
    ADH blockade prevents toxic metabolite formation (Brent NEJM 2001)
  2. 2. sodium_bicarbonate_bridge
    rxcui 36676
    1-2 mEq/kg IV bolus • IV • bolus + drip if needed
    trigger: Severe acidosis pH <7.3 (EXTRIP 2015)
    Buffer while arranging HD (AACT 2023)
  3. 3. folate_or_folinic_methanol
    50 mg IV q4-6h • IV • q4-6h x 24 h
    trigger: Methanol ingestion suspected or confirmed (AACT 2023)
    Accelerates formate detox (AACT 2023)
  4. 4. thiamine_pyridoxine_EG
    Thiamine 100 mg IV q6h + Pyridoxine 100 mg IV q6h • IV • q6h
    trigger: EG ingestion suspected or confirmed (AACT 2023)
    Shifts glyoxylate away from oxalate (AACT 2023)
  5. 5. normal_saline
    rxcui 7407
    500-1000 mL bolus then maintenance • IV • continuous
    trigger: Volume depletion / forced diuresis (AACT 2023)
    Volume support; UOP target (AACT 2023)

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Reported ingestion of methanol (windshield wash, bootleg ethanol) or ethylene glycol (antifreeze) (AACT 2023); Unexplained HAGMA (EXTRIP 2015); Osmolar gap >10 (or >25 highly suspicious) (EXTRIP 2015).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Toxic alcohols (methanol / ethylene glycol)** (tox.toxic-alcohols.core.v1).
Phenotype framing: Rule out DKA, alcoholic ketoacidosis, salicylate, lactic acidosis, uremia, isopropanol — osmolar gap without HAGMA (AACT 2023)
Scope: Identify high-suspicion ingestion / unexplained HAGMA / osmolar gap; differentiate isopropanol — no HAGMA (AACT 2023)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Methanol / Ethylene glycol — fomepizole-first antidote ladder + cofactors + HD (AACT 2023)** — step "Step 1 — Fomepizole load (alcohol dehydrogenase blockade)".
1. fomepizole 15 mg/kg IV over 30 min IV load (single) (ADH_inhibitor_4MP, first line) — Brent NEJM 2001 (Methylpyrazole for Toxic Alcohols Study Group) — fomepizole is preferred over ethanol drip (no CNS depression, no infusion adjustment, no ICU bed requirement)

Setting playbook (ed) — Recognize HAGMA + osmolar gap pattern, start empiric fomepizole, arrange HD if EXTRIP criteria met (AACT 2023)
2. fomepizole_load 15 mg/kg IV over 30 min IV load — Osmolar gap >25 OR known ingestion + acidosis OR confirmed toxic alcohol level (EXTRIP 2015) (ADH blockade prevents toxic metabolite formation (Brent NEJM 2001))
3. sodium_bicarbonate_bridge 1-2 mEq/kg IV bolus IV bolus + drip if needed — Severe acidosis pH <7.3 (EXTRIP 2015) (Buffer while arranging HD (AACT 2023))
4. folate_or_folinic_methanol 50 mg IV q4-6h IV q4-6h x 24 h — Methanol ingestion suspected or confirmed (AACT 2023) (Accelerates formate detox (AACT 2023))
5. thiamine_pyridoxine_EG Thiamine 100 mg IV q6h + Pyridoxine 100 mg IV q6h IV q6h — EG ingestion suspected or confirmed (AACT 2023) (Shifts glyoxylate away from oxalate (AACT 2023))
6. normal_saline 500-1000 mL bolus then maintenance IV continuous — Volume depletion / forced diuresis (AACT 2023) (Volume support; UOP target (AACT 2023))

Non-pharmacologic actions:
- Notify nephrology / dialysis — emergent HD if EXTRIP criteria met (AACT 2023)
- IV access × 2 large-bore (AACT 2023)
- Continuous cardiac + SpO2 monitoring (AACT 2023)
- NPO (likely intubation/HD) (AACT 2023)
- Psych evaluation if intentional (AACT 2023)
- Contact regional poison center / toxicology (AACT 2023)

AVOID / contraindication checks:
- Fomepizole_preferred_over_ethanol_when_available (AACT 2023)
- Ethanol_drip_requires_ICU_for_level_monitoring_and_CNS_depression (AACT 2023)
- Fomepizole_dose_must_increase_during_HD (AACT 2023)
- No_HD_for_isopropanol_no_acidosis_clinical_supportive_only (AACT 2023)

Monitoring

Regimen monitoring:
- methanol or EG level q4-6h through treatment (AACT 2023)
- ABG q2h during acidosis (AACT 2023)
- osmolar gap q4-6h serial (AACT 2023)
- creatinine q6h for AKI (AACT 2023)
- visual acuity methanol q2-4h (AACT 2023)
- UOP q1h (AACT 2023)
- ethanol level q1-2h if ethanol drip (AACT 2023)
- fomepizole redose q12h or q4h during HD (AACT 2023)

Setting (ed) monitoring:
- q4-6h methanol/EG level until <20 (AACT 2023)
- q2h ABG, osmolar gap (AACT 2023)
- q2h electrolytes (AACT 2023)
- Urinalysis q4h for new oxalate crystals (EG) (AACT 2023)
- Visual acuity q2-4h (methanol) (AACT 2023)
- Hourly UOP (AACT 2023)

Follow-up plan: Ophthalmology for methanol survivors (EXTRIP 2015); nephrology if AKI/HD; psych safety plan; PCP med review
- Close-out criterion: Discharge plan + safety plan documented

Monitoring phase: q2h ABG/pH, q2h electrolytes, q4h methanol/EG levels through HD, UOP, neuro/visual exam, fomepizole redose q12h (EXTRIP 2015; AACT 2023)

Disposition

Current setting: ed — Recognize HAGMA + osmolar gap pattern, start empiric fomepizole, arrange HD if EXTRIP criteria met (AACT 2023)

Disposition criteria:
- Discharge: very rare; only if osmolar gap explained by ethanol AND levels confirmed undetectable (AACT 2023)
- Admit ICU + nephrology: any HD candidate, severe acidosis, fomepizole running (AACT 2023)
- Admit ward: known minor exposure with stable course on fomepizole, no HD criteria (AACT 2023)

Escalation triggers (move to higher acuity):
- pH <7.3 → emergent HD (AACT 2023)
- Level >50 mg/dL methanol or EG → emergent HD (AACT 2023)
- AKI / oliguria → emergent HD (AACT 2023)
- Vision impairment (methanol) → emergent HD + ophthalmology (AACT 2023)
- Cannot tolerate fomepizole → ethanol drip → ICU (AACT 2023)
- Mental status declining → ICU + intubation prep (AACT 2023)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Methanol level >50 mg/dL OR ethylene glycol level >50 mg/dL [EXTRIP 2015]
- [LIFE_THREATENING] Arterial pH <7.3 in toxic alcohol context [EXTRIP 2015]
- [LIFE_THREATENING] Methanol ingestion + new visual symptoms (blurred vision, snowfield blindness, optic disk edema) [EXTRIP 2015]

Citations

- Pending — manifest is scaffold-level. Anchors: 2015 EXTRIP toxic alcohols (Roberts et al, Crit Care Med); AACT/EAPCCT methanol + EG position papers; ACMT clinical pathway [PMID:29766750](https://pubmed.ncbi.nlm.nih.gov/29766750/)
- Cited evidence (PMID 23900119) [PMID:23900119](https://pubmed.ncbi.nlm.nih.gov/23900119/)

Last reconciled with current guidelines: 2026-04-13.
References
  • Pending — manifest is scaffold-level. Anchors: 2015 EXTRIP toxic alcohols (Roberts et al, Crit Care Med); AACT/EAPCCT methanol + EG position papers; ACMT clinical pathway — PMID:29766750
  • Cited evidence (PMID 23900119) — PMID:23900119