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1998 C OPYRIGHT Ó 2008 BY T HE J OURNAL OF B ONE AND J OINT S URGERY, I NCORPORATED Isopropyl Alcohol Poisoning from Cast Application A Case Report By James C. Krieg, MD Investigation performed at the Department of Orthopaedic Surgery, Harborview Medical Center, Seattle, Washington C ast treatment has been a mainstay of fracture management for decades. In an age when surgical treatment is thought to be first-line therapy for many fractures, cast treatment is often considered to be the conservative mode of care. Cast treatment is not, however, without its own risks of complication. One of the recognized complications from cast application is thermal injury. In order to minimize this risk, isopropyl alcohol is often applied to fiberglass casts during the curing stage. We present a rare case of transcutaneous isopropyl alcohol poisoning in a child undergoing cast management of a femoral fracture. The parents of the child were informed that data concerning the case would be submitted for publication, and they consented. Our institutional review board exempts case reports from the approval process. Case Report 3.5-year-old boy was admitted with a chief complaint of pain in the left thigh. He had been sitting in a shopping cart that overturned, causing the left thigh to become trapped underneath the cart. The child was admitted to the hospital, where he was diagnosed with a spiral fracture of the left femoral shaft. Closed fracture reduction and application of a hip spica cast with the boy under general anesthesia was recommended. The child was taken to the operating room the evening of admission. After induction of oral endotracheal general anesthesia, a closed reduction of the fracture was performed, after which a fiberglass spica cast was applied. The period of anesthesia was unremarkable, and stable vital signs were recorded throughout the procedure. Radiographs obtained in the operating room demonstrated adequate reduction. While the fiberglass was curing, it was noted to be generating a large amount of heat. Isopropyl alcohol (rubbing alcohol) was poured directly over the cast in an effort to cool it. An estimated 24 to 32 oz (0.7 to 0.95 L) of 70% isopropyl alcohol was used. The child was awakened and extubated in the operating room. He was brought to the recovery room in stable A condition. The nurses’ notes in the recovery room stated that the child was easily arousable and was crying upon transfer to the pediatric ward. The nurses’ notes on the ward indicated that the child was crying and in pain within two hours of arrival. One teaspoonful (4.93 mL) of acetaminophen and codeine elixir was administered orally at that time. No other doses of narcotic medications were given. After having several episodes of small emesis approximately six hours after arrival on the ward, he was given 9 mg of Phenergan (promethazine) intravenously to control nausea. The first postoperative day, approximately ten hours after arriving on the ward, the patient was noted to be unarousable. He had stable vital signs but had no response to painful or other stimuli. He was transferred to the pediatric intensive care unit, and a workup was begun to discover the cause of the coma. A computed tomography scan of the head and a magnetic resonance imaging scan of the brain showed negative results. An electroencephalogram revealed diffuse encephalopathy but no focal abnormality. No seizure activity or focal neurological findings were seen. The results of a complete blood-cell count and measurement of venous blood-gas levels were normal. Abnormal results included a serum glucose level of 198 mg/dL (11 mmol/L) with an osmolality of 336 mOsm/kg (336 mmol/kg), serum acetone of 41, urine acetone 31, and a serum toxicology screen that was positive for isopropanol. The modest elevation in glucose level most likely was a result of the intravenous administration of dextrose. With the moderate elevation of the serum glucose level, diabetic ketoacidosis was effectively ruled out, and a diagnosis of isopropyl alcohol poisoning was made. The presumed method of poisoning was transcutaneous absorption of the isopropyl alcohol used to cool the fiberglass cast. Inhalation may have contributed as well, after extubation. Treatment included supportive measures that consisted of oxygen supplementation by mask, intravenous hydration, and monitoring. Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated. J Bone Joint Surg Am. 2008;90:1998-9 d doi:10.2106/JBJS.H.00053 1999 T H E J O U R N A L O F B O N E & J O I N T S U R G E RY J B J S . O R G V O L U M E 9 0-A N U M B E R 9 S E P T E M B E R 2 008 d d ISOPROPYL ALCOHOL POISONING FROM C A S T A P P L I C AT I O N d The child began to awaken on the second postoperative day. He was transferred to a ward and by the third postoperative day was fully alert, had no focal neurological signs, and was discharged home. The femoral fracture healed uneventfully in the spica cast, which was removed after six weeks. At the time of the fourmonth follow-up visit, the patient was walking without difficulty and had no neurological abnormalities on examination. Discussion ast treatment has been a mainstay of fracture management for many decades. As with any intervention, it is not without risk. Among these, thermal injury can result from the exothermic nature of the chemical reaction by which the cast materials, either plaster of Paris or fiberglass, cure. Recent attention has been drawn to this potential source of thermal injury1,2. Halanski et al. described several interventions used in an attempt to minimize the risk of thermal injury during cast application, including the application of isopropyl alcohol to the cast during the exothermic phase1,2. This technique was employed in the case of our patient and resulted in the unforeseen absorption of enough isopropyl alcohol to cause acute poisoning. Isopropyl alcohol is a common source of poisoning in children3. Signs and symptoms of isopropanol intoxication include lethargy and gastric irritation, often resulting in emesis. Hypotension can occur and is refractory to treatment4. Isopropanol is metabolized into acetone by alcohol dehydrogenase. Acetone is also a neurodepressant. The combination of isopropanol and acetone can present as a prolonged depression of consciousness. Laboratory findings include ketosis, evident in the serum and urine, with a lack of acidosis. There is also an C osmolar gap. If done, a toxicology screen will be positive for both isopropanol and acetone. The most common method of poisoning is oral ingestion. Less common routes of poisoning have been described, including transdermal and inhalation poisoning5-9. These have typically occurred during wound care or sponge bathing, generally done to control fever. Experimental studies have supported the transdermal route of absorption10,11. Treatment consists of supportive care, including respiratory and circulatory support if needed. In rare instances, severe poisoning can be treated by dialysis12. Of note, Halanski et al.1 also found in their model that fiberglass casts made from six-ply casting tape did not generate sufficient heat to cause tissue damage. In the case of our patient, the thickness of the spica cast was much thicker than sixply. Although the exact thickness is unknown, caution should be observed when applying casts, such as hip spica casts, that require many layers of cast material. As of this writing, we are not aware of this particular mode of isopropyl alcohol poisoning being reported in the Englishlanguage literature regarding the pediatric population. Because of the limited efficacy of isopropyl alcohol and its association with the risk of isopropanol poisoning, we no longer recommend the use of isopropyl alcohol to cool casts. n James C. Krieg, MD Department of Orthopaedics and Sports Medicine, Harborview Medical Center, 325 Ninth Avenue, Box 359798, Seattle, WA 98104. E-mail address: [email protected] References 1. Halanski MA, Halanski AD, Oza A, Vanderby R, Munoz A, Noonan KJ. Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity. J Bone Joint Surg Am. 2007;89:2369-77. 2. Halanski M, Noonan KJ. Cast and splint immobilization: complications. J Am Acad Orthop Surg. 2008;16:30-40. 3. Bronstein AC, Spyker DA, Cantilena LR Jr, Green J, Rumack BH, Heard SE. 2006 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS). Clin Toxicol (Phila). 2007;45:815-917. 4. Zaman F, Pervez A, Abreo K. Isopropyl alcohol intoxication: a diagnostic challenge. Am J Kidney Dis. 2002;40:E12. 7. McFadden SW, Haddow JE. Coma produced by topical application of isopropanol. Pediatrics. 1969;43:622-3. 8. Senz EH, Goldfarb DL. Coma in a child following use of isopropyl alcohol in sponging. J Pediatr. 1958;53:322-3. 9. Garrison RF. Acute poisoning from use of isopropyl alcohol in tepid sponging. J Am Med Assoc. 1953;152:317-8. 10. Turner P, Saeed B, Kelsey MC. Dermal absorption of isopropyl alcohol from a commercial hand rub: implications for its use in hand decontamination. J Hosp Infect. 2004;56:287-90. 5. Leeper SC, Almatari AL, Ingram JD, Ferslew KE. Topical absorption of isopropyl alcohol induced cardiac and neurologic deficits in an adult female with intact skin. Vet Hum Toxicol. 2000;42:15-7. 11. Martinez TT, Jaeger RW, deCastro FJ, Thompson MW, Hamilton MF. A comparison of the absorption and metabolism of isopropyl alcohol by oral, dermal and inhalation routes. Vet Hum Toxicol. 1986;28: 233-6. 6. Vivier PM, Lewander WJ, Martin HF, Linakis JG. Isopropyl alcohol intoxication in a neonate through chronic dermal exposure: a complication of a culturally-based umbilical care practice. Pediatr Emerg Care. 1994;10:91-3. 12. Lacouture PG, Wason S, Abrams A, Lovejoy FH Jr. Acute isopropyl alcohol intoxication. Diagnosis and management. Am J Med. 1983;75: 680-6.