Blackout in a can

A 19 yo M presenting with non specific complaints of nausea/ vomiting/ abdominal pain and diffuse bodyache and foind to have an AG metabolic and respiratory acidosis with lactate of 13.2 and pH of 7.04.

We went through the differential diagnosis of above which included methanol/ ethylene glycol/ isopropyl alcohol amongst others. This patient had indeed ingested several cans of “Four Loko” (aka “liquid cocaine”, ” black-out in a can”) which is ethanol with caffeine and his presentation was thought to be from alcohol ketoacidosis.

– isopropyl alcohol does NOT cause metabolic acidosis as it gets metabolized to ketones and this does not consume bicarbonate. Case report  of diagnostic dilemma with this kind of alcohol

– if methanol/ ethylene glycol is suspected, there is more benefit than harm if  Fomepizole is started – review paper

– ethanol is a competitive substrate for alcohol dehydrogenase (ADH) which also metabolizes ethylene glycol. Serum ethanol level of 100 mg/dl is needed to divert the ADH and prevent metabolsim of ethylene glycol into the toxic metabolites