Clinical note
A visual schematic for clarifying the temporal relationship between the anion and osmol gaps in toxic alcohol poisoning

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Abstract

Delayed treatment of ethylene glycol or methanol poisoning can result in life-threatening complications, but obtaining quantitative levels is delayed by several hours in most hospitals. Calculating the anion gap and the osmol gap are recommended to hasten identification and treatment in cases of suspected toxic alcohol poisoning. However, relying on the anion and osmol gap calculations without understanding the temporal relationship between these 2 gaps can lead to delayed identification and increased morbidity in cases of toxic alcohol poisoning. Our “Mountain” schematic illustrates the presence of an elevated osmol gap found early in toxic alcohol poisoning and the presence of an elevated anion gap found later in the course of poisoning. Using the “Mountain” diagram as a clarification of the temporal relationship between the anion and the osmol gap can improve the diagnostic use of these screening assays.

Section snippets

Case no. 1

A 23-year-old man presented to the ED for psychiatric clearance for suicidal ideation. Physical examination was unremarkable and routine screening labs for psychiatric clearance were normal: Na 134 mEq/L, Cl 100 mEq/L, HCO3 25 mEq/L, BUN 17 mg/dL, Cr 0.9 mg/dL, anion gap 9, ethanol nondetectable, and urine toxicology screen negative. The patient was transferred to an inpatient psychiatric facility 4 hours after ED arrival. The patient was sent back to the same ED 36 hours later with severe

Discussion

In the year 2000, approximately 5,000 cases of ethylene glycol ingestion and 2,000 cases of methanol ingestion were reported to the American Association of Poison Control Centers (AAPCC) Toxic Exposure Surveillance System (TESS).8 Ethylene glycol is commonly found in antifreeze solutions, deicing solutions, hydraulic brake fluid, foam stabilizers, and chemical solvents. Methanol is commonly found in windshield washing solutions, gas-line antifreeze solutions, paints, solvents, and copier

Conclusion

In cases of suspected toxic alcohol poisoning, use of the “Mountain” can clarify the relationship between the anion gap and the osmol gap and improve the diagnostic use of these screening assays.

Acknowledgements

The authors thank Kirk L. Cumpston, DO, and Sean M. Bryant, MD, for encouraging the practical use of the “Mountain.”

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