↑osmolar gap + anion-gap acidosis; EG → oxalate crystals/renal; MeOH → visual loss
ABCDE A-B-C; fomepizole early; bicarbonate; dialysis + cofactors for severe.
Calculators: osm ag
Antidote: Fomepizole (or ethanol) — blocks alcohol dehydrogenase
Supportive: Bicarbonate + Hemodialysis (severe)
Cofactors: EG → thiamine + pyridoxine; MeOH → folate
Order set Osmolar + anion gap VBG Fomepizole (or ethanol) Levels if available Dialysis if severe Criteria Admit All suspected toxic-alcohol ingestion
ICU Severe acidosis, ↓GCS, organ injury
Dialysis EXTRIP: methanol >60 mg/dL with fomepizole (>50 without) [2023 update], EG >50 mg/dL with fomepizole, severe acidosis (pH <7.15), or end-organ injury (visual, renal, coma)
Discharge Acidosis resolved, gap normal, antidote course done, psych review
Clinical detail — differentials, red flags, pitfalls, disposition Red flags Visual loss (methanol) Renal failure/oxalate (EG) Severe acidosis Differentials DKA Lactic acidosis Salicylates Uraemia Common mistakes Waiting for levels to treat Forgetting cofactors (folate/thiamine/pyridoxine) Auto-dialysing when levels unavailable and gap closing on fomepizole — continue blockade (fomepizole-first era) Not increasing fomepizole/ethanol dosing during dialysis Disposition & follow-up ADH blockade + dialysis; ICU.
Discharge package Medications —
Follow-up Psychiatry review; renal/vision follow-up
Warning symptoms Visual changes, reduced urine
💊 Treatment detail — doses & preparation Fomepizole alcohol dehydrogenase inhibitor
Dose 15 mg/kg IV load, then 10 mg/kg q12h ×4 doses, then 15 mg/kg q12h until level <20 mg/dL
Preparation 1 g/mL vial dilute in 100 mL NS/D5W over 30 min; increase dose during dialysis
Monitor Ethylene glycol/methanol level, osmolal gap, acidosis; add folate/thiamine
Thiamine (Pabrinex) vitamin B1
Dose 100–250 mg IV/PO TDS before glucose in at-risk (alcohol, malnourished)
Preparation IV ampoules slow push/in short infusion
Monitor Give BEFORE dextrose (Wernicke precipitation)
Folic acid vitamin
Dose 5 mg OD (deficiency/methotrexate cover — give on non-MTX days)
Preparation 5 mg tablets
Monitor Correct B12 deficiency FIRST if coexisting
Ethanol (alternative) antidote
Dose If no fomepizole: loading 0.8 g/kg then infusion titrated to level 100–150 mg/dL
Preparation IV or oral per pharmacy protocol
Monitor Level monitoring — hard to titrate; dialysis still needed
📖 AACT / EXTRIP toxic alcohols Reviewed July 2026