1. Do you need a cuppa? Dr. Anushma Sharma ST5 Paediatrics Department of Community Paediatrics Salford

2. AIM 1. Present an interesting case 2. Discuss the outcome 3. Discuss the causes of the presenting symptoms

3. Admission 1 1 year old Vomiting, loose stools, unwell Tachycardiac, irrtable, breathless Metabolic acidosis – pH 7.13, pCO2 2.2, BE -23, Lac 27, Glu 5.3 Improved quickly within 12 hours with ventilatory support and fluids + sodium bicarbonate correction

4. Metabolic disorder suspected Investigations ammonia acyl carnitine plasma amino acids free fatty acids urine organic and amino acids LFT and renal funtions salicylate levels

5. Admission 2 13 months Had been well Found unresponsive on bedroom floor at 0800 No hypoglycaemia Severe metabolic acidosis pH 6.91, pCO2 2.96, Bicarb 4.3, BE - 27.9, lactate>30 Sent to PICU and recovered in 12 hours Skin biopsy and toxicology investigations

6. Previously..... Parents 18 years old, both unemployed, separated H/o domestic violence Good pregnancy NVD No significant neonatal diagnoses Satisfactory growth and development

7.  Previously............ 7 weeks old Unwitnessed fall from sofa while being watched by mother's friend Attended A+E promptly Parietal skull fracture Discharged back to mother after child protection investigations 11 th admission Recent Burn????

8. Toxicology Urine positive for Glycolate

9. Antifreeze= Ethylene Glycol Colourless Odourless Very sweet Present in Radiator fluid, Deicer, Wind screen wash, Window cleaning fluid

10. Fake vodka health warning in UK ingestion. Counterfeit vodka seized by council trading standard teams. Photograph: Nottinghamshire County Council/PA The Guardian, Saturday 31 December 2011

11. Industrial safety measures Fluorescein dye is often added to antifreeze to help identify the source of a leak. The fluorescein in the fluid fluoresces when viewed under ultraviolet light. Denatonium benzoate, a bittering agent, is added to many antifreeze products to try to prevent ingestion

12. Ethylene Glycol Toxicity Toxic dose requiring medical trematment is 0.1ml/kg body weight or 4 ml for 20 Kg child Lethal dose in humans is 1.4ml/kg or 56 ml for a 20 kg child Ethylene glycol does not evaporate so inhalational exposure is unlikely Ethylene glycol is not absorbed through skin so dermal exposure is also uncommon

13. Outcome Forensic samples obtained Police investigations started and mother was taken in custody BC and sister 10 months old in foster care

14. Metabolism Ethyl alcohol Fomipezole

16. NPIS annual Report 2010-2011 ➲ Prospective audit ➲ Toxic alcohol and glycol cases reported through telephone enquiries to the NPIS in 2010 ➲ Aim: 1. To provide information on the frequency, current management and outcomes of systemic toxic alcohol poisoning. 2. To provide information on which to base the planning of clinical services for this type of poisoning, including appropriate availability of assays and antidotes.

17. Results ➲ 488 individual exposures ➲ 250 in non hospital sourced ➲ 89 (18%) cases less than 5 years old ➲ 238 in hospital sources ➲ 182 potentially systemic exposures ➲ 99 (20%) reqiured treartment with antidotes ➲ 33 haemodialysis, heamofiltration ➲ At least 2 severe cases each week nationally ➲ Main difficulty in management is unavailability of lab assay and inadequate stock of antidote

22. Summary ➲ Glycol and Toxic alcohol toxicity though less common in UK is a significant differntial diagnosis to consider especially in cases of disproportionate metabolic acidosis ➲ It is important to plan and consider how we can treat such a case in our unit, especially when most of us donot stock any of the antidotes

23. Questions?