Several labourers after drinking illicit liquor 24 h ago; one has blurred "snowfield" vision, vomiting, RR 30; pH 7.08, anion gap 28, osmolar gap 32 (methanol) — or antifreeze ingestion (ethylene glycol) with AKI
Red flags
Visual disturbance
pH <7.15
Coma or seizures
Oliguria
Multiple patients from one source
Differential diagnosis
DKA / alcoholic ketoacidosis
Lactic acidosis
Salicylate
Uraemia
Isopropanol (osmolar gap without acidosis)
When to admit, call ICU or discharge
Admit: All suspected toxic-alcohol ingestions
ICU: Severe acidosis, reduced GCS, organ injury, ethanol infusion therapy
Dialysis: EXTRIP thresholds or end-organ injury
Key points
Methanol blinds (formate on the optic nerve); ethylene glycol destroys kidneys (oxalate).
Ethanol works as ADH blockade when fomepizole is unavailable — target 100–150 mg/dL and watch glucose.
Early dialysis removes both the parent alcohol and the toxic acid.
Never
Wait for methanol/EG levels before blocking ADH
Exclude poisoning because the osmolar gap is normal late
Forget to increase fomepizole or ethanol during dialysis
Skip the cofactors
Common mistakes
Waiting for levels
Missing late presentations
No cofactors
Under-dosing antidote during dialysis
Disposition and follow-up
ICU with dialysis; ophthalmology/nephrology follow-up.
ICU Decoded — original critical-care and internal-medicine pathways by
Dr Javed Akhtar, each cited to a current guideline. For education and quick
reference; verify every dose against local protocols before prescribing.