Cast 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.
A 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 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 4+, urine acetone 3+, 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.
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 four-month follow-up visit, the patient was walking without difficulty and had no neurological abnormalities on examination.