elimination Supportive care includes close monitoring of vital signs and anticipation of life-threatening events, particularly cardiac arrhythmias secondary to hypocalcemia Replenish intravascular volume, obtain an EKG, and place the patient on a cardiac monitor Intubation and mechanical ventilation should be provided as needed for airway protection and control of acid–base balance Correct acidosis immediately with sodium bicarbonate and appropriate ventilation Hypocalcemia may present as skeletal muscle disturbances (tetany) or cardiac dysfunction (prolonged QT interval) These may be alleviated by the prompt administration of calcium (e.g., 10% calcium gluconate, 0.3 to 0.6 mL/kg) Thiamine and pyridoxine are vitamins that act as cofactors in the nontoxic metabolic pathways of ethylene glycol and, theoretically, divert its metabolism toward formation of nontoxic metabolites Therefore, thiamine (0.25 to 0.5 mg/kg) and pyridoxine (1 to mg/kg) are recommended for the first 24 hours of treatment Fomepizole (or ethanol if fomepizole is unavailable) administration inhibits ethylene glycol metabolism by alcohol dehydrogenase (previously discussed under “Methanol”) Start treatment as soon as possible to interrupt further formation of organic acids As with methanol, alcohol dehydrogenase inhibition is indicated for ethylene glycol concentrations of 20 mg/dL or higher If a serum ethylene glycol level cannot be obtained in a timely fashion, it can be estimated by the formula (osmolar gap × 6), assuming no other alcohols are contributing to the osmolar gap Hemodialysis is indicated if there is renal failure, metabolic acidosis, or severe electrolyte disturbances, regardless of the serum ethylene glycol concentration Hemodialysis may be considered for patients who are stable hemodynamically but who have very elevated blood ethylene glycol levels For patients with normal acid–base status and renal function, the decision to perform hemodialysis versus continued, prolonged fomepizole therapy depends on the serum concentration and local resources Consulting a regional poison control center can help guide management Foods/Fish CLINICAL PEARL