PII S0736-4679(99)00134-1 Selected Topics: Toxicology OVERLOOKED SOURCES OF ETHANOL Faiz Khan, MD, Kumar Alagappan, MD, and Keith Cardell, MD Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park, New York Correspondence Address: Faiz Khan, MD, Dept. of Emergency Medicine, Long Island Jewish Medical Center, 270 – 05 76th Ave., New Hyde Park, NY 11040 e Abstract—The case of a 55-year-old female who pre- sented to the emergency department with acute ethanol intoxication and suicidal ideation is reported. After initiat- ing routine management, we discovered that her serum ethanol levels remained persistently elevated as a result of the patient’s secretly ingesting mouthwash. This occurred after she was searched and allowed to retain personal hy- giene products. Alcohol-dependent patients may consume ethanol products that are not manufactured for ingestion. These products include cosmetics, cough and cold remedies, and personal hygiene products. The ethanol content of these nonbeverage ethanol (NBE) products exceeds that of many conventional alcoholic beverages. Financial constraints and ease of availability are factors leading to their consumption. This report serves as a reminder to be aware of the exis- tence and popularity of NBE in order to avoid potential morbidity and even mortality associated with its use. © 1999 Elsevier Science Inc. e Keywords—nonbeverage ethanol; alcoholic; ethanol lev- els; cough and cold remedies; mouthwash INTRODUCTION Emergency physicians often manage patients presenting with acute ethanol intoxication. Management principles in the vast majority of uncomplicated cases consist of supportive measures, frequent neurologic examinations, provision of a monitored alcohol-free environment, checking a serum glucose, toxicology screen and ethanol level, and awaiting patient functional sobriety. A gener- ally unrecognized source of alcohol consumption is non- beverage ethanol (NBE). The following report illustrates a case where NBE was overlooked in the Emergency Department (ED). The patient was a 55-year-old female with a history of chronic alcoholism, hypothyroidism, and depression who presented to the ED at 7:30 PM crying and repeating that she no longer wanted to live. After reassurance from the staff, she was led to a separate room and put on 1:1 observation. Belongings that were potentially harmful were removed. The patient was allowed to retain per- sonal hygiene products. Her history revealed a drinking binge and noncompliance with medications for 7 days, in an effort to end her life. She denied any co-ingestions or somatic complaints. Her last drink was about 1 h before arrival and consisted of four or five wine coolers with dinner. Her prior psychiatric history was notable for 20 hospitalizations for depression over the preceding 5 years. She had never attempted suicide but admitted to frequent ideation. She had been alcohol-dependent for 12 years and had participated in several detoxification pro- grams. Her medications included levothyroxine, valproic acid, sertraline, and estrogen. Physical examination revealed a well-nourished mid- dle-age white female smelling of alcohol. She was ex- tremely anxious but in no distress. Vital signs were: blood pressure 120/70 mmHg, pulse 100 beats/min, res- pirations 22 breaths/min, temperature 36.1°C (97 °F). The pupils were 3 mm, equal and reactive, and the rest of her physical examination was normal except for a slight Selected Topics: Toxicology is coordinated by Kenneth Kulig, MD, of Denver, Colorado RECEIVED: 17 June 1998; FINAL SUBMISSION RECEIVED: 16 December 1998; ACCEPTED: 8 January 1999 The Journal of Emergency Medicine, Vol. 17, No. 6, pp. 985–988, 1999 Copyright © 1999 Elsevier Science Inc. Printed in the USA. All rights reserved 0736-4679/99 $–see front matter 985