Download Isopropyl Alcohol Poisoning from Cast Application

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
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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
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ISOPROPYL ALCOHOL POISONING
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C A S T A P P L I C AT I O N
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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
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Acad Orthop Surg. 2008;16:30-40.
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