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DIMETHYL-P-PHENYLENEDIAMINE

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Dimethyl-p-phenylenediamine (DMPD) is an aromatic amine.

Specific Substances

    1) Dimethyl-p-phenylenediamine
    2) N,N-Dimethyl-p-fenylendiamin
    3) N,N-Dimethyl-p-phenylenediamine
    4) N,N-Dimethyl-p-benzenediamine
    5) N,N-Dimethyl-1,4-(dimethylamino) aniline
    6) C.I. 76075
    7) Dimethyl-para-phenylenediamine
    8) DMPD
    9) N,N-Dimethyl-1,4-benzenediamine
    10) N,N-Dimethyl-1,4-phenylenediamine
    11) N,N-Dimethyl-p-phenylenediamine
    12) p-(Dimethylamino)aniline
    13) p-Amino-N,N-dimethylaniline
    14) p-Aminodimethylaniline
    15) p-Dimethylaminophenylamine
    16) p-Phenylenediamine, N,N-dimethyl-
    17) NIOSH/RTECS ST 0874000
    18) Molecular Formula: C8-H12-N2
    19) CAS 99-98-9
    1.2.1) MOLECULAR FORMULA
    1) C8-H12-N2

Available Forms Sources

    A) FORMS
    1) Properly stored DMPD appears as reddish violet crystals (Budavari, 1996). Older reports indicate that freshly purified DMPD is a colorless or pale yellow liquid which may become black and tarry after standing several hours (Hanzlik, 1922).
    2) DMPD also occurs as the dihydrochloride salt (Budavari, 1996).
    3) DMPD is also a metabolite from the riboflavin-dependent reductive cleavage of the azo dyes BUTTER YELLOW, METHYL YELLOW, METHYL ORANGE and METHYL RED. Butter yellow is a potent liver carcinogen in animals (Kensler et al, 1942; Chung et al, 1981).
    B) SOURCES
    1) DMPD is prepared by reduction of p-nitrosodimethylaniline with hydrochloric acid and zinc dust or by reduction of methyl orange (Sax & Lewis, 1987; Budavari, 1996).
    C) USES
    1) DMPD is an aromatic amine used in the production of methylene blue, as a photodeveloper, an analytical reagent for hydrogen sulfide detection, and as a reagent for organic synthesis (Sax & Lewis, 1987).
    2) It is also used as a chemical intermediate for the synthesis of dyes and diazonium chloride salts, as an analytical reagent to detect chloramine in water (EPA, 1985), and as an electron donor in spectrophotometric assays for dopamine beta-monooxygenase (Wilamasena & Wimalasena, 1991).
    3) DMPD also occurs as the dihydrochloride salt, which is used in microscopy and as a reagent to test for acetone, thallic salts, uric acid, lignin, ozone, hydrogen peroxide, bromine and hydrogen sulfide (Budavari, 1996).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) Human experience with dimethyl-p-phenylenediamine (DMPD) is limited. DMPD may be toxic by inhalation of the vapor or by the oral, dermal, subcutaneous, intraperitoneal or intravenous routes.
    1) DMPD is a skin and eye irritant and sensitizer. Highly concentrated solutions may produce vesication. Life threatening toxicity may result from adult skin exposure to very minute quantities (1 teaspoon), based on animal studies. This has not been confirmed in humans. Ingestions have not been reported, but esophageal or gastric irritation might be predicted based on this agent's other irritant properties.
    2) DMPD is a weak inducer of methemoglobinemia in rats. It has produced hyperglycemia, hyperexcitability, dyspnea, seizures and death in animals.
    B) Paraphenylenediamine, a closely related compound and metabolite of DMPD, has caused severe eye reactions including hypersensitivity, optic neuritis, protrusion and possibly lenticular opacities in humans.
    0.2.7) NEUROLOGIC
    A) Convulsions and death have been produced in animals exposed to DMPD.
    0.2.8) GASTROINTESTINAL
    A) There is insufficient information concerning gastrointestinal effects in humans. Gastric irritation may occur, based on the chemical's other irritant properties.
    0.2.13) HEMATOLOGIC
    A) Methemoglobinemia has been produced in animals.
    0.2.14) DERMATOLOGIC
    A) Vesication, irritation, allergic dermatitis, and delayed hemorrhage of the skin have been reported following skin exposure to DMPD. Dermal absorption of DMPD can result in systemic toxicity.
    0.2.16) ENDOCRINE
    A) DMPD has produced hyperglycemia in animals.
    0.2.20) REPRODUCTIVE
    A) Teratogenic effects in humans exposed to DMPD have not been reported. There is limited information concerning teratogenic effects of DMPD in animals. Negative and positive effects have been reported.
    0.2.21) CARCINOGENICITY
    A) At the time of this review, no data were available to assess the carcinogenic potential of this agent.

Laboratory Monitoring

    A) Monitor methemoglobin, hemoglobin, and blood glucose.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) Treatment is symptomatic and supportive.
    B) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting.
    C) ACTIVATED CHARCOAL: Administer charcoal as a slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
    D) SEIZURES: Administer a benzodiazepine; DIAZEPAM (ADULT: 5 to 10 mg IV initially; repeat every 5 to 20 minutes as needed. CHILD: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed) or LORAZEPAM (ADULT: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist. CHILD: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue).
    1) Consider phenobarbital or propofol if seizures recur after diazepam 30 mg (adults) or 10 mg (children greater than 5 years).
    2) Monitor for hypotension, dysrhythmias, respiratory depression, and need for endotracheal intubation. Evaluate for hypoglycemia, electrolyte disturbances, and hypoxia.
    E) METHEMOGLOBINEMIA: Determine the methemoglobin concentration and evaluate the patient for clinical effects of methemoglobinemia (ie, dyspnea, headache, fatigue, CNS depression, tachycardia, metabolic acidosis). Treat patients with symptomatic methemoglobinemia with methylene blue (this usually occurs at methemoglobin concentrations above 20% to 30%, but may occur at lower methemoglobin concentrations in patients with anemia, or underlying pulmonary or cardiovascular disorders). Administer oxygen while preparing for methylene blue therapy.
    F) METHYLENE BLUE: INITIAL DOSE/ADULT OR CHILD: 1 mg/kg IV over 5 to 30 minutes; a repeat dose of up to 1 mg/kg may be given 1 hour after the first dose if methemoglobin levels remain greater than 30% or if signs and symptoms persist. NOTE: Methylene blue is available as follows: 50 mg/10 mL (5 mg/mL or 0.5% solution) single-dose ampules and 10 mg/1 mL (1% solution) vials. Additional doses may sometimes be required. Improvement is usually noted shortly after administration if diagnosis is correct. Consider other diagnoses or treatment options if no improvement has been observed after several doses. If intravenous access cannot be established, methylene blue may also be given by intraosseous infusion. Methylene blue should not be given by subcutaneous or intrathecal injection. NEONATES: DOSE: 0.3 to 1 mg/kg.
    G) Concomitant use of methylene blue with serotonergic drugs, including serotonin reuptake inhibitors (SRIs), selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), norepinephrine-dopamine reuptake inhibitors (NDRIs), triptans, and ergot alkaloids may increase the risk of potentially fatal serotonin syndrome.
    H) Observe patients with ingestion carefully for the possible development of esophageal or gastrointestinal tract irritation or burns. If signs or symptoms of esophageal irritation or burns are present, consider endoscopy to determine the extent of injury.
    0.4.3) INHALATION EXPOSURE
    A) INHALATION: Move patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer oxygen and assist ventilation as required. Treat bronchospasm with an inhaled beta2-adrenergic agonist. Consider systemic corticosteroids in patients with significant bronchospasm.
    0.4.4) EYE EXPOSURE
    A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Range Of Toxicity

    A) There is little specific, peer reviewed information regarding the range of toxicity for DMPD. The decision to treat should be based on clinical judgement, and should not be based on range of toxicity estimates.
    1) Ingestion of 1 teaspoonful to 1 ounce, or dermal exposure to 1 teaspoonful of DMPD, has been estimated as fatal to adult humans. Inhalation of very high concentrations of DMPD vapors has been fatal to experimental animals. There are no known estimates of the concentration of DMPD which would be lethal to a human following inhalation.

Clinical Effects

Summary Of Exposure

    A) Human experience with dimethyl-p-phenylenediamine (DMPD) is limited. DMPD may be toxic by inhalation of the vapor or by the oral, dermal, subcutaneous, intraperitoneal or intravenous routes.
    1) DMPD is a skin and eye irritant and sensitizer. Highly concentrated solutions may produce vesication. Life threatening toxicity may result from adult skin exposure to very minute quantities (1 teaspoon), based on animal studies. This has not been confirmed in humans. Ingestions have not been reported, but esophageal or gastric irritation might be predicted based on this agent's other irritant properties.
    2) DMPD is a weak inducer of methemoglobinemia in rats. It has produced hyperglycemia, hyperexcitability, dyspnea, seizures and death in animals.
    B) Paraphenylenediamine, a closely related compound and metabolite of DMPD, has caused severe eye reactions including hypersensitivity, optic neuritis, protrusion and possibly lenticular opacities in humans.

Vital Signs

    3.3.2) RESPIRATIONS
    A) TACHYPNEA - There is insufficient information concerning respiratory effects in humans following exposure to DMPD. Increased respiratory rate has been reported in animals following parenteral or oral administration of lethal concentrations of DMPD (Hanzlik, 1922). Dyspnea has been produced in rabbits exposed to extremely high vapor concentrations of DMPD (Hanzlik, 1992).
    3.3.3) TEMPERATURE
    A) HYPOTHERMIA - There is insufficient information concerning effects of DMPD on body temperature in humans. Decreased body temperature has been reported in animals following parenteral or oral administration of lethal concentrations of DMPD (Hanzlik, 1922). Body temperature increased during seizure activity in some animals.

Heent

    3.4.3) EYES
    A) ANIMAL STUDIES have produced the following results:
    1) CONJUNCTIVITIS has been reported with a 1% aqueous solution in rabbits (Grant & Schuman, 1993).
    2) CORNEAL OPACITY has been reported with a 1% aqueous solution in rabbits (Grant & Schuman, 1993).
    3) PROTRUSION of the eyes due to edema of the surrounding tissues has been reported in animals given the related compound PARAPHENYLENEDIAMINE systemically (Grant & Schuman, 1993).
    B) EYE EFFECTS OF RELATED COMPOUNDS -
    1) Pain, burning, redness, swelling, conjunctival edema, erosion of the cornea, iritis and iridocyclitis, and severe corneal ulceration with permanent impairment of vision have been reported from application of dyes containing the closely related compound, PARAPHENYLENEDIAMINE (Grant & Schuman, 1993).
    C) OPTIC NEURITIS - Retrobulbar or optic neuritis has been reported from use of hair dyes containing the closely related compound PARAPHENYLENEDIAMINE (Grant & Schuman, 1993).
    D) LENTICULAR OPACITIES or cataracts were observed in persons using hair dyes containing the closely related compound PARAPHENYLENEDIAMINE and in rats given the latter as a 4% solution applied to the head for a year (Grant & Schuman, 1993).

Neurologic

    3.7.1) SUMMARY
    A) Convulsions and death have been produced in animals exposed to DMPD.
    3.7.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) SEIZURES
    a) Seizures and hyperexcitability have been produced in experimental animals exposed to DMPD (Hanzlik, 1922) Herrmann & DuBois, 1949).

Gastrointestinal

    3.8.1) SUMMARY
    A) There is insufficient information concerning gastrointestinal effects in humans. Gastric irritation may occur, based on the chemical's other irritant properties.
    3.8.2) CLINICAL EFFECTS
    A) GASTROINTESTINAL IRRITATION
    1) Cases of human ingestions have not been reported, but esophageal or gastric irritation might be predicted based on this agent's irritant effects on the skin (Hanzlik, 1922).
    3.8.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) NAUSEA VOMITING
    a) There is insufficient information concerning gastrointestinal effects in humans. Nausea and vomiting in cats and dogs has resulted from gastric administration of phenylenediamines (Hanzlik, 1922).

Hematologic

    3.13.1) SUMMARY
    A) Methemoglobinemia has been produced in animals.
    3.13.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) METHEMOGLOBINEMIA
    a) RATS - DMPD was a weak inducer of methemoglobin when intraperitoneally administered to rats at a single dose of 1.08 X 10(-4) moles/kg (Lin et al, 1972).
    1) The parent azo-dye, N,N-dimethyl-4-aminoazobenzene, was more active than DMPD, suggesting that the amine reduction product was not the active species for inducing methemoglobinemia (Lin et al, 1972).
    2) ERYTHROCYTES ABNORMAL
    a) IN-VITRO STUDY
    1) FERRIHEMOGLOBIN, FREE RADICAL FORMATION - The addition of DMPD to solutions of purified human oxyhemoglobin has resulted in the formation of ferrihemoglobin and DMPD radicals (Storle & Eyer, 1992).

Dermatologic

    3.14.1) SUMMARY
    A) Vesication, irritation, allergic dermatitis, and delayed hemorrhage of the skin have been reported following skin exposure to DMPD. Dermal absorption of DMPD can result in systemic toxicity.
    3.14.2) CLINICAL EFFECTS
    A) BULLOUS ERUPTION
    1) VESICATION - Application to healthy skin of greater than 0.001 cc of DMPD per square centimeter of skin produced blisters in a small number of human subjects (Hanzlik, 1922).
    B) ERUPTION
    1) IRRITATION - Application (without occlusion) to healthy skin of 0.001 cc of DMPD per square centimeter of skin produced itching, local heat, tenderness, erythema and a maculopapular rash in a small number of human subjects (Hanzlik, 1922).
    2) Application of the salt (hydrochloride) of DMPD to intact skin did not result in local or systemic effects in 6 human subjects, possibly because the DMPD salt is not readily absorbed through the skin (Hanzlik, 1922). DMPD vapor exposure of skin did not produce significant skin effects in any of 5 human subjects (Hanzlik, 1922).
    C) DERMATITIS
    1) ALLERGIC DERMATITIS - DMPD has produced allergic dermatitis in humans (Sax & Lewis, 1989). Itching, wheal development and erythema developed in 3 subjects 8 days after experimental dermal exposure to DMPD at concentrations ranging from 0.001 cc to 0.005 cc per square centimeter of skin (Hanzlik, 1922).
    D) HEMORRHAGE
    1) Hemorrhages in the deeper skin layers developed in a few humans 2 to 3 days after skin exposure to 0.001 cc to 0.005 cc of DMPD per square centimeter (Hanzlik, 1922). The lesions were healed by the 8th day following exposure.
    E) SYSTEMIC DISEASE
    1) There is little information concerning the systemic effects following human skin exposure to DMPD. Dermal exposure to 0.001 to 0.005 cc of DMPD per square centimeter of skin produced local effects, but no apparent systemic effects in 6 human subjects (Hanzlik, 1922).
    2) Estimated from animal studies, a fatal dermal dose in a 60-kilogram adult would be about 3.6 cc for 25 square centimeters of skin, or about 1 teaspoonful of DMPD (Hanzlik, 1922).
    3.14.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) URTICARIA
    a) LOCAL DERMAL EFFECTS (RABBIT) - DMPD applied to intact rabbit skin (without occlusion) in concentrations of 0.0001 cc to 0.0062 cc per square centimeter of skin per kilogram of body weight produced wheal formation, skin edema, and discoloration of the skin at the site of DMPD application (Hanzlik, 1922).
    2) SYSTEMIC EFFECTS
    a) RABBIT - DMPD applied to intact rabbit skin (without occlusion) in concentrations of 0.0001 cc to 0.0062 cc per square centimeter of skin per kilogram of body weight produced cyanosis, tachypnea, convulsions, wheezing, decreased body temperature, and death due to respiratory and cardiac arrest (Hanzlik, 1922).
    b) Animal studies have provided evidence of systemic toxicity as a result of dermal exposure to DMPD. Estimated from these animal studies, a fatal dermal dose in a 60 kilogram adult would be about 3.6 cc for 25 square centimeters of skin, or about 1 teaspoonful of DMPD (Hanzlik, 1922).

Endocrine

    3.16.1) SUMMARY
    A) DMPD has produced hyperglycemia in animals.
    3.16.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) HYPERGLYCEMIA
    a) Hyperglycemia occurred in rats given a lethal dose of DMPD (Herrmann & DuBois, 1949).

Reproductive

    3.20.1) SUMMARY
    A) Teratogenic effects in humans exposed to DMPD have not been reported. There is limited information concerning teratogenic effects of DMPD in animals. Negative and positive effects have been reported.
    3.20.2) TERATOGENICITY
    A) CONGENITAL ANOMALY
    1) CHICKS - Para-dimethylaminoazobenzene, an azo dye made from DMPD and aniline, was teratogenic in chicks when injected into the yolk at 6 mg in polyethylene glycol with or without ethanol. The role of ethanol was not understood, but it appeared to have a sparing effect (Pizzarello & Ford, 1968).
    B) LACK OF EFFECT
    1) RATS - DMPD was not teratogenic when given orally at doses up to 150 mg/kg on days 6 through 15 to pregnant Sprague-Dawley rats in the absence of significant maternal toxicity (DiNardo et al, 1985).
    3.20.3) EFFECTS IN PREGNANCY
    A) LACK OF INFORMATION
    1) At the time of this review, no data were available to assess the potential effects of exposure to this agent during pregnancy or lactation.

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS99-98-9 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed
    3.21.2) SUMMARY/HUMAN
    A) At the time of this review, no data were available to assess the carcinogenic potential of this agent.
    3.21.4) ANIMAL STUDIES
    A) CARCINOMA
    1) N,N-DIMETHYL-p-AMINOAZOBENZENE, a parent azo-dye of DMPD, has been a potent liver carcinogen when given orally to rats (Sugiura et al, 1945; Miller & Baumann, 1945).
    B) LACK OF EFFECT
    1) LACK OF EFFECT
    a) DMPD was not carcinogenic when fed to rats for 147 to 515 days in a diet based on rice and carrots (Sugiura et al, 1945).
    b) DMPD (as the dihydrochloride salt) was not carcinogenic in an 8-month rat feeding study at 0.056 percent in a semi-synthetic diet (Miller & Baumann, 1945).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor methemoglobin, hemoglobin, and blood glucose.
    4.1.2) SERUM/BLOOD
    A) HEMATOLOGIC
    1) Hemoglobin, hematocrit, and other hematological parameters should be closely monitored along with methemoglobin levels in cases of significant exposure.
    B) BLOOD/SERUM CHEMISTRY
    1) Carefully monitor blood glucose in patients with significant exposure.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients symptomatic following exposure should be observed in a controlled setting until all signs and symptoms have fully resolved.

Monitoring

    A) Monitor methemoglobin, hemoglobin, and blood glucose.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    B) EMESIS/NOT RECOMMENDED
    1) EMESIS: Ipecac-induced emesis is not recommended because of the potential for CNS depression and seizures.
    C) ACTIVATED CHARCOAL
    1) PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION
    a) Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion. Administration in the prehospital setting has the potential to significantly decrease the time from toxin ingestion to activated charcoal administration, although it has not been shown to affect outcome (Alaspaa et al, 2005; Thakore & Murphy, 2002; Spiller & Rogers, 2002).
    1) In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should not be administered in the prehospital setting, due to the risk of aspiration in the event of spontaneous emesis.
    2) The addition of flavoring agents (cola drinks, chocolate milk, cherry syrup) to activated charcoal improves the palatability for children and may facilitate successful administration (Guenther Skokan et al, 2001; Dagnone et al, 2002).
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.2) PREVENTION OF ABSORPTION
    A) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    B) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.3) TREATMENT
    A) SUPPORT
    1) Treatment is symptomatic and supportive.
    B) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    C) SEIZURE
    1) SUMMARY
    a) Attempt initial control with a benzodiazepine (eg, diazepam, lorazepam). If seizures persist or recur, administer phenobarbital or propofol.
    b) Monitor for respiratory depression, hypotension, and dysrhythmias. Endotracheal intubation should be performed in patients with persistent seizures.
    c) Evaluate for hypoxia, electrolyte disturbances, and hypoglycemia (or, if immediate bedside glucose testing is not available, treat with intravenous dextrose).
    2) DIAZEPAM
    a) ADULT DOSE: Initially 5 to 10 mg IV, OR 0.15 mg/kg IV up to 10 mg per dose up to a rate of 5 mg/minute; may be repeated every 5 to 20 minutes as needed (Brophy et al, 2012; Prod Info diazepam IM, IV injection, 2008; Manno, 2003).
    b) PEDIATRIC DOSE: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed (Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008).
    c) Monitor for hypotension, respiratory depression, and the need for endotracheal intubation. Consider a second agent if seizures persist or recur after repeated doses of diazepam .
    3) NO INTRAVENOUS ACCESS
    a) DIAZEPAM may be given rectally or intramuscularly (Manno, 2003). RECTAL DOSE: CHILD: Greater than 12 years: 0.2 mg/kg; 6 to 11 years: 0.3 mg/kg; 2 to 5 years: 0.5 mg/kg (Brophy et al, 2012).
    b) MIDAZOLAM has been used intramuscularly and intranasally, particularly in children when intravenous access has not been established. ADULT DOSE: 0.2 mg/kg IM, up to a maximum dose of 10 mg (Brophy et al, 2012). PEDIATRIC DOSE: INTRAMUSCULAR: 0.2 mg/kg IM, up to a maximum dose of 7 mg (Chamberlain et al, 1997) OR 10 mg IM (weight greater than 40 kg); 5 mg IM (weight 13 to 40 kg); INTRANASAL: 0.2 to 0.5 mg/kg up to a maximum of 10 mg/dose (Loddenkemper & Goodkin, 2011; Brophy et al, 2012). BUCCAL midazolam, 10 mg, has been used in adolescents and older children (5-years-old or more) to control seizures when intravenous access was not established (Scott et al, 1999).
    4) LORAZEPAM
    a) MAXIMUM RATE: The rate of intravenous administration of lorazepam should not exceed 2 mg/min (Brophy et al, 2012; Prod Info lorazepam IM, IV injection, 2008).
    b) ADULT DOSE: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist (Manno, 2003; Brophy et al, 2012).
    c) PEDIATRIC DOSE: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue (Brophy et al, 2012; Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008; Sreenath et al, 2009; Chin et al, 2008).
    5) PHENOBARBITAL
    a) ADULT LOADING DOSE: 20 mg/kg IV at an infusion rate of 50 to 100 mg/minute IV. An additional 5 to 10 mg/kg dose may be given 10 minutes after loading infusion if seizures persist or recur (Brophy et al, 2012).
    b) Patients receiving high doses will require endotracheal intubation and may require vasopressor support (Brophy et al, 2012).
    c) PEDIATRIC LOADING DOSE: 20 mg/kg may be given as single or divided application (2 mg/kg/minute in children weighing less than 40 kg up to 100 mg/min in children weighing greater than 40 kg). A plasma concentration of about 20 mg/L will be achieved by this dose (Loddenkemper & Goodkin, 2011).
    d) REPEAT PEDIATRIC DOSE: Repeat doses of 5 to 20 mg/kg may be given every 15 to 20 minutes if seizures persist, with cardiorespiratory monitoring (Loddenkemper & Goodkin, 2011).
    e) MONITOR: For hypotension, respiratory depression, and the need for endotracheal intubation (Loddenkemper & Goodkin, 2011; Manno, 2003).
    f) SERUM CONCENTRATION MONITORING: Monitor serum concentrations over the next 12 to 24 hours. Therapeutic serum concentrations of phenobarbital range from 10 to 40 mcg/mL, although the optimal plasma concentration for some individuals may vary outside this range (Hvidberg & Dam, 1976; Choonara & Rane, 1990; AMA Department of Drugs, 1992).
    6) OTHER AGENTS
    a) If seizures persist after phenobarbital, propofol or pentobarbital infusion, or neuromuscular paralysis with general anesthesia (isoflurane) and continuous EEG monitoring should be considered (Manno, 2003). Other anticonvulsants can be considered (eg, valproate sodium, levetiracetam, lacosamide, topiramate) if seizures persist or recur; however, there is very little data regarding their use in toxin induced seizures, controlled trials are not available to define the optimal dosage ranges for these agents in status epilepticus (Brophy et al, 2012):
    1) VALPROATE SODIUM: ADULT DOSE: An initial dose of 20 to 40 mg/kg IV, at a rate of 3 to 6 mg/kg/minute; may give an additional dose of 20 mg/kg 10 minutes after loading infusion. PEDIATRIC DOSE: 1.5 to 3 mg/kg/minute (Brophy et al, 2012).
    2) LEVETIRACETAM: ADULT DOSE: 1000 to 3000 mg IV, at a rate of 2 to 5 mg/kg/min IV. PEDIATRIC DOSE: 20 to 60 mg/kg IV (Brophy et al, 2012; Loddenkemper & Goodkin, 2011).
    3) LACOSAMIDE: ADULT DOSE: 200 to 400 mg IV; 200 mg IV over 15 minutes (Brophy et al, 2012). PEDIATRIC DOSE: In one study, median starting doses of 1.3 mg/kg/day and maintenance doses of 4.7 mg/kg/day were used in children 8 years and older (Loddenkemper & Goodkin, 2011).
    4) TOPIRAMATE: ADULT DOSE: 200 to 400 mg nasogastric/orally OR 300 to 1600 mg/day orally divided in 2 to 4 times daily (Brophy et al, 2012).
    D) METHEMOGLOBINEMIA
    1) SUMMARY
    a) Determine the methemoglobin concentration and evaluate the patient for clinical effects of methemoglobinemia (ie, dyspnea, headache, fatigue, CNS depression, tachycardia, metabolic acidosis). Treat patients with symptomatic methemoglobinemia with methylene blue (this usually occurs at methemoglobin concentrations above 20% to 30%, but may occur at lower methemoglobin concentrations in patients with anemia, or underlying pulmonary or cardiovascular disorders). Administer oxygen while preparing for methylene blue therapy.
    2) METHYLENE BLUE
    a) INITIAL DOSE/ADULT OR CHILD: 1 mg/kg IV over 5 to 30 minutes; a repeat dose of up to 1 mg/kg may be given 1 hour after the first dose if methemoglobin levels remain greater than 30% or if signs and symptoms persist. NOTE: Methylene blue is available as follows: 50 mg/10 mL (5 mg/mL or 0.5% solution) single-dose ampules (Prod Info PROVAYBLUE(TM) intravenous injection, 2016) and 10 mg/1 mL (1% solution) vials (Prod Info methylene blue 1% intravenous injection, 2011). REPEAT DOSES: Additional doses may be required, especially for substances with prolonged absorption, slow elimination, or those that form metabolites that produce methemoglobin. NOTE: Large doses of methylene blue may cause methemoglobinemia or hemolysis (Howland, 2006). Improvement is usually noted shortly after administration if diagnosis is correct. Consider other diagnoses or treatment options if no improvement has been observed after several doses. If intravenous access cannot be established, methylene blue may also be given by intraosseous infusion. Methylene blue should not be given by subcutaneous or intrathecal injection (Prod Info methylene blue 1% intravenous injection, 2011; Herman et al, 1999). NEONATES: DOSE: 0.3 to 1 mg/kg (Hjelt et al, 1995).
    b) CONTRAINDICATIONS: G-6-PD deficiency (methylene blue may cause hemolysis), known hypersensitivity to methylene blue, methemoglobin reductase deficiency (Shepherd & Keyes, 2004)
    c) FAILURE: Failure of methylene blue therapy suggests: inadequate dose of methylene blue, inadequate decontamination, NADPH dependent methemoglobin reductase deficiency, hemoglobin M disease, sulfhemoglobinemia, or G-6-PD deficiency. Methylene blue is reduced by methemoglobin reductase and nicotinamide adenosine dinucleotide phosphate (NADPH) to leukomethylene blue. This in turn reduces methemoglobin. Red blood cells of patients with G-6-PD deficiency do not produce enough NADPH to convert methylene blue to leukomethylene blue (do Nascimento et al, 2008).
    d) DRUG INTERACTION: Concomitant use of methylene blue with serotonergic drugs, including serotonin reuptake inhibitors (SRIs), selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants (TCAs), norepinephrine-dopamine reuptake inhibitors (NDRIs), triptans, and ergot alkaloids may increase the risk of potentially fatal serotonin syndrome (U.S. Food and Drug Administration, 2011; Stanford et al, 2010; Prod Info methylene blue 1% IV injection, 2011).
    3) TOLUIDINE BLUE OR TOLONIUM CHLORIDE (GERMANY)
    a) DOSE: 2 to 4 mg/kg intravenously over 5 minutes. Dose may be repeated in 30 minutes (Nemec, 2011; Lindenmann et al, 2006; Kiese et al, 1972).
    b) SIDE EFFECTS: Hypotension with rapid intravenous administration. Vomiting, diarrhea, excessive sweating, hypotension, dysrhythmias, hemolysis, agranulocytosis and acute renal insufficiency after overdose (Dunipace et al, 1992; Hix & Wilson, 1987; Winek et al, 1969; Teunis et al, 1970; Marquez & Todd, 1959).
    c) CONTRAINDICATIONS: G-6-PD deficiency; may cause hemolysis.
    E) IRRITATION SYMPTOM
    1) Observe patients with ingestion carefully for the possible development of esophageal or gastrointestinal tract irritation or burns. If signs or symptoms of esophageal irritation or burns are present, consider endoscopy to determine the extent of injury.
    F) HYPERGLYCEMIA
    1) If significant hyperglycemia occurs, careful blood glucose monitoring and insulin therapy might be required.
    G) MONITORING OF PATIENT
    1) Carefully observe patients with ingestion exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.

Inhalation Exposure

    6.7.1) DECONTAMINATION
    A) Move patient from the toxic environment to fresh air. Monitor for respiratory distress. If cough or difficulty in breathing develops, evaluate for hypoxia, respiratory tract irritation, bronchitis, or pneumonitis.
    B) OBSERVATION: Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
    C) INITIAL TREATMENT: Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta-2 adrenergic agonists, if bronchospasm develops. Consider systemic corticosteroids in patients with significant bronchospasm (National Heart,Lung,and Blood Institute, 2007). Exposed skin and eyes should be flushed with copious amounts of water.
    6.7.2) TREATMENT
    A) OBSERVATION REGIMES
    1) Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Eye Exposure

    6.8.1) DECONTAMINATION
    A) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).
    6.8.2) TREATMENT
    A) CONSULTATION
    1) This agent may have potentially significant ocular toxicity.
    2) If ocular toxicity is found or suspected, early ophthalmologic consultation is advisable.
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) DECONTAMINATION: Remove contaminated clothing and wash exposed area thoroughly with soap and water for 10 to 15 minutes. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).
    6.9.2) TREATMENT
    A) IRRITATION SYMPTOM
    1) Treat dermal irritation or burns with standard topical therapy. Patients developing dermal hypersensitivity reactions may require treatment with systemic or topical corticosteroids or antihistamines.
    B) SKIN ABSORPTION
    1) Some chemicals can produce systemic poisoning by absorption through intact skin. Carefully observe patients with dermal exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
    C) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Enhanced Elimination

    A) LACK OF INFORMATION
    1) No studies have addressed the utilization of extracorporeal elimination techniques in poisoning with this agent.

Range Of Toxicity

Summary

    A) There is little specific, peer reviewed information regarding the range of toxicity for DMPD. The decision to treat should be based on clinical judgement, and should not be based on range of toxicity estimates.
    1) Ingestion of 1 teaspoonful to 1 ounce, or dermal exposure to 1 teaspoonful of DMPD, has been estimated as fatal to adult humans. Inhalation of very high concentrations of DMPD vapors has been fatal to experimental animals. There are no known estimates of the concentration of DMPD which would be lethal to a human following inhalation.

Minimum Lethal Exposure

    A) ROUTE OF EXPOSURE
    1) MINIMUM LETHAL EXPOSURE -
    a) ORAL -
    1) Phenylenediamines (o- or p-), chemicals related to DMPD, have been rated as very toxic following ingestion. Lethality for these chemicals has been estimated to occur following ingestion of 50 to 500 mg/k, or between 1 teaspoon to 1 ounce in an adult (Gosselin et al, 1984). Specific data on which these estimates were based have not been reviewed. These estimates may not be accurate.
    2) The lowest published lethal doses in various species of experimental animal species by the oral or parenteral routes ranged from 20 to 150 mg/kg (RTECS , 2001).
    b) DERMAL -
    1) Dermal exposure to 1 teaspoonful or about 3.6 cc for 25 square centimeters of skin has been estimated to produce lethality in a human adult. This estimate is extrapolated from studies involving rabbits (Hanzlik, 1922).
    2) The lowest published lethal dose by the dermal route in the rabbit is 60 mg/kg (RTECS , 2001).
    c) INHALATION -
    1) No toxicity values were found for this route of exposure. Inhalation of of high concentrations of DMPD vapors has produced toxicity and death in experimental animals.
    2) The lowest published lethal concentrations by the inhalation route in guinea pigs and rabbits were 240 to 500 ppb (RTECS , 2001).

Maximum Tolerated Exposure

    A) ROUTE OF EXPOSURE
    1) Vesication occurred in a small number of human subjects following dermal exposure to DMPD concentrations of > 0.001 cc (MAXIMUM DOSE of 0.005) per square centimeter of skin. Primary skin irritation, allergic dermatitis, and delayed skin hemorrhage were produced in a small number of humans following dermal exposure to 0.001 cc per square centimeter of skin. Systemic effects were not reported (Hanzlik, 1922).
    2) This report dates from 1922 and has not been confirmed in larger studies.

Workplace Standards

    A) ACGIH TLV Values for CAS99-98-9 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    B) NIOSH REL and IDLH Values for CAS99-98-9 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    C) Carcinogenicity Ratings for CAS99-98-9 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    D) OSHA PEL Values for CAS99-98-9 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) References: RTECS, 2001

Pharmacology Toxicology

Toxicologic Mechanism

    A) DMPD is a potent inhibitor of the diphosphopyridine nucleotide-dependent fermentation of glucose in yeast, producing 100 percent inhibition at 10(-4) Molar (Kensler et al, 1942).
    1) The toxicity of DMPD in inhibiting fermentation may be related to the fact that its semiquinone free-radical is very stable (Kensler et al, 1942).
    2) The inhibition of glucose fermentation was partially prevented by the addition of strong reducing agents such as CYSTEINE, GLUTATHIONE, and ASCORBIC ACID (Kensler et al, 1942).
    a) DMPD can condense with cysteine in the presence of ferric ion and zinc chloride, a result suggesting that it can react with sulfhydryl groups of enzymes in vivo (Vassel, 1941; Kensler et al, 1942).
    3) The inhibition of glucose fermentation was almost completely overcome by addition of large amounts of DPN (diphosphopyridine nucleotide) (Kensler et al, 1942).
    a) It would appear that DMPD competes with DPN for active dehydrogenase centers (Kensler et al, 1942).
    4) The N-acetyl derivative of DMPD did not inhibit fermentation and would appear to be a product of a detoxification pathway in rats (Kensler et al, 1942).

Physicochemical

Physical Characteristics

    A) DMPD is a colorless to reddish-violet solid or crystals or asbestos-like needles which may be liquified if impure (EPA, 1985; Sax & Lewis, 1989; Sax & Lewis, 1987).

Molecular Weight

    A) 136.22 (EPA, 1985)

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