Poisoning by alcohol surrogates

One of the leading positions in the statistics of household intoxications is occupied by poisoning with alcohol surrogates. In addition to ethanol, a person may intentionally or accidentally consume methanol, isopropyl or butyl alcohol, as well as other alcohol products with a pronounced toxic effect. When alcoholic surrogates enter the body, there is a toxic effect not only of ethyl alcohol, but also of other dangerous substances: methyl alcohol, acetone, etc., which causes the development of an acute condition requiring emergency medical care. [1]

Epidemiology

Alcohol surrogate poisoning most often occurs in people with chronic alcoholism. Less often it is registered in adolescents who have no opportunity to purchase quality alcoholic beverages or do not have enough information about the possible danger. In some cases, poisoning occurs in children or adults who have consumed surrogate alcohol accidentally, out of ignorance.

Alcohol surrogate poisoning is one of the first among all intoxications (more than 60%) and poses a serious danger not only to health but also to the life of the victim. About 98% of deaths occur before emergency medical care is rendered. And only up to 2% of patients die while in clinical conditions. The overwhelming majority of those poisoned are patients with chronic alcoholism.

Causes of the alcohol surrogate poisoning

Alcohol surrogate poisoning is listed under ICD-10 codes T51.1-T52.9. Surrogates fall into two categories: those containing ethanol and those not containing ethanol. The first category includes:

• Industrial alcohol (aka denatured alcohol) - it contains wood alcohol and aldehyde.
• Butyl alcohol - its use is fatal (it is enough to drink 30 ml of the remedy).
• Sulfite and hydrolyzed alcohol derived from wood - contains both ethanol and methanol.
• Alcoholic lotions, perfumes - may contain more than 50% ethyl alcohol and other impurities not intended for consumption.
• Furniture varnish of the polish type - is represented by several varieties of alcohol compounds at once.
• Alcohol-based wood stains contain toxic coloring components.

Alcohol surrogates that do not contain ethanol are called false surrogates. Instead of ethanol, they contain methanol or ethylene glycol.

Alcohol surrogate poisoning is most often registered in persons suffering from alcohol dependence. Less often intoxication is diagnosed in children and adolescents who drink the liquid accidentally or unknowingly. [2]

Risk factors

Many factors can lead to poisoning by alcohol surrogates - in particular, experts consider the psychological characteristics of the individual, his social environment and physiological characteristics.

Among the social factors, the following are dominant:

• alcohol or drug use in the family - e.g. By parents, brothers, etc..;
• low income, no money;
• frequent stress against the background of lack of opportunity to purchase quality alcohol;
• lack of family stability, problems in the family;
• an unfavorable social environment;
• Lack of social assistance and support.

Possible psychological and physiological factors:

• your own insecurities, low self-esteem;
• physical disabilities;
• mental disorders.

In addition, alcohol surrogates poisoning is often caused by improper storage of alcohol-containing and chemical liquids, free access of children to places where toxic substances are stored.

Pathogenesis

Acute alcohol poisoning is usually caused by the consumption of liquids containing more than 12% ethyl alcohol or any amount of alcoholic surrogate. Toxicokinetics involves the passage of two limited phases of distribution of the active toxic component. The first phase consists in saturation of tissues and organs with the intoxicant, which occurs faster than its biological transformation and excretion, which leads to the creation of its increased concentration in the bloodstream. It overcomes cell membranes without problems, is absorbed in the digestive system. The organs with intensive blood supply - i.e. Kidneys, liver and lungs - are particularly quickly affected.

The presence of food masses in the stomach inhibits the absorption of intoxicant: if the alcohol surrogate was taken on an empty stomach, or the patient additionally suffers from gastric pathologies (ulcer, gastritis), the rate of resorption is significantly increased. In the liver, alcohols undergo oxidation, then the toxic agent enters the lungs and kidneys.

The toxic effect of an alcoholic surrogate depends:

• the rate of absorption (the faster the concentration of the substance in the blood increases, the more pronounced its poisoning effect becomes);
• from the toxicokinetic phase (the resorption phase implies a stronger toxic effect, whereas in the elimination phase this effect is lower);
• from the concentration of intoxicant in the bloodstream.
• The pathogenetic mechanism of alcohol surrogate poisoning is nonspecific and has much in common with the mechanisms of other exogenous intoxications:
• energy supply of cells of vital organs and systems against the background of toxic load is disturbed;
• water-electrolyte metabolism is compromised;
• products of "lethal synthesis" of certain intoxicants are formed, "membrane toxins" accumulate, and insufficiency of antioxidant systems develops.

Symptoms of the alcohol surrogate poisoning

The clinical picture of poisoning with alcohol surrogates can be different, which depends on what substance the person was poisoned with. Symptomatology may be relatively mild if the victim has consumed a liquid with ethanol in its composition, or severe and life-threatening if poisoning with methyl alcohol or ethylene glycol has occurred.

Poisoning by ethanol-based surrogates shows signs of commonly known intoxication:

• emotional-motor agitation;
• facial hyperemia;
• a euphoric state;
• increased sweating;
• hypersalivation;
• psycho-physical relaxation.
• After a while intoxication is supplemented or replaced by intoxicating signs:
• the skin is pale;
• urination is increasing;
• pupils dilating;
• dry mucous membranes;
• coordination and concentration of attention is impaired, speech becomes blurred, incomprehensible.

In methyl alcohol poisoning, the amount of toxic liquid consumed is crucial. Thus, the lethal amount of methanol is 50-150 ml. First of all, kidneys and nervous system are affected, optic nerves and retina are damaged.

The first signs appear fairly quickly:

• nausea, vomiting;
• relatively weak effects of intoxication and euphoria;
• vision problems ranging from blurred images to double vision and even blindness;
• pupil dilation;
• Temperature elevation within the subfibrillary range;
• dry skin and mucous membranes;
• arrhythmia;
• impaired consciousness;
• pain in the abdomen, lower back, joints and muscles;
• seizures.

Over time, the symptoms worsen, the person becomes comatose, and paralysis occurs.

In case of poisoning with surrogate containing ethylene glycol, first of all kidneys and liver are affected - up to the appearance of acute functional failure. The nervous system is also affected. Symptomatology can be divided into several stages, depending on the period of poisoning:

• The early stage of poisoning lasts about 12 h and is characterized by fairly good health and standard signs of alcohol intoxication.
• At the next stage, signs of nervous system damage appear. There is nausea to vomiting, severe head pain, dry mouth, diarrhea, blue skin. Pupils dilate, breathing is difficult, heart rate increases, there is hyperthermia and psycho-motor agitation. Some victims lose consciousness, convulsions appear.
• Hepatonephrotoxic stage is detected in 48-96 hours from the moment of poisoning. Signs of acute kidney and liver failure appear, skin and sclerae turn yellow, itching appears, urine darkens. Diuresis decreases up to anuria.

Acute poisoning with alcohol surrogates

In acute poisoning with alcohol surrogates there is a toxic effect on the central nervous system, resulting in depressed consciousness. The severity of intoxication determines the depth of coma and the development of complications.

Alcohol surrogates can be a wide variety of liquids and substances, including denatured alcohol, perfumes, hygiene products, adhesives, and so on.

In addition to alcohol as such, perfumes and hygienic liquids, people are often poisoned by so-called "fallen" products. Outwardly, real quality and fake drinks are almost identical, and it is difficult to distinguish them. An unfavorable alternative to vodka can become and moonshine, containing in its composition harmful impurities in the form of syrupy oils. Sometimes the consequences of taking such a common but dangerous product can be quite severe.

In addition to the above, acute poisoning can be obtained with the use of medical alcohol tinctures, which are either not intended for internal use, or allowed to be taken only in strictly limited dosages (literally drops). If they are drunk alternatively to conventional alcoholic beverages, it can lead to the development of acute poisoning.

Alcohol surrogate poisoning in children

Alcohol poisoning accounts for about 6-8% of all cases of poisoning in children. It is impossible to name the minimum dangerous dosage of alcohol or surrogate drink, although experts note that any amount of intoxicant can be dangerous for children. In babies of newborns and infants intoxication can occur even as a result of inhalation of alcohol vapors (e.g., inhalations, compresses or lotions, skin rubs).

After accidental or deliberate use of alcohol surrogates, the child's central nervous system is depressed, kidney, liver and digestive system function is impaired. Vomiting begins, dizziness, tachycardia, the skin becomes pale. Possible loss of consciousness, convulsions.

One of the most dangerous consequences of such a toxic process becomes lethal. In addition, a small patient may develop hepatitis, acute hepatic and renal failure, acute pancreatitis, respiratory failure, brain damage, mental disorders.

To avoid unfavorable consequences, doctors advise:

• regardless of age, children should not consume any alcoholic beverages;
• Do not use any alcohol-containing products on children (both for care and treatment);
• any remedies and preparations containing alcohols and toxic substances should only be kept out of the child's reach.

Complications and consequences

Clinical characteristics of alcohol surrogate poisoning include complicated and uncomplicated course of pathology, which may be accompanied by deep or superficial coma.

The likelihood and severity of complications increase as the content of the toxic agent in the bloodstream increases. Respiratory disorders are most often caused by obturation-aspiration processes and manifest as tongue retraction, increased salivation and bronchorrhea, aspiration of vomit, bronchiolaryngospasm. Inhalation of gastric contents together with toxic fluid leads to the development of aspiration pneumonitis, which may occur in the form of laryngo-bronchobstructive syndrome and respiratory distress syndrome. It is possible to develop draining pneumonia, atelectasis: predominantly posterior pulmonary regions are affected.

The cardiovascular system is also affected, but these pathologies are nonspecific. In most cases, the victims have tachycardia, decreased vascular tone. There may be a decrease in blood pressure up to a collaptoid state. As myocardiodystrophy forms, acute heart failure occurs (more often of the left ventricular type). Hematocrit increases, blood coagulation ability is disturbed (increased), which is manifested by microcirculatory disorders.

Serious failures of hemostasis develop, water-salt and acid-base equilibrium is disturbed, combined decompensated acidosis is formed.

The consequences affect, first of all, the neuropsychic sphere. There are illusory-hallucinatory attacks, episodes of psychogenic excitation. With severe poisoning with alcohol surrogates, a convulsive syndrome develops, asthenovegetative disorders appear. In patients who have survived alcohol coma, delirium syndrome occurs almost immediately after leaving the coma state.

Kidneys and liver are affected, which is manifested by hepatoy nephropathy, acute alcoholic hepatitis. Myorenal syndrome develops less frequently.

In acute intoxication with ethanol-containing liquids, exacerbation of chronic pathologies of the digestive and hepatobiliary system is observed.

Diagnostics of the alcohol surrogate poisoning

Clinical diagnosis follows the general diagnostic principle used in acute poisoning. The presence of relatives or friends who are able to clarify the situation and point out a possible alcohol surrogate product consumed is considered positive.

The immediate diagnostic process is based on the identification of characteristic symptoms or syndromes of poisoning.

Among modern express methods of qualitative and quantitative determination of alcohol, gas-liquid chromatography is the leader, which allows to detect both ethanol and aliphatic alcohols, ketones, aliphatic and aromatic carbons, fluorinated organochlorine derivatives, esters and glycols.

Tests to determine the level of ethyl alcohol in the blood are mandatory. The test is performed twice with a 1-hour interval. Important: when taking blood for ethanol or other alcohols and esters, the skin at the needle puncture site must not be treated with alcohol, as this will lead to incorrect results.

In parallel with the determination of the presence of ethanol, biological media are examined to assess the level of isopropyl, amyl, butyl and other higher alcohols.

Mandatory laboratory diagnostics also include:

• general blood test (clinical);
• urinalysis;
• Blood biochemistry (indicators of total bilirubin, direct bilirubin, total protein, glucose, urea, creatinine).

The frequency of performing these tests depends on the severity of alcohol surrogate poisoning, as well as the duration of hospitalization.

Instrumental diagnostics necessarily includes electrocardiography (at least twice). In addition, ultrasound diagnosis (ECHO-scopy) of the brain, abdominal organs, pancreas, kidneys, as well as gastroduodenoscopy, fibrogastroscopy, computer and magnetic resonance imaging of the brain. If it is a question of poisoning with higher alcohols, which have a damaging effect on the mucous tissues of the digestive system, carrying out esophagofibrogastroscopy is initiated repeatedly on a mandatory basis.

Differential diagnosis

Differential diagnosis should be made if poisoning with ethyl alcohol or its surrogates is suspected. It should be taken into account that signs of alcohol poisoning can be masked by many life-threatening conditions:

• head injuries;
• acute circulatory disorders of the ischemic type;
• acute hemorrhagic circulatory disorders;
• encephalitis, meningitis;
• hypoglycemic or hyperglycemic states;
• carbon monoxide poisoning, psychopharmacologic drugs;
• drug intoxication;
• hepatic encephalopathy;
• psychiatric pathologies.

It is important to realize that the above pathologies and conditions can occur both independently and against the background of alcohol intake. In such a situation, it is necessary to be particularly vigilant and thoroughly examine the patient.

If there is no obvious positive dynamics of inpatient treatment of a comatose patient during three hours of therapy, they speak of possible unidentified complications or pathologies, and/or question the correctness of the diagnosis. In such situations, diagnosis is directed to exclude other poisoning, trauma, somatic diseases.

Treatment of the alcohol surrogate poisoning

Patients with alcohol surrogate poisoning require intensive care at toxicology clinics and other inpatient units where resuscitation and emergency diagnostic procedures are available. The earlier the correct diagnosis is made, the better the prognosis.

Inpatient care begins with normalization of ventilation and respiratory function in general. In case of aspiration/obstruction, mouth and upper respiratory tract cleansing is performed. To reduce salivation and bronchorrhea, Atropine is administered in 1-2 ml of 0.1% solution p/k.

If indicated, perform artificial ventilation of the lungs, oxygen inhalation. After normalization of breathing do probe gastric lavage.

If severe hemodynamic disturbances are noted, antishock treatment is given:

• Intravenous administration of plasma substitutes, such as Polyglucin, Hemodez or Reopolyglucin (400 ml);
• infusion of 400 ml of 5% glucose, 400 ml of isotonic sodium chloride solution with Metadoxil (600 mg - 10 ml);
• In case of persistently low blood pressure, 60 to 100 mg of Prednisolone (intravenous drip with glucose) should be administered.

To avoid epilepsy-type seizures and obstructive respiratory distress, drugs such as Bemegrid and analeptics in high doses are not recommended.

Gastric probe lavage is performed from the supine position using up to 7-8 liters of room temperature water in stages of approximately 500 ml until clear lavage water is available.

If the trachea cannot be intubated, gastric lavage is not performed on a patient who is deeply comatose.

The state of metabolic acidosis is corrected by intravenous administration of 600-1000 ml of 4% sodium bicarbonate. If there is obvious hyperosmolarity of blood, hemodialysis is prescribed. In order to accelerate oxidative processes after the consumption of ethanol-containing drinks, it is recommended to administer 0.06% sodium hypochlorite in the amount of 400 ml (via central catheter to prevent vascular damage), as well as 500 ml of 20% glucose with 20 units of insulin and vitamin complex:

• vitamin _B1 solution 5% in the amount of 3 to 5 ml;
• vitamin _B6 solution 5% in the amount of 5 ml;
• nicotinic acid 1% in the amount of 3 to 5 ml;
• ascorbic acid up to 10 ml.

If a patient with alcohol surrogate poisoning develops aspiration-obturation syndrome, emergency bronchoscopy is administered.

Medications for symptomatic treatment:

• When the respiratory center is depressed, Cordiamine is administered no more than 1-2 ml of 20% solution subcutaneously, intramuscularly or intravenously (taking into account the possible development of epileptic and obturation complications).
• In signs of heart failure (sharp decrease in blood pressure and palpitations) prescribe cardiac glycosides - for example, Corglycone 0.06% 1 ml, or Mildronate 20% 10 ml.
• In case of a critical drop in blood pressure below 80/40 mmHg, 20% caffeine in the amount of 2 ml is administered subcutaneously.
• With a strong increase in blood pressure over 180/105 mm Hg. Intravenously slowly administered 25% magnesia sulfate in an amount of 10 to 20 ml, Papaverine 2%, No-shpa 2-4 ml intravenously or intravenously, Eufillin 2.4% to 10 ml drip, Trental 5 ml intravenous drip.

For dysuria, the bladder is catheterized, and diuretics are used less frequently.

Clinical guidelines for the treatment of alcohol surrogate poisoning

The following clinical guidelines should be followed for poisoning from alcohol surrogates containing ethyl alcohol:

1. Prevent the development of complications such as aspiration/obturation, sanitize the oral cavity, provide oxygen therapy, tracheal intubation and further sanitation of the tracheobronchial tree, and ventilator/ventilation when indicated.
2. Flush the stomach with a stomach tube.
3. Determine blood glucose levels.
4. Provide venous access.
5. Administer intravenous 40% glucose solution (if there are no contraindications).
6. Administer 100 mg of thiamine.
7. Administer 500 ml of 1.5% Reamberine intravenously.
8. Monitor body temperature.
9. If the patient is in a coma, record and evaluate electrocardiogram values.
10. Monitor blood pressure readings, perform pulse oximetry.
11. Transport the patient for inpatient care.

Methanol poisoning:

1. If the patient is comatose, prevent obstruction/aspiration, sanitize the oral cavity, intubate the trachea, and perform ventilator/ventilation when indicated.
2. Flush the stomach with a stomach tube.
3. Provide venous access, administer crystalloid solutions, sodium bicarbinate.
4. Monitor vital functions and electrocardiogram values.
5. Transport the injured person for inpatient treatment.

In acute poisoning with ethylene glycol or isopropyl alcohol:

1. If patient is comatose, prevent possible obturation/aspiration, sanitize oral cavity, intubate trachea, and perform ventilator/ventilator if indicated.
2. Gastric lavage with a stomach tube.
3. Provide venous access, administer crystalloid solutions, sodium bicarbonate, 1% calcium chloride solution (200 ml).
4. Record and monitor electrocardiogram readings.
5. Control vital functions.
6. Take the patient to the hospital.

Emergency treatment for alcohol surrogate poisoning

If there is a suspicion that a person is poisoned by alcohol surrogates, then he must necessarily be given emergency assistance, the extent of which will depend on the severity of the condition of the victim.

If unconsciousness is noted, the patient should be laid on his side on a flat and flat surface: in this position, possible aspiration of vomit is excluded. Then it is imperative to call an ambulance. In case of obvious respiratory and cardiac disorders, first call the ambulance and then perform artificial respiration and indirect cardiac massage.

If the victim is conscious, the sequence of actions is as follows:

• the patient is given a sorbent and a saline laxative;
• offer to drink an enveloping liquid - e.g. Starch solution, sour cream;
• take the victim to the hospital emergency room or first aid station.

Prevention

To avoid poisoning by alcohol surrogates, it is necessary to strictly follow the recommendations of specialists:

• Do not consume alcoholic beverages purchased at unauthorized points of sale or from hand, or without excise stamps;
• do not drink liquids without labels, always read the composition of the product carefully;
• do not store alcohol-containing and chemical solutions without labels, avoid storing such liquids in places not intended for this purpose;
• not to consume alcoholic beverages of suspicious quality, with strange appearance, inadequate packaging, odor, taste;
• Do not consume alcoholic liquids intended for technical operation - including disinfectants, cleaning solutions, solvents, etc..;
• Do not use pharmacy alcohol preparations in doses other than those given in the instructions;
• Do not drink alcohol with dubious and unfamiliar people, avoid casual company.

The most effective preventive recommendation is to stop drinking alcohol altogether.

Forecast

Regardless of what kind of alcohol surrogates poisoned a person, the consequences can be quite serious. The prognosis is determined by the amount of alcohol consumed, as well as the timeliness of emergency care.

It is noticed that if the victim has alcohol dependence, intoxication is more complicated, and more fatal cases are registered than in patients who do not suffer from chronic alcoholism.

Methanol poisoning can have an extremely negative effect on visual function, up to complete loss of vision (final, without possibility of recovery). Ethylene glycol can cause renal dysfunction: in most cases, kidney failure results in the death of the patient.

Poisoning with alcohol surrogates is a fairly common phenomenon. And often only awareness of the signs of the toxic process and the ability to provide first aid can save the life of the victim.