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Key Features

  • Alcohol quickly equilibrates between intracellular and extracellular compartments, adding 22 mOsm/L for every 100 mg/dL (or 21.7 mmol/L) of ethanol

  • Ethanol ingestion should be considered in any case of stupor or coma with an elevated osmolal gap (measured osmolality-calculated osmolality > 10 mOsm/kg [> 10 mmol/kg])

  • However, the combination of an increased anion gap metabolic acidosis and an osmolal gap exceeding 10 mOsm/kg [10 mmol/kg] is not specific for toxic alcohol ingestion and may occur with alcoholic ketoacidosis or lactic acidosis

  • Other toxic alcohols such as methanol and ethylene glycol cause an osmolal gap and a metabolic acidosis with an increased anion gap

Diagnosis

  • The following substances and conditions can produce an osmolar gap:

    • Methanol

    • Ethylene glycol

    • Isopropyl alcohol

    • Ethanol toxicity

    • Acetone

    • Propylene glycol

    • Severe alcoholic or diabetic ketoacidosis

    • Lactic acidosis

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