Ethylene Glycol: Systemic Agent

Clear, colorless, syrupy (viscous) liquid at room temperature. Often colored fluorescent yellow-green when used in automotive antifreeze.

Ethylene glycol is a useful industrial compound found in many consumer products. Examples include antifreeze, hydraulic brake fluids, some stamp pad inks, ballpoint pens, solvents, paints, plastics, films, and cosmetics. It can also be a pharmaceutical vehicle. Ethylene glycol has a sweet taste and is often ingested by accident or on purpose. Ethylene glycol breaks down into toxic compounds in the body. Ethylene glycol and its toxic byproducts first affect the central nervous system (CNS), then the heart, and finally the kidneys. Ingesting enough can cause death. Ethylene glycol is odorless.

• Indoor Air: Ethylene glycol can release into indoor air as a liquid spray (aerosol), vapor, or mist.
• Water: Ethylene glycol can pollute water.
• Food: Ethylene glycol can pollute food.
• Outdoor Air: Ethylene glycol can release into outdoor air as a liquid spray (aerosol), vapor, or mist.
• Agricultural: If ethylene glycol releases as a liquid spray (aerosol) or mist, it may pollute agricultural products. If ethylene glycol releases as a vapor, it is unlikely to pollute agricultural products.

Systemic ethylene glycol toxicity can occur through ingestion. Breathing ethylene glycol vapors may irritate eyes and lungs but is unlikely to cause systemic toxicity. Ethylene glycol does not absorb well through the skin so systemic toxicity is unlikely. Eye exposure may lead to local adverse health effects but is unlikely to result in systemic toxicity.

First Responders should use a NIOSH-certified Chemical, Biological, Radiological, Nuclear (CBRN) Self Contained Breathing Apparatus (SCBA) with a Level A protective suit. Responders should wear these when entering an area with an unknown contaminant or when entering an area where the amount of the contaminant is unknown. Level A protection is necessary until monitoring results confirm the contaminant and the amount of the contaminant.
NOTE: Safe use of protective clothing and equipment requires specific skills from training and experience.

Select this level when workers need the greatest level of skin, respiratory, and eye protection. This is the maximum protection for workers in danger of exposure to unknown chemical hazards or levels above the IDLH or greater than the AEGL-2.

• A NIOSH-certified CBRN full-face-piece SCBA operated in a pressure-demand mode or a pressure-demand supplied air hose respirator with an auxiliary escape bottle.
• A Totally-Encapsulating Chemical Protective (TECP) suit that protects against CBRN agents.
• Chemical-resistant gloves (outer).
• Chemical-resistant gloves (inner).
• Chemical-resistant boots with a steel toe and shank.
• Optional items: Coveralls, long underwear, and a hard hat worn under the TECP suit.

Select this level when workers need the highest level of respiratory protection but a lower level of skin protection. This is the minimum protection for workers in danger of exposure to unknown chemical hazards or levels above the IDLH or greater than AEGL-2. It includes a non-encapsulating, splash-protective, chemical-resistant splash suit that provides Level A protection against liquids but is not airtight.

• A NIOSH-certified CBRN full-face-piece SCBA operated in a pressure-demand mode or a pressure-demand supplied air hose respirator with an auxiliary escape bottle.
• A hooded chemical-resistant suit that protects against CBRN agents.
• Chemical-resistant gloves (outer).
• Chemical-resistant gloves (inner).
• Chemical-resistant boots with a steel toe and shank.
• Optional items: Coveralls, long underwear, a hard hat worn under the chemical-resistant suit, and chemical-resistant disposable boot-covers worn over the chemical-resistant suit.

Select this level when: 1) workers know the contaminant and the amount present 2) when meeting the respiratory protection criteria factors for using Air Purifying Respirators (APR) or Powered Air Purifying Respirators (PAPR). This level is appropriate when decontaminating patient/victims.

• A NIOSH-certified CBRN tight-fitting APR with a canister-type gas mask or CBRN PAPR for air levels greater than AEGL-2.
• A NIOSH-certified CBRN PAPR with a loose-fitting face-piece, hood, or helmet. It should include a filter or a combination organic vapor, acid gas, and particulate cartridge/filter combination or a continuous flow respirator for air levels greater than AEGL-1.
• A hooded chemical-resistant suit that protects against CBRN agents.
• Chemical-resistant gloves (outer).
• Chemical-resistant gloves (inner).
• Chemical-resistant boots with a steel toe and shank.
• Optional items: Escape mask, face shield, coveralls, long underwear, a hard hat worn under the chemical-resistant suit, and chemical-resistant disposable boot-covers worn over the chemical-resistant suit.

Select this level when workers know the contaminant and the amount present. Select when the amount is below the appropriate occupational exposure limit or less than AEGL-1 for the stated duration times.

• Limited to coveralls or other work clothes, boots, and gloves.

• Ethylene glycol reacts with strong oxidants and acids.

• Lower explosive (flammable) limit in air (LEL): 3.2%. Upper explosive (flammable) limit in air (UEL): 15.3%.

• Ethylene glycol is combustible.
• Extinguish fires using an agent suitable for the type of surrounding fire.
• Use “alcohol” foam, dry chemical, or carbon dioxide.
• Keep run-off water out of sewers and water sources.

• Isolate tanks, rail cars, or tank trucks involved in fires for 0.5 mi (800 m) in all directions. Also  consider initial evacuation for 0.5 mi (800 m) in all directions.
• This agent is not listed in the DOT ERG 2004 Table of Initial Isolation and Protective Action Distances.
• Immediately isolate an ethylene glycol spill or leak area for at least 330 ft (100 m) in all directions. This and other public safety actions are listed in the DOT ERG 2004 orange-bordered section of the guidebook (Guide 111).

• Vapors are heavier than air and will collect in poorly ventilated, low-lying, or confined areas (e.g., sewers, basements, and tanks).
• Hazardous amounts may develop quickly in enclosed, poorly ventilated, or low-lying areas. Keep out of these areas and upwind.

• OSHA: PV 2024
• NIOSH: 5523

• AIR MATRIX
  Bost RO, Sunshine I [ 1980]. Ethylene-glycol analysis by gas-chromatography. J Anal Toxicol 4(2):102-103.Cao XL, Zhu J [2001]. Monitoring method for airborne glymes and its application in fuel exhaust emission measurement. Chemosphere 45(6-7):911-917.NIOSH [1996]. NMAM 5523, Issue 1: Glycols. In: NIOSH Manual of analytical methods. 4th ed. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 94-113.
  Pendergrass SM [1999]. Determination of glycols in air: development of sampling and analytical methodology and application to theatrical smokes. Am Ind Hyg Assoc J 60:452-457.Potter W [1999]. Ethylene glycol Method PV2024. OSHA Salt Lake City, UT: U.S. Department of Labor, OSHA Salt Lake Technical Center, Chromatography Team.
• OTHER
  No references were identified for this sampling matrix for this agent.
• SOIL MATRIX
  Davidsen JM, Grypa RD [1995]. Gas chromatographic methods for the determination of ethylene oxide and its reaction products in spices and herbs [Abstract]. 210th American Chemical Society National Meeting, Chicago, Illinois, August 20-24.
• SURFACES
  No references were identified for this sampling matrix for this agent.
• WATER
  Houz? P, Chaussard J [1993]. Simultaneous determination of ethylene glycol, propylene glycol, 1,3-butylene glycol and 2,3-butylene glycol in human serum and urine by wide-bore column gas chromatography. J Chromatogr B: Biomed Appl 619(2):251-257.Kenyon AS, Shi X, Wang Y, Ng WH, Prestridge R, Sharp K [1998]. Simple, at-site detection of diethylene glycol/ethylene glycol contamination of glycerin and glycerin- based raw materials by thin-layer chromatography. J AOAC Int 81(1):44-50.Maurer HH, Peters FT, Paul LD, Kraemer T [2001]. Validated gas chromatographic–mass spectrometric assay for determination of the antifreezes ethylene glycol and diethylene glycol in human plasma after microwave-assisted pivalylation. J Chromatogr B: Biomed Appl 754(2):401-409.Nilsson L, Jones AW [1992]. 2,3-Butanediol: A potential interfering substance in the assay of ethylene glycol by an enzymatic method. Clin Chim Acta 208(3):225-229.Oudhoff KA, Schoenmakers PJ, Kok WT [2003]. Characterization of polyethylene glycols and polypropylene glycols by capillary zone electrophoresis and micellar electrokinetic chromatography. J Chromatogr A 985(1-2):479-491.Szymanski A, Wyrwas B, Szymanowska M, Lukaszewski Z [2001]. Determination of short-chained poly(ethylene glycols) and ethylene glycol in environmental samples. Water Res 35(15):3599-3604.Wahl A, Azaroual N, Imbenotte M, Mathieu D, Forzy G, Cartigny B, Vermeersch G, Lhermitte M [1998]. Poisoning with methanol and ethylene glycol: 1H NMR spectroscopy as an effective clinical tool for diagnosis and quantification. Toxicology 128(1):73-81.

After ingestion, ethylene glycol rapidly absorbs (within 1 to 4 hours) through the stomach. Following absorption, 80% or more of ethylene glycol chemically converts into toxic compounds. Ethylene glycol toxicity is categorized into three broad overlapping stages of adverse health effects. Stage 1 (the neurological stage) lasts from 30 minutes to 12 hours after ingestion. Stage 2 (the cardiopulmonary stage) occurs between 12 and 24 hours after ingestion. Stage 3 (the renal stage) occurs between 24 and 72 hours after ingestion. The co-ingestion of alcohol can significantly delay adverse health effects.

Early ethylene glycol intoxication is like ethanol intoxication but there is no odor of alcohol on the patient/victim’s breath. Initial adverse health effects caused by ethylene glycol intoxication include:

• central nervous system depression,
• intoxication,
• euphoria,
• stupor, and
• respiratory depression.
• Nausea and vomiting may occur as a result of gastrointestinal irritation.
• Severe toxicity may result in coma, loss of reflexes, seizures (uncommon), and irritation of the tissues lining the brain.

The toxic metabolic by-products of ethylene glycol metabolism cause a build-up of acid in the blood. This process is called metabolic acidosis. These toxic substances also affect the cardiopulmonary system and can cause renal failure. Metabolic acidosis commonly occurs after ethylene glycol intoxication, but absence of acidosis does not exclude ethylene glycol toxicity. Serum ethylene glycol levels do not correlate well with clinical presentation.
Untreated ethylene glycol poisoning can be fatal.

• Exposure to vapors of ethylene glycol may cause irritation.
• Exposure to liquid ethylene glycol may result in swelling of the eyelid and cornea, swelling of the conjunctiva and iris, and conjunctival or corneal injury.

• Mild to moderate, Stage 1: Reduced level of consciousness (CNS depression), euphoria, dizziness, headache, slurred speech, drowsiness, disorientation, inability to coordinate movements (ataxia), irritation and restlessness, involuntary eye movements (nystagmus), and nausea and vomiting (emesis).
• Mild to moderate, Stage 2: Increased heart rate (tachycardia); abnormal or disordered heart rhythms (dysrhythmia); increased blood pressure (hypertension); and build-up of toxic breakdown products in the blood stream (metabolic acidosis), resulting in increased rate and depth of breathing (hyperventilation).
• Mild to moderate, Stage 3: Effects are unusual following a mild to moderate exposure.
• Severe, Stage 1: Decreased reflex responses, seizures, loss of consciousness, and coma.
• Severe, Stage 2: More severe build-up of toxic breakdown products in the blood stream, resulting in increased rate and depth of breathing; heart damage, including congestive heart failure, resulting in buildup of fluid in the lungs (pulmonary edema); lung damage, including adult respiratory distress syndrome (ARDS), resulting in a decreased oxygen supply to the body; multi-system organ failure; and death.
• Severe, Stage 3: Reduced urine excretion; absence of urine excretion; and acute kidney failure, causing a build-up of toxic chemicals and chemical imbalances in the blood stream.

• Exposure to very high levels of ethylene glycol vapors causes irritation of mucous membranes and the upper respiratory tract.
• Exposure to levels of ethylene glycol concentrations higher than 80 ppm results in intolerable respiratory discomfort and cough.

• Irritation.

The purpose of decontamination is to quickly and effectively remove toxic substances for the safety of an individual and/or their equipment. Decontaminate carefully because absorbed agent can release from clothing and skin as a gas. Your Incident Commander will provide you with decontaminants specific for the agent released or the agent believed to have been released.

The following are recommendations to protect the first responders from the release area:

• Position the decontamination corridor upwind and uphill of the hot zone. The warm zone should include two decontamination corridors. One decontamination corridor is used to enter the warm zone and the other for exiting the warm zone into the cold zone. The decontamination zone for exiting should be upwind and uphill from the zone used to enter.
• Decontamination area workers should wear appropriate PPE. See the PPE section of this card for detailed information.
• A solution of detergent and water with a pH value of at least 8 but not higher than 10.5 should be available for decontamination procedures. Soft brushes should be available to remove contamination from the PPE. Labeled, durable 6-mil polyethylene bags should be available for disposal of contaminated PPE.

The following methods can be used to decontaminate an individual:

• Decontamination of First Responder:
  • Begin washing PPE of the first responder using soap and water solution and a soft brush. Always move in a downward motion (from head to toe). Make sure to get into all areas, especially folds in the clothing. Wash and rinse (using cold or warm water) until the contaminant is thoroughly removed.
  • Remove PPE by rolling downward (from head to toe) and avoid pulling PPE off over the head. Remove the SCBA after other PPE is removed.
  • Place all PPE in labeled durable 6-mil polyethylene bags.
• Decontamination of Patient/Victim:
  • Remove the patient/victim from the contaminated area and into the decontamination corridor.
  • Remove all clothing (at least down to their undergarments) and place the clothing in a labeled durable 6-mil polyethylene bag.
  • Thoroughly wash and rinse the contaminated skin of the patient/victim using a soap and water solution with cold or warm water. Be careful not to break the patient/victim’s skin during the decontamination process, and cover all open wounds.
  • Cover the patient/victim to prevent shock and loss of body heat.
  • Move the patient/victim to an area where emergency medical treatment is available.

Initial treatment is primarily supportive. In the case of a large ingestion:

• Treatment under a physician’s direction within the first 30 to 60 minutes should include an attempt to aspirate stomach contents.
• As ethylene glycol absorbs rapidly from the gastrointestinal (GI) tract, gastric aspiration by use of a nasogastric tube may be useful.

Fomepizole and ethanol are effective antidotes against ethylene glycol toxicity. Administer fomepizole or ethanol as soon as possible once the patient/victim is admitted to a medical care facility. See Long Term Implications: Medical Treatment for further instruction.

• Immediately remove the patient/victim from the source of exposure.
• Immediately wash eyes with large amounts of tepid water for at least 15 minutes.
• Seek medical attention immediately.

• Immediately remove the patient/victim from the source of exposure.
• Ensure that the patient/victim has an unobstructed airway.
• Do not induce vomiting (emesis).
• Treat seizures with diazepam under a physician’s direction or per local EMS protocol.
• Monitor heart function. Evaluate for low blood pressure (hypotension), abnormal heart rhythms (dysrhythmias), and reduced respiratory function (respiratory depression).
• Evaluate for low blood sugar (hypoglycemia), electrolyte disturbances, and low oxygen levels (hypoxia).
• Seek medical attention immediately.

• Immediately remove the patient/victim from the source of exposure.
• Evaluate respiratory function and pulse.
• Ensure that the patient/victim has an unobstructed airway.
• If shortness of breath occurs or breathing is difficult (dyspnea), administer oxygen.
• Assist ventilation as required. Always use a barrier or bag-valve-mask device.
• If breathing has ceased (apnea), provide artificial respiration.
• Seek medical attention immediately.

• Immediately remove the patient/victim from the source of exposure.
• See the Decontamination section for patient/victim decontamination procedures.
• Seek medical attention immediately.

• For large ingestions of ethylene glycol, attempt to aspirate stomach (gastric) contents using a nasogastric tube, if possible within the first 30 to 60 minutes. In all patient/victims with known or suspected ethylene glycol poisoning, perform the following tests:
  • Blood tests (CBC, blood glucose, serum electrolytes, magnesium, calcium, BUN, creatinine, lactate, ethylene glycol level, and ethanol level)
  • Arterial blood gas (ABG) levels and osmolarity
  • Urinalysis.
• Repeat these tests as necessary to closely monitor the progression of toxic effects. Contact a medical toxicologist or a regional poison control center for assistance in evaluating the anion and osmolar gaps and to decide whether antidotal therapy, intravenous sodium bicarbonate, or hemodialysis is needed.
• Administer antidotes fomepizole or ethanol intravenously as soon as possible to block the conversion of ethylene glycol to formic acid and prevent acidosis.
  • Fomepizole is preferred as its efficacy and safety have been demonstrated, and its therapeutic dose is more easily maintained. Once the patient/victim has become acidotic, administration of fomepizole or ethanol may not provide much benefit, but can be administered at the discretion of the physician in charge.
• Administer folinic acid (leucovorin) intravenously to increase the rate at which formate is metabolized into less toxic chemicals.
• Hemodialysis is the most effective form of treatment for an acidotic patient/victim. Hemodialysis may be used when the blood ethylene glycol level is greater than 50 mg/dL, with severe metabolic or fluid abnormalities despite other therapeutic interventions, or in cases of kidney failure.
• Caution: Ethanol and fomepizole dosing must be adjusted during hemodialysis. Thiamine and pyridoxine facilitate a more rapid metabolism of ethylene glycol to non-toxic metabolites and should be given as a single dose IV (100 mg daily).

Kidney (renal) failure can occur 24 to 72 hours after acute ethylene glycol ingestion. Some loss of kidney function may be permanent. In the absence of improvement of renal function, the patient/victim may die or require permanent hemodialysis. Injury to the nerves of the head and neck (cranial nerve palsies) may be of short-term or long-term duration. This may affect the nerves that control facial movement, eye movement and vision, hearing, and swallowing. Loss of the ability to move a body part (palsy) may occur 4 to 18 days post exposure in patient/victims with delayed, inadequate, or no treatment. Brain swelling (cerebral edema) causes an impaired level of consciousness. This may cause generalized seizures, brain death, or permanent brain damage. Accumulation of fluid in the lungs (pulmonary edema), due to heart or lung damage, may occur. Muscle inflammation (myositis) may occur.

Ethylene glycol is not classifiable as a human carcinogen. Limited studies have not found ethylene glycol to be a carcinogen. It is not known whether chronic or repeated exposure to ethylene glycol increases the risk of reproductive toxicity or developmental toxicity. Chronic or repeated exposure to ethylene glycol may lead to: irritation of the throat, mild headache, low backache, loss of consciousness, and nystagmus. These will resolve if the source of exposure is removed.

• Consult with the Incident Commander regarding the agent dispersed, dissemination method, level of PPE required, location, geographic complications (if any), and the approximate number of remains.
• Coordinate responsibilities and prepare to enter the scene as part of the evaluation team along with the FBI HazMat Technician, local law enforcement evidence technician, and other relevant personnel.
• Begin tracking remains using waterproof tags.

• Wear PPE until confirming that all remains are free of contamination.
• Establish a preliminary (holding) morgue.
• Gather evidence and place it in a clearly labeled waterproof container. Hand any evidence over to the FBI.
• Remove and tag personal effects.
• Perform a thorough external evaluation and a preliminary identification check.
• See the Decontamination section for decontamination procedures.
• Decontaminate remains before removing from the incident site.

The following methods can help decontaminate the environment/spillage disposal:

• Do not touch or walk through the spilled agent if at all possible. However, if required, personnel should wear the appropriate PPE during environmental decontamination. See the PPE section of this card for detailed information.
• Keep combustibles (e.g., wood, paper, and oil) away from the spilled agent. Use water spray to reduce vapors or divert vapor cloud drift. Avoid allowing water runoff to contact the spilled agent.
• Do not direct water at the spill or the source of the leak.
• Stop the leak if it is possible to do so without risk to personnel. Turn leaking containers so that gas escapes instead of liquid.
• Prevent entry into waterways, sewers, basements, or confined areas.
• Isolate the area until gas has dispersed.
• Ventilate the area.

Agents can seep into the crevices of equipment making it dangerous to handle. The following methods can help decontaminate equipment:

• Not established/determined