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ETHYLENE GLYCOL BUTYL ETHER

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Ethylene glycol butyl ether (EGBE) is a solvent used in a variety of applications. Monoalkyl ethers are rapidly metabolized via alcohol and aldehyde dehydrogenases to their respective alkoxyacetic acids. These metabolites appear to be the primary toxic agents. EGBE is easily absorbed through the gastrointestinal, pulmonary and dermal routes.

Specific Substances

    1) 0-butyl ethylene glycol
    2) 2BE
    3) 2-Butoxyethanol
    4) 3-Oxa-1-heptanol
    5) Beta-Butoxyethanol
    6) Beta-Hydroxybutyl ether
    7) BUCS Butyl cellosolve
    8) Butyl cellu-sol
    9) Butyl glycol
    10) Butyl oxitol
    11) Chimec NR
    12) Dowanol EB
    13) EGBE
    14) Ethylene glycol Monobutyl ether
    15) Ethylene Glycol N-Butyl Ether
    16) Glycol butyl ether
    17) Glycol monobutyl ether
    18) Monobutyl glyco ether
    19) Monobutyl ethylene glycol ether
    20) Poly-Solv EB
    21) CAS 111-76-2
    22) BUTOKSYETLOWY ALKOHOL (POLISH)
    1.2.1) MOLECULAR FORMULA
    1) C6-H14-O2

Available Forms Sources

    A) FORMS
    1) Ethylene glycol monobutyl ether is a mobile colorless liquid with a mild ethereal odor (CHRIS , 1991).
    B) USES
    1) Ethylene glycol monobutyl ether is used in cleaners and surface coatings, as a solvent in household cleaners and aerosols, and as a chemical intermediate (HSDB , 2000).
    2) Ethylene glycol monobutyl ether is also found in agricultural chemicals and nonvolatile herbicides (HSDB , 2000).
    3) Ethylene glycol monobutyl ether is used as a solvent for paints, printing inks, dyestuffs, and dry cleaning; agricultural chemicals; nonvolatile herbicides; brake oils; detergents for automobile industry; penetrants and softeners (ITI, 1988).
    4) Ethylene glycol monobutyl ether is used as a solvent for nitrocellulose, resins, albumen (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) USES: Ethylene glycol butyl ether (EGBE) is a glycol ether. They are used and found in many solvent mixtures. These solvents are commonly used as cleaning products, automotive fluids, lacquers, varnish removers, and dyeing and printing textiles.
    B) TOXICOLOGY: Toxic effects are likely due to both the parent compound and metabolites, but the mechanisms of toxicity are unknown.
    C) EPIDEMIOLOGY: It is a common unintentional exposure in children and adults, and usually does not cause toxicity. Life-threatening effects are rare, but have been reported following large, deliberate ingestion.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Most inadvertent ingestions of household products containing EGBE are asymptomatic.
    2) SEVERE TOXICITY: In large and intentional exposures, central nervous system depression, metabolic acidosis, renal injury, hypotension, seizures, acute lung injury, mild elevations in liver enzymes, hemolytic anemia, and disseminated intravascular coagulation have been reported.
    0.2.3) VITAL SIGNS
    A) WITH POISONING/EXPOSURE
    1) Hyperventilation has been reported following acute exposure.
    0.2.13) HEMATOLOGIC
    A) Hemolytic anemia, non-hemolytic anemia, thrombocytopenia, and DIC have been reported in overdose. Erythropenia, reticulocytosis, granulocytosis, and leukocytosis may occur. More intense exposure is likely to cause fragility of erythrocytes and hematuria.
    0.2.20) REPRODUCTIVE
    A) Fetal toxicity has only been observed in animals at maternally toxic doses.
    0.2.21) CARCINOGENICITY
    A) No studies were found on the possible carcinogenicity of EGBE at the time of this review.

Laboratory Monitoring

    A) Asymptomatic patients who inadvertently ingest small amounts of household products (10% EGBE or less) do not require testing.
    B) Monitor vital signs and mental status.
    C) In significant ingestions, monitor CBC, serum electrolytes, liver enzymes, renal function, urinalysis, and urine output.
    D) Serum ethanol, methanol, and ethylene glycol concentrations are theoretically useful in assessing concurrent ingestions.
    E) Monitor arterial blood gases for worsening metabolic acidosis.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Treatment is symptomatic and supportive.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Treatment is symptomatic and supportive. Fluid resuscitation and hemodialysis may be needed for severe acid-base abnormality. Treat severe acidosis (pH less than 7.1) with intravenous sodium bicarbonate. Begin with 1 to 2 mEq/kg in adults and 1 mEq/kg in children, repeat every 1 to 2 hours as required. Treat severe hypotension with IV 0.9% NaCl at 10 to 20 mL/kg. Add dopamine or norepinephrine if unresponsive to fluids. Alcohol dehydrogenase inhibition with ethanol or fomepizole has been used, however, its effectiveness is unclear. There are reports of progression of acidosis following fomepizole treatment. Hemodialysis for severe and persistent symptoms has shown to improve clinical and metabolic status.
    C) DECONTAMINATION
    1) PREHOSPITAL: Gastrointestinal decontamination is not indicated due to rapid absorption and the risk of CNS depression after large ingestion. Irrigate exposed eyes after ocular exposure. Remove contaminated clothing and wash exposed skin. Remove patients with inhalational exposure to fresh air. Administer oxygen if respiratory irritation develops.
    2) HOSPITAL: Irrigate exposed eyes after ocular exposure. Remove contaminated clothing and wash exposed skin. In patients with inhalational exposure, administer oxygen if respiratory irritation develops. ACTIVATED CHARCOAL: Given the potential for CNS depression placing the patient at increased risk of aspiration, activated charcoal is not recommended unless the airway is protected via endotracheal intubation.
    D) AIRWAY MANAGEMENT
    1) Orotracheal intubation and mechanical ventilation may be required if significant CNS depression occurs.
    E) ANTIDOTE
    1) There is no specific antidote for the treatment of EGBE exposure. Although ethanol and fomepizole are not approved for use in EGBE poisoning, they may be effective in preventing formation of the acid metabolites and lessening toxicity. They should be considered for large ingestions in patients developing metabolic acidosis or renal insufficiency. ETHANOL VS FOMEPIZOLE: Fomepizole is easier to use clinically, requires less monitoring, and does not cause CNS depression or hypoglycemia. Ethanol requires continuous administration and frequent monitoring of serum ethanol and glucose levels, and may cause CNS depression and hypoglycemia (especially in children). The drug cost associated with ethanol use is generally much lower than with fomepizole; however, other costs associated with ethanol use (continuous intravenous infusion, hourly blood draws and ethanol levels, possibly greater use of hemodialysis) may make the costs more comparable.
    a) ETHANOL: Ethanol is given to maintain a serum ethanol concentration of 100 to 150 mg/dL. This can be accomplished by using a 5% to 10% ethanol solution administered IV through a central line. Intravenous therapy dosing, which is preferred, is 0.8 g/kg as a loading dose (8 mL/kg of 10% ethanol) administered over 20 to 60 minutes as tolerated, followed by an infusion rate of 80 to 150 mg/kg/hr (for 10% ethanol, 0.8 to 1.3 mL/kg/hr for a nondrinker; 1.5 mL/kg/hr for a chronic alcoholic). During hemodialysis, either add ethanol to the dialysate to achieve 100 mg/dL concentration or increase the rate of infusion during dialysis (for 10% ethanol, 2.5 to 3.5 mL/kg/hr). Blood ethanol concentrations must be monitored hourly and the infusion adjusted accordingly.
    b) FOMEPIZOLE: Fomepizole is administered as a 15 mg/kg loading dose, followed by four bolus doses of 10 mg/kg every 12 hours. If therapy is needed beyond this 48 hour period, the dose is then increased to 15 mg/kg every 12 hours for as long as necessary. Fomepizole is also effectively removed by hemodialysis; therefore, doses should be repeated following each round of hemodialysis.
    F) ENHANCED ELIMINATION
    1) Hemodialysis is indicated for severe acid-base and/or fluid-electrolyte abnormalities despite conventional therapy, or renal failure. However, in a case of severe toxicity following a large ingestion of a product containing EGBE, hemodialysis did not significantly enhance elimination of butoxyacetic acid, the toxic active metabolite.
    G) PATIENT DISPOSITION
    1) HOME CRITERIA: Asymptomatic patients with unintentional ingestions of a sip or taste or household products (up to 10% EGBE) can be managed at home. Asymptomatic patients with brief inhalational exposures may be observed at home.
    2) OBSERVATION CRITERIA: All symptomatic patients, or those with large or intentional ingestions should be referred to a healthcare facility.
    3) ADMISSION CRITERIA: Patients with mental status changes, metabolic acidosis, renal or hepatic injury, hemolysis, hypotension or pulmonary toxicity need to be admitted.
    4) CONSULT CRITERIA: Consult a medical toxicologist or Poison Center for assistance in managing patients with large ingestions, significant toxicity or in whom diagnosis is unclear.
    H) PITFALLS
    1) Failure to recognize co-ingestions, or ingestion of another toxic alcohol. Failure to recognize progression and worsening of symptoms.
    I) TOXICOKINETICS
    1) EGBE is rapidly absorbed orally, and can be absorbed vial prolonged dermal and inhalational exposures. Distribution is rapid and extensive. It is primarily metabolized by alcohol and aldehyde dehydrogenase to butoxyaldehyde and glycine conjugate and mainly excreted in the urine as metabolites.
    J) DIFFERENTIAL DIAGNOSIS
    1) Mostly other toxic alcohols or glycols: methanol, ethylene glycol, diethylene glycol, isopropanol, ethanol, and other glycol ethers.

Range Of Toxicity

    A) TOXICITY: Severe toxicity has been described in adults who ingested 30 to 63.5 mL of pure EGBE. Children ingesting small amounts (less than 10 mL) of dilute household products (less than 10% ethylene glycol butyl ether) generally do not develop evidence of poisoning. The threshold limit value weighted average for an 8 hour shift (TLV-TWA) is 20 ppm, 700 ppm is considered immediately dangerous to life and health.

Clinical Effects

Summary Of Exposure

    A) USES: Ethylene glycol butyl ether (EGBE) is a glycol ether. They are used and found in many solvent mixtures. These solvents are commonly used as cleaning products, automotive fluids, lacquers, varnish removers, and dyeing and printing textiles.
    B) TOXICOLOGY: Toxic effects are likely due to both the parent compound and metabolites, but the mechanisms of toxicity are unknown.
    C) EPIDEMIOLOGY: It is a common unintentional exposure in children and adults, and usually does not cause toxicity. Life-threatening effects are rare, but have been reported following large, deliberate ingestion.
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Most inadvertent ingestions of household products containing EGBE are asymptomatic.
    2) SEVERE TOXICITY: In large and intentional exposures, central nervous system depression, metabolic acidosis, renal injury, hypotension, seizures, acute lung injury, mild elevations in liver enzymes, hemolytic anemia, and disseminated intravascular coagulation have been reported.

Vital Signs

    3.3.1) SUMMARY
    A) WITH POISONING/EXPOSURE
    1) Hyperventilation has been reported following acute exposure.
    3.3.2) RESPIRATIONS
    A) CASE REPORT: HYPERVENTILATION has been reported in a case of ingestion of one liter of window cleaner over a 3 day period (Felgenhauer et al, 1993).

Heent

    3.4.3) EYES
    A) CONJUNCTIVITIS: Drops applied to rabbit eyes have produced redness, conjunctivitis, and slight corneal clouding, with complete recovery in 4 days (Grant & Schuman, 1993). Exposure to vapors has caused mild eye irritation (Carpenter et al, 1956).
    3.4.5) NOSE
    A) IRRITATION: Nasal irritation has been noted during industrial exposures to vapors (Carpenter et al, 1956).

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) HYPOTENSIVE EPISODE
    1) Large ingestions have been reported to result in severe systolic hypotension requiring vasoactive amines and intravenous fluids (Burkhart & Donovan, 1998; McKinney et al, 2000; Gijsenbergh et al, 1989; Bauer et al, 1992).
    2) CASE REPORT: Severe hypotension, requiring dopamine infusion for 7 hours, was reported after oral ingestion in a 23-year-old woman (Gijsenbergh et al, 1989).
    3) CASE REPORT: Hypotension developed in a 53-year-old man who ingested 500 mL of a solution containing 9.1% ethylene glycol butyl ether and 2.5% ethanol (Bauer et al, 1992).
    B) CONDUCTION DISORDER OF THE HEART
    1) CASE REPORT: Ventricular tachycardia and hypotension were reported complications prior to death from cardiac arrest in an 87-year-old woman who ingested an unknown amount of 6.5% EGBE (Litovitz et al, 1990).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) ACUTE LUNG INJURY
    1) CASE REPORT: ARDS developed in a 53-year-old man after ingestion of 500 milliliters of a solution containing 9.1% ethylene glycol butyl ether (45.5 mL of EGBE); he recovered after initiation of PEEP and supportive care (Bauer et al, 1992).
    B) TOXIC EFFECT OF GAS, FUMES AND/OR VAPORS
    1) ABSORPTION: Pulmonary absorption occurs (Johanson & Boman, 1991).
    C) SUFFOCATING
    1) Aspiration may occur following large ingestions (Burkhart & Donovan, 1998).
    3.6.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) PULMONARY HEMORRHAGE
    a) Repeated exposure in animals caused pulmonary hemorrhage (Carpenter et al, 1956).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) COMA
    1) CNS depression, from lethargy to coma, may commonly occur following significant ingestions (Burkhart & Donovan, 1998; McKinney et al, 2000).
    2) CASE REPORTS
    a) ADULT
    1) An 18-year-old man ingested 360 to 480 mL of a glass cleaner containing 22% EGBE, and became lethargic and weak approximately 10 hours after exposure (Gualtieri et al, 2003).
    2) An 87-year-old woman was found in coma following ingestion of an unknown amount of disinfectant cleaner containing 6.5% EGBE (Litovitz et al, 1990).
    3) A 53-year-old man became comatose approximately 10 hours after ingestion of 500 mL of a household cleaner containing 9.1% EGBE (Bauer et al, 1992).
    4) A 50-year-old woman presented in coma 12 hours after ingestion of 250 to 500 mL of 12% EGBE (Rambourg-Schepens et al, 1988), and another woman developed coma in 4 hours (onset one hour) after ingestions of 500 mL of 12.7% EGBE (Gijsenbergh et al, 1989).
    B) SEIZURE
    1) Burkhart & Donovan (1998) reported tonic-clonic seizures in an adult following the ingestion of 20 to 30 ounces of a product containing EGBE 25% to 35%, propylene glycol 15% to 25%, and monoethanolamine 5% to 10%. Seizures were controlled with lorazepam and phenytoin (Burkhart & Donovan, 1998).

Hepatic

    3.9.2) CLINICAL EFFECTS
    A) LIVER DAMAGE
    1) CASE REPORT: Mild elevations in liver function tests were reported in one massive overdose by a chronic alcoholic (Bauer et al, 1992).
    2) CASE REPORT: Mild elevations in liver function tests developed in an 18-year-old man after ingestion of 360 to 480 milliliters of a glass cleaner containing 22% EGBE (Gualtieri et al, 2003).
    3.9.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) HEPATOCELLULAR DAMAGE
    a) Repeated exposure in animals caused liver injury, presumably secondary to hemolytic effects (Ghanayem et al, 1987).

Genitourinary

    3.10.2) CLINICAL EFFECTS
    A) ABNORMAL RENAL FUNCTION
    1) Animal studies suggest that EGBE may have somewhat more renal toxicity than other glycol ethers.
    B) HEMOLYSIS
    1) CASE REPORT: Hemoglobinuria was described 3 days after overdose in a 50-year-old woman (Rambourg-Schepens et al, 1988), and 2 days after overdose in a 23-year-old woman. The occurrence of this effect coincided with peak urinary butoxyacetic acid levels (Gijsenbergh et al, 1989).
    2) CASE REPORT: Although urinalysis indicated hematuria and the presence of proteins and ketones, no evidence of permanent renal injury developed in an 18-year-old man following an ingestion of EGBE (360 to 480 mL of a 22% solution) on two separate occasions. He was treated with ethanol and hemodialysis (Gualtieri et al, 2003).
    C) CRYSTALLURIA
    1) OXALURIA: Urinary excretion of oxalate crystals has been reported after oral ingestion (Rambourg-Schepens et al, 1988), but was absent in a similar case (Gijsenbergh et al, 1989).
    D) RENAL FAILURE SYNDROME
    1) CASE REPORT: Renal failure was reported in an elderly woman who ingested an unknown amount of 6.5% EGBE (Litovitz et al, 1990).
    E) ABNORMAL URINE
    1) B-MICROGLOBINURIA has been reported following ingestions.
    a) CASE REPORT: A one liter ingestion of window cleaner in a 27-year-old female reportedly increased B-microglobulin level to 5662 mcg/24 hours (Felgenhauer et al, 1993).
    F) ALBUMINURIA
    1) CASE REPORT: Slight albuminuria developed in a 53-year-old man after ingestion of 500 mL of a 9.1% solution of EGBE (Bauer et al, 1992).

Acid-Base

    3.11.2) CLINICAL EFFECTS
    A) ACIDOSIS
    1) Metabolic acidosis has been described after large ingestions (250 to 500 milliliters of solutions containing 6.5% to 22% EGBE) (Rambourg-Schepens et al, 1988; Gijsenbergh et al, 1989; Litovitz et al, 1990; Bauer et al, 1992; Gualtieri et al, 2003; McKinney et al, 2000).
    2) CASE REPORT - McKinney et al (2000) described a case of rapid onset and persistent hyperchloremic metabolic acidosis, hypotension, and CNS depression following a massive ingestion of EGBE, treated with ethanol therapy (no dialysis) for 48 hours. The patient recovered with no apparent sequelae. The authors suggested that acidosis may not be a reliable indicator for the use of hemodialysis (McKinney et al, 2000).
    B) OSMOLALITY DISTURBANCE
    1) Plasma osmolality increases in a linear fashion with increasing concentrations of EGBE. The increase in osmolality is so small that it is not expected to be clinically useful, even with toxic ingestions. A plasma EGBE level of greater than 10 mmol/liter would be expected to yield an osmolal gap of 12 msom/kg (Browning & Curry, 1992).

Hematologic

    3.13.1) SUMMARY
    A) Hemolytic anemia, non-hemolytic anemia, thrombocytopenia, and DIC have been reported in overdose. Erythropenia, reticulocytosis, granulocytosis, and leukocytosis may occur. More intense exposure is likely to cause fragility of erythrocytes and hematuria.
    3.13.2) CLINICAL EFFECTS
    A) HEMOLYTIC ANEMIA
    1) Hemolytic anemia has been observed in animals (Carpenter et al, 1956; Ghanayem et al, 1987) 1989, 1990), and in two reported human overdoses (Rambourg-Schepens et al, 1988; Gijsenbergh et al, 1989).
    2) In vitro studies have shown that human erythrocytes are comparatively insensitive to the hemolytic effects of butoxyacetic acid, a metabolite of butyl ethers, given at concentrations several-fold higher than required to cause hemolysis of rat erythrocytes (Ghanayem, 1989; Ghanayem & Sullivan, 1993).
    B) DISSEMINATED INTRAVASCULAR COAGULATION
    1) Disseminated intravascular coagulation (DIC) may occur following large ingestions (Burkhart & Donovan, 1998; Litovitz et al, 1990).
    2) CASE REPORT: DIC was a reported complication in a fatality due to EGBE ingestion (Litovitz et al, 1990).
    3) CASE REPORT: DIC was evident in a 19-year-old male following a large ingestion of a product containing EGBE. Laboratory values included PT greater than 60 sec, PTT greater than 120 sec, fibrinogen 112 mg/dL, and positive D-dimer (Burkhart & Donovan, 1998).
    C) ANEMIA
    1) CASE REPORT: Thrombocytopenia and non-hemolytic hypochromic anemia and mild prolongation of PT (15.5 seconds) were noted in one case of massive overdose (Bauer et al, 1992).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) SYSTEMIC DISEASE
    1) ABSORPTION: EGBE is not significantly irritating to the skin but absorbed through the skin in toxic amounts (Clayton & Clayton, 1981; Johanson & Boman, 1991)
    B) DISORDER OF SKIN
    1) VISIBLE CHANGES: Fingers exposed to EGBE for 2 hours showed decrease in finger volume and skin fold thickness with a wrinkled and less elastic skin appearance (Johanson & Ferstrom, 1988).

Reproductive

    3.20.1) SUMMARY
    A) Fetal toxicity has only been observed in animals at maternally toxic doses.
    3.20.2) TERATOGENICITY
    A) ANIMAL STUDIES
    1) EGBE was embryo- and fetotoxic in an inhalation study with pregnant rats at 100 and 200 ppm; however, there was also maternal toxicity. In the same report 200 ppm produced embryotoxicity in the presence of maternal toxicity in rabbits but EGBE was not fetotoxic (Tyl et al, 1984).
    2) In another study, no congenital defects were found in rats from maternal exposure at 200 ppm (Nelson, 1984). When applied to the shaved skin of pregnant rats, EGBE was not embryotoxic, fetotoxic, or teratogenic (Hardin, 1984).
    3) Shorter alkyl glycol ethers have produced greater embryotoxicity than those having longer chains in vapor exposure studies in rats (Nelson, 1984).
    4) No embryonic or teratogenic effects were seen after exposure to pregnant rats at maternally nontoxic doses (NIOSH, 1983).
    5) Subsequent reports showed that exposure of pregnant rats at 100 ppm or rabbits at 200 ppm during organogenesis resulted in maternal toxicity and embryotoxicity, including decreased number of viable implantations per litter. Poorly ossified or unossified skeletal elements were also observed in rats (Chemical Manufacturers Association, 1985).

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS111-76-2 (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) IARC Classification
    a) Listed as: 2-Butoxyethanol
    b) Carcinogen Rating: 3
    1) The agent (mixture or exposure circumstance) is not classifiable as to its carcinogenicity to humans. This category is used most commonly for agents, mixtures and exposure circumstances for which the evidence of carcinogenicity is inadequate in humans and inadequate or limited in experimental animals. Exceptionally, agents (mixtures) for which the evidence of carcinogenicity is inadequate in humans but sufficient in experimental animals may be placed in this category when there is strong evidence that the mechanism of carcinogenicity in experimental animals does not operate in humans. Agents, mixtures and exposure circumstances that do not fall into any other group are also placed in this category.
    3.21.2) SUMMARY/HUMAN
    A) No studies were found on the possible carcinogenicity of EGBE at the time of this review.
    3.21.4) ANIMAL STUDIES
    A) ADRENAL GLAND
    1) RATS - A slight increase in pheochromocytomas (most were benign with one malignant tumor) of the adrenal gland have been reported in female rats at the highest concentration (125 ppm {604 mg/m(3) }). This was higher than previously observed in historical control information maintained by NTP. A non-statistically significant increase in hyperplasia was also reported in females (Hughes et al, 2001 ).
    a) Based on these findings the NTP concluded that there was no evidence that EGBE was carcinogenic in male rats, and equivocal evidence of carcinogenic potential in females.
    2) MICE - In studies conducted in mice, an increase in the incidence of hemangiosarcomas of the liver in males (significant at 250 ppm {1208 mg/m(3)}) was reported, as well as, a higher incidence of hyperplasia of the epithelium of the forestomach in females. Severity of hyperplasia was directly affected by an increased exposure to EGBE. These findings indicated that both male and female B6C3F(1) mice exposed to EGBE showed evidence of carcinogenic activity (Hughes et al, 2001 ).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Asymptomatic patients who inadvertently ingest small amounts of household products (10% EGBE or less) do not require testing.
    B) Monitor vital signs and mental status.
    C) In significant ingestions, monitor CBC, serum electrolytes, liver enzymes, renal function, urinalysis, and urine output.
    D) Serum ethanol, methanol, and ethylene glycol concentrations are theoretically useful in assessing concurrent ingestions.
    E) Monitor arterial blood gases for worsening metabolic acidosis.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) In significant ingestions, monitor CBC, serum electrolytes, liver enzymes, renal function, urinalysis, and urine output.
    2) Serum ethanol, methanol, and ethylene glycol concentrations are theoretically useful in assessing concurrent ingestions.
    3) SERUM OSMOLALITY: Unlike ethylene glycol (EG), which produces a linear increase in serum osmolality with increasing EG serum concentrations, the butyl ether did NOT affect osmolality measurements in an in vitro study (Lund et al, 1983).
    a) Another study demonstrated that plasma osmolality increased in a linear fashion with increasing concentrations of EGBE (Browning & Curry, 1992). The increase in osmolality was so small that it is not expected to be clinically useful, even with toxic ingestions. A plasma EGBE level of greater than 10 mmol/liter would be expected to yield an osmolal gap of 12 msom/kilogram.
    B) ACID/BASE
    1) Monitor arterial blood gases for worsening metabolic acidosis.
    4.1.3) URINE
    A) URINALYSIS
    1) Obtain urinalysis (look for oxalate crystals and hemoglobin).

Methods

    A) CHROMATOGRAPHY
    1) Gas chromatography using pentafluorobenzylbromide has been employed to monitor urine and blood samples for EGBE and its metabolites, among which is butoxyacetic acid, BAA (Smallwood et al, 1984; Groeseneken et al, 1989).
    2) Gas chromatography using pentafluorobenzyl chloride with electron dense capture has been recommended as a more sensitive method for analyzing biologic specimens. However, it does not detect butoxyacetic acid in blood and it requires several urine samples from an individual for more accurate information (Johanson et al, 1986).
    3) BUTOXYACETIC ACID (BAA): A sensitive method for detecting BAA, an active metbaolite of ethylene glycol butyl ether, has been developed and is based on ion-pair extraction combined with derivatization with pentafluorobenzyl chloride followed by capillary gas chromatography with electron capture detection (GC-ECD) (Johanson, 1993).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) Patients with mental status changes, metabolic acidosis, renal or hepatic injury, hemolysis, hypotension or pulmonary toxicity need to be admitted.
    6.3.1.2) HOME CRITERIA/ORAL
    A) Asymptomatic patients with unintentional ingestions of a sip or taste or household products (up to 10% EGBE) can be managed at home. Asymptomatic patients with brief inhalational exposures may be observed at home.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a medical toxicologist or Poison Center for assistance in managing patients with large ingestions, significant toxicity or in whom diagnosis is unclear.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) All symptomatic patients, or those with large or intentional ingestions should be referred to a healthcare facility.
    B) Immediate supportive measures should be given since massive toxic ingestions cause CNS depression, respiratory paralysis, hypotension, and metabolic acidosis in the first few hours postingestion.
    C) Close monitoring for renal toxicity and possible hemolysis are mandatory in the subsequent days until recovery is achieved, on the average, by the second week postingestion.
    D) Home observation and simple dilution is appropriate for pediatric ingestions of less than 10 mL of glass cleaners containing less than 10% ethylene glycol butyl ether (Dean & Krenzelok, 1992).
    6.3.3) DISPOSITION/INHALATION EXPOSURE
    6.3.3.1) ADMISSION CRITERIA/INHALATION
    A) Although the vapors are known to produce slight and temporary irritation of the respiratory system at high concentrations (CHRIS , 1990), admission should be recommended for examination and monitoring because of the hazard posed by skin absorption enhanced by the low vapor pressure at room temperature (Clayton & Clayton, 1981)
    1) Narcosis and kidney and liver damage have been reported together with respiratory and eye irritation following exposure of humans to 300 to 600 ppm (Clayton & Clayton, 1981).

Monitoring

    A) Asymptomatic patients who inadvertently ingest small amounts of household products (10% EGBE or less) do not require testing.
    B) Monitor vital signs and mental status.
    C) In significant ingestions, monitor CBC, serum electrolytes, liver enzymes, renal function, urinalysis, and urine output.
    D) Serum ethanol, methanol, and ethylene glycol concentrations are theoretically useful in assessing concurrent ingestions.
    E) Monitor arterial blood gases for worsening metabolic acidosis.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) PREHOSPITAL: Gastrointestinal decontamination is not indicated due to rapid absorption and the risk of CNS depression after large ingestion. Irrigate exposed eyes after ocular exposure. Remove contaminated clothing and wash exposed skin. Remove patients with inhalational exposure to fresh air. Administer oxygen if respiratory irritation develops.
    6.5.2) PREVENTION OF ABSORPTION
    A) ACTIVATED CHARCOAL
    1) Given the potential for CNS depression placing the patient at increased risk of aspiration, activated charcoal is not recommended unless the airway is protected via endotracheal intubation.
    6.5.3) TREATMENT
    A) MONITORING OF PATIENT
    1) Asymptomatic patients who inadvertently ingest small amounts of household products (10% EGBE or less) do not require testing.
    2) Monitor vital signs and mental status.
    3) In significant ingestions, monitor CBC, serum electrolytes, liver enzymes, renal function, urinalysis, and urine output.
    4) Serum ethanol, methanol, and ethylene glycol concentrations are theoretically useful in assessing concurrent ingestions.
    5) Monitor arterial blood gases for worsening metabolic acidosis.
    B) ACUTE LUNG INJURY
    1) ONSET: Onset of acute lung injury after toxic exposure may be delayed up to 24 to 72 hours after exposure in some cases.
    2) NON-PHARMACOLOGIC TREATMENT: The treatment of acute lung injury is primarily supportive (Cataletto, 2012). Maintain adequate ventilation and oxygenation with frequent monitoring of arterial blood gases and/or pulse oximetry. If a high FIO2 is required to maintain adequate oxygenation, mechanical ventilation and positive-end-expiratory pressure (PEEP) may be required; ventilation with small tidal volumes (6 mL/kg) is preferred if ARDS develops (Haas, 2011; Stolbach & Hoffman, 2011).
    a) To minimize barotrauma and other complications, use the lowest amount of PEEP possible while maintaining adequate oxygenation. Use of smaller tidal volumes (6 mL/kg) and lower plateau pressures (30 cm water or less) has been associated with decreased mortality and more rapid weaning from mechanical ventilation in patients with ARDS (Brower et al, 2000). More treatment information may be obtained from ARDS Clinical Network website, NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary, http://www.ardsnet.org/node/77791 (NHLBI ARDS Network, 2008)
    3) FLUIDS: Crystalloid solutions must be administered judiciously. Pulmonary artery monitoring may help. In general the pulmonary artery wedge pressure should be kept relatively low while still maintaining adequate cardiac output, blood pressure and urine output (Stolbach & Hoffman, 2011).
    4) ANTIBIOTICS: Indicated only when there is evidence of infection (Artigas et al, 1998).
    5) EXPERIMENTAL THERAPY: Partial liquid ventilation has shown promise in preliminary studies (Kollef & Schuster, 1995).
    6) CALFACTANT: In a multicenter, randomized, blinded trial, endotracheal instillation of 2 doses of 80 mL/m(2) calfactant (35 mg/mL of phospholipid suspension in saline) in infants, children, and adolescents with acute lung injury resulted in acute improvement in oxygenation and lower mortality; however, no significant decrease in the course of respiratory failure measured by duration of ventilator therapy, intensive care unit, or hospital stay was noted. Adverse effects (transient hypoxia and hypotension) were more frequent in calfactant patients, but these effects were mild and did not require withdrawal from the study (Wilson et al, 2005).
    7) However, in a multicenter, randomized, controlled, and masked trial, endotracheal instillation of up to 3 doses of calfactant (30 mg) in adults only with acute lung injury/ARDS due to direct lung injury was not associated with improved oxygenation and longer term benefits compared to the placebo group. It was also associated with significant increases in hypoxia and hypotension (Willson et al, 2015).
    C) ACIDOSIS
    1) METABOLIC ACIDOSIS: Treat severe metabolic acidosis (pH less than 7.1) with sodium bicarbonate, 1 to 2 mEq/kg is a reasonable starting dose(Kraut & Madias, 2010). Monitor serum electrolytes and arterial or venous blood gases to guide further therapy.
    D) FOMEPIZOLE
    1) Fomepizole (4-MP) is not FDA approved for glycol ether poisoning and there are no published reports describing its use in humans with glycol ether poisoning. Theoretically, it should be as useful as ethanol. Fomepizole is a specific antagonist of alcohol dehydrogenase, and has been demonstrated to be highly effective in the treatment of ethylene glycol poisoning (Battistella, 2002; Druteika et al, 2002; Sivilotti et al, 2000; Borron et al, 1999; Brent et al, 1999).
    2) DOSE
    a) An initial loading dose of 15 mg/kg is intravenously infused over 30 minutes followed by doses of 10 mg/kg/every 12 hours for 4 doses, then 15 mg/kg every 12 hours until ethylene glycol concentrations are below 20 mg/dL (Prod Info ANTIZOL(R) IV injection, 2006).
    b) HEMODIALYSIS: The frequency of dosing should be increased during dialysis. If dialysis is begun 6 hours or more since the last fomepizole dose the next scheduled dose should be administered. Dosing during dialysis should be increased to every 4 hours (Prod Info ANTIZOL(R) IV injection, 2006).
    1) If the last fomepizole dose was administered one to three hours before completion of dialysis, half of the next scheduled dose should be administered at the completion of dialysis. If the last fomepizole dose was administered more than 3 hours before completion of hemodialysis, the next scheduled dose should be administered when dialysis is completed.
    3) INDICATIONS
    a) Anion gap metabolic acidosis associated with a history of EGBE ingestion.
    b) Any symptomatic patient with a history of EGBE ingestion.
    c) A good history of substantial EGBE ingestion.
    d) Keep in mind that EGBE serum levels are not routinely available, and interpretation is difficult since a toxic range has not been established. Thus, the endpoint of therapy will often be arbitrary.
    4) CASE REPORT
    a) A 16-month-old infant with CNS depression was treated with a single dose of fomepizole (15 milligrams/kilogram) due to persistent metabolic acidosis following ingestion of an unknown quantity of a cleaning product containing 2-butoxyethanol (10-30%), monoethanolamine (5-10%), alkoxylated linear alcohols (1-5%) ethylenediaminetetraacetic acid (1-5%), potassium hydroxide (1-5%) and water (30-60%) (Osterhoudt , 2002). Metabolic acidosis resolved within 2 hours. No adverse effects related to therapy were reported. Based on a lack of butoxy-ethanol and butyoxyacetic acid quantification, it is not possible to conclude that fomepizole directly resolved the reversal of acidosis observed in this case.
    E) ETHANOL
    1) EFFICACY
    a) ETHANOL THERAPY: The role of ethanol therapy in preventing EGBE toxicity is uncertain. Putative evidence suggests that ethanol therapy is beneficial. No human studies evaluating efficacy in poisoned patients are available. Ethanol was used in combination with hemodialysis in one case with a successful outcome (Bauer et al, 1992). In another case, McKinney et al (2000) reported treatment with IV ethanol over a 48 hour period (and no dialysis) with a successful outcome and no apparent sequelae in a patient with persistent hyperchloremic metabolic acidosis, hypotension and CNS depression prior to ethanol therapy.
    b) Co-administration of ethanol with three glycol ethers, including EGBE, has resulted in the accumulation of these ethers in rat blood (Romer et al, 1985), thus inferring the protective inhibition of alcohol dehydrogenases.
    c) The presence of the acid metabolite butoxyethanol in animals, and studies showing inhibition of the elimination of the glycol ether by ethanol administration in animals (Johanson et al, 1986) are suggestive evidence that ethanol therapy may prevent acidosis.
    d) PYRAZOLE: The administration of pyrazole (an ethanol dehydrogenase inhibitor) to rats one hour prior to administration of ethylene glycol butyl ether inhibited metabolism to butoxyacetic acid and prevented hematologic, liver, and renal toxicity (Ghanayem et al, 1987).
    e) Studies have shown that pretreatment with pyrazole resulted in a significant increase in the half-life and area under the curve and a decrease in the systemic clearance of EGBE (Ghanayem et al, 1990).
    2) INDICATIONS
    a) Anion gap metabolic acidosis associated with a history of EGBE ingestion.
    b) Any symptomatic patient with a history of EGBE ingestion.
    c) A good history of substantial EGBE ingestion.
    d) Keep in mind that EGBE serum levels are not routinely available, and interpretation is difficult since a toxic range has not been established. Thus, the endpoint of ethanol therapy will often be arbitrary.
    3) ETHANOL THERAPY
    a) CONCENTRATIONS AVAILABLE (V/V)
    1) In the United States, 5% or 10% (V/V) ethanol in 5% dextrose for intravenous infusion is no longer available commercially (Howland, 2011). Ethanol 10% (V/V) contains approximately 0.08 gram ethanol/mL.
    2) ABSOLUTE ETHANOL or dehydrated ethanol, USP contains no less than 99.5% volume/volume or 99.2% weight/weight of ethanol with a specific gravity of not more than 0.7964 at 15.56 degrees C. Absolute ethanol is hygroscopic (absorbs water from the atmosphere) and when exposed to air may be less than 99.5% ethanol by volume (S Sweetman , 2002).
    b) PREPARATION OF 10% V/V ETHANOL IN A 5% DEXTROSE SOLUTION
    1) A 10% (V/V) solution can be prepared by the following method (Howland, 2011):
    a) If available, use sterile ethanol USP (absolute ethanol). Add 55 mL of the absolute ethanol to 500 mL of 5% dextrose in water for infusion. This yields a total volume of 555 mL. This produces an approximate solution of 10% ethanol in 5% dextrose for intravenous infusion (Howland, 2011).
    4) PRECAUTIONS
    a) HYPOGLYCEMIA
    1) Hypoglycemia may occur, especially in children. Monitor blood glucose frequently (Howland, 2011; Barceloux et al, 2002).
    b) CONCURRENT ETHANOL
    1) If the patient concurrently has ingested ethanol, then the ethanol loading dose must be modified so that the blood ethanol level does not exceed 100 to 150 mg/dL (Barceloux et al, 2002).
    c) DISULFIRAM
    1) Fomepizole is preferred as an alcohol dehydrogenase inhibitor in patients taking disulfiram. If fomepizole is not available, ethanol therapy should be initiated in those patients with signs or symptoms of severe poisoning (acidemia, toxic blood level) despite a history of recent disulfiram (Antabuse(R)) ingestion.
    2) The risk of not treating these patients is excessive, especially if hemodialysis is not immediately available.
    3) Administer the ethanol cautiously with special attention to the severity of the "Antabuse reaction" (flushing, sweating, severe hypotension, and cardiac dysrhythmias).
    4) Be prepared to treat hypotension with fluids and pressor agents (norepinephrine or dopamine). Monitor ECG and vital signs carefully. Hemodialysis should be performed as soon as adequate vital signs are established, and every effort should be made to obtain fomepizole.
    5) LOADING DOSE
    a) INTRAVENOUS LOADING DOSE
    1) Ethanol is given to maintain a patient’s serum ethanol concentration at 100 to 150 mg/dL. This can be accomplished by using a 5% or 10% ethanol solution administered intravenously through a central line (10% ethanol is generally preferred due to the large volumes required for 5%). Intravenous therapy dosing, which is preferred, is 0.8 g/kg as a loading dose (8 mL/kg of 10% ethanol) administered over 20 to 60 minutes as tolerated. Begin the maintenance infusion as soon as the loading dose is infused (Howland, 2011).
    b) ORAL LOADING DOSE
    1) Oral ethanol may be used as a temporizing measure until intravenous ethanol or fomepizole can be obtained, but it is more difficult to achieve the desired stable ethanol concentrations. The loading dose is 0.8 g/kg (4 mL/kg) of 20% (40 proof) ethanol diluted in juice administered orally or via a nasogastric tube(Howland, 2011).
    6) MAINTENANCE DOSE
    a) MAINTENANCE DOSE
    1) Maintain a serum ethanol concentration of 100 to 150 mg/dL. Intravenous administration is preferred, but oral ethanol may be used if intravenous is unavailable(Howland, 2011; Barceloux et al, 2002).
    INTRAVENOUS ADMINISTRATION OF 10% ETHANOL
    Non-drinker to moderate drinker80 to 130 mg/kg/hr (0.8 to 1.3 mL/kg/hr)
    Chronic drinker150 mg/kg/hr (1.5 mL/kg/hr)
    ORAL ADMINISTRATION OF 20% (40 proof) ETHANOL*
    Non-drinker to moderate drinker80 to 130 mg/kg/hr (0.4 to 0.7 mL/kg/hr) orally or via nasogastric tube
    Chronic drinker150 mg/kg/hr (0.8 mL/kg/hr) orally or via nasogastric tube
    *Diluted in juice

    b) MAINTENANCE DOSE/ETHANOL DIALYSATE
    1) During hemodialysis maintenance doses of ethanol should be increased in accordance with the recommendation given below, or ethanol should be added to the dialysate to achieve a concentration of 100 milligrams/deciliter (Pappas & Silverman, 1982).
    c) MAINTENANCE DOSE/ETHANOL-FREE DIALYSATE
    1) Maintain a serum ethanol concentration of 100 to 150 mg/dL(Howland, 2011; Barceloux et al, 2002):
    INTRAVENOUS ADMINISTRATION OF 10% ETHANOL - 250 to 350 mg/kg/hr (2.5 to 3.5 mL/kg/hr)
    ORAL ADMINISTRATION OF 20% (40 proof) ETHANOL* - 250 to 350 mg/kg/hr (1.3 to 1.8 mL/kg/hr) orally or via nasogastric tube
    *Diluted in juice

    2) Variations in blood flow rate and the ethanol extraction efficiency of the dialyzer will affect the dialysance(McCoy et al, 1979).
    3) If the ethanol dialysance ((CL)D) is calculated, the infusion rate during dialysis (Kod) can be individually adjusted using the following expression (McCoy et al, 1979): 
    Kod = Vmax x   Cp   + (CL)D x Cp
             -------
             Km + Cp
where Cp = desired blood ethanol level
*  Vmax = 175 mg/kg/hr in chronic ethanol drinkers 
*  Vmax = 75 mg/kg/hr in non-chronic drinkers
*  Km = 13.8 mg/dL

    7) PEDIATRIC DOSE
    a) There is very little information on ethanol dosing in the pediatric patient (Barceloux et al, 2002). The loading dose and maintenance infusion should be the same as for an adult non-drinker. Loading dose is 0.8 g/kg (8 mL/kg) of 10% ethanol infused over 1 hour, maintenance dose is 80 mg/kg/hr (0.8 mL/kg/hr) of 10% ethanol (Howland, 2011).
    b) Blood ethanol concentration should be initially monitored hourly and the infusion rate should be adjusted to obtain an ethanol concentration of 100 to 150 mg/dL (Howland, 2011; Barceloux et al, 2002).
    1) Monitor blood glucose and mental status frequently during therapy (Howland, 2011). Ethanol-induced hypoglycemia is more common in children (Barceloux et al, 2002) and children may develop more significant CNS depression.
    8) MONITORING PARAMETERS
    a) ETHANOL CONCENTRATION
    1) Blood ethanol concentrations should be determined every 1 to 2 hours until concentrations are maintained within the therapeutic range (100 - 150 mg/dL). Thereafter concentrations should be monitored every 2 to 4 hours. Any change in infusion rate will require monitoring every 1 to 2 hours until the therapeutic range is reached and maintained (Barceloux et al, 2002).
    b) ADDITIONAL MONITORING
    1) Monitor serum electrolytes and blood glucose, monitor for CNS depression (Howland, 2011).
    9) DURATION OF THERAPY
    a) SERUM CONCENTRATIONS AVAILABLE: Ethanol therapy should be continued until the following criteria are met:
    1) Glycol ether blood concentration, measured by a reliable technique, is no longer detectable.
    2) Glycol ether-induced acidosis (pH, blood gases), clinical findings (CNS, hyperventilation), electrolyte abnormalities (calcium, potassium), and osmolal gap have resolved.
    3) Glycol ether serum concentrations are not routinely available and a toxic range has not been established.
    b) NO SERUM CONCENTRATIONS AVAILABLE: There is no data to guide the decision to terminate therapy. Treat until the patient's clinical findings resolve. Observe closely for recurrent toxicity after ethanol is discontinued.
    1) If the clinical findings have not resolved, it may indicate the continued presence of glycol ether, metabolites, or both or some other etiology.
    c) Metabolite concentrations have not been studied in blood (Rambourg-Schepens et al, 1988a; Groeseneken et al, 1986b). The biological half-life of ethoxyacetic acid (ethylene glycol monomethyl ether metabolite) in man following inhalation exposure is 21 to 24 hours (Groeseneken et al, 1986a).
    d) Serum osmolality may not be indicative of exposure (Lund et al, 1983a).
    10) MONITORING OF PATIENT
    a) ETHANOL/ETHYLENE GLYCOL BUTYL ETHER INGESTION: Patients who have concurrently ingested ethanol and EGBE may have a normal acid-base profile and urinalysis. Consider implementing the ethanol treatment regimen in these patients. Determine blood ETOH level before beginning ETOH therapy and modify loading dose accordingly.
    b) ETHANOL DOSING: (Concurrent ingested ethanol)
    1) To modify the loading dose for the patients who have concurrently ingested ethanol use the following equation to calculate the loading dose:
    1) LD = {100 mg/dL - existing ethanol plasma concentration(mg/dL)} x (apparent Vd)
    2) The apparent volume of distribution (Vd) ethanol was obtained from the pharmacokinetic literature and is reported to be approximately 0.6 liter/kilogram (Ekins et al, 1985).
    3) Note the loading dose obtained by this method is the amount of pure ethanol in milligrams/kilogram. It must be converted for intravenous and oral use to milliliters/kilogram. This can be accomplished by using the relationship:
    1) LD(mL/kg) = LD(mg/kg) / {(specific gravity of ethanol) x (concentration as a fraction)}
    4) Ten percent (V/V) ethanol for intravenous infusion:
    1) LD(mL/kg) = LD(mg/kg) / {790 mg/mL x (10/100)}
    5) 95 percent (V/V) ethanol for oral use:
    1) LD(mL/kg) = LD(mg/kg) / {790 mg/mL x (95/100)}
    6) Calculation of loading dose assumes instantaneous absorption.
    F) THIAMINE
    1) Thiamine, 100 milligrams intravenously daily, is recommended to stimulate the conversion of glyoxylate to alpha-hydroxy-beta-ketoadipate, a non-toxic metabolite of ethylene glycol poisonings (Parry & Wallach, 1974).
    G) PYRIDOXINE
    1) Administer 100 milligrams intravenously daily, to allow adequate stores of cofactor necessary for the conversion of glyoxylate to nontoxic glycine (Gibbs & Watts, 1970; Lavelle, 1977; Harrison, 1980).

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.
    D) Because low vapor pressure at room temperature causes skin absorption to contribute substantially to over-all hazard (Clayton & Clayton, 1981), remove and isolate contaminated clothing and shoes and flush all exposed mucocutaneous surfaces.
    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).

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) DERMAL DECONTAMINATION
    1) 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) GENERAL TREATMENT
    1) If large areas of skin have been exposed to EGBE, it would be prudent to follow the treatment recommendations listed in oral/parenteral exposure since percutaneous absorption has been demonstrated in vivo in human volunteers (Johanson & Ferstrom, 1988).
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Enhanced Elimination

    A) HEMODIALYSIS
    1) Hemodialysis has not been shown to affect outcome in EGBE poisoning. In a case of severe toxicity following a large ingestion of a product containing ethylene glycol butyl ether, hemodialysis did not significantly enhance elimination of butoxyacetic acid, the toxic active metabolite (Burkhart & Donovan, 1998).
    2) INDICATIONS: Severe acid-base and/or fluid-electrolyte disturbances despite conventional therapy; renal failure.
    3) CASE REPORT: McKinney et al (2000) reported using NO hemodialysis in a patient with persistent hyperchloremic metabolic acidosis, hypotension, and CNS depression. The patient responded to a 48-hour ethanol infusion. No apparent sequelae were reported, which suggested to the authors that acidosis may not be a reliable indication for hemodialysis in ethylene glycol butyl ether poisonings.

Abstracts

Case Reports

    A) ROUTE OF EXPOSURE
    1) ORAL: A 50-year-old woman ingested 250 to 500 mL of a window cleaner containing 12% EGBE and became comatose and severely acidotic. The estimated ingestion was 60 mL of pure EGBE. She was comatose 12 hours later, required mechanical ventilation, and had metabolic acidosis (blood pH 7.23, pO2 11.18, pCO2 1.43, HCO3 5mmol/L). Hypokalemia increased serum creatinine; oxaluria and hemoglobinuria were also noted. Supportive care was the only treatment given and the patient was discharged on the 10th day postingestion (Rambourg-Schepens et al, 1988).
    2) ORAL: A 23-year-old woman ingested 500 mL of a window cleaner containing 12.7% EGBE and became comatose, hypotensive, and markedly acidotic. With a content of 12.7% EGBE and 3.2% ethanol, the total estimated dose of EGBE ingestion was 63.5 mL or 0.89 grams/kg. The admission EGBE level was reported at 43.2 mg/dL. One hour postingestion, she was comatose and hypotensive, thus requiring fluids and dopamine infusion. She awoke 4 hours postingestion. At 7 hours postingestion, marked metabolic acidosis was noted (pH 7.08, pCO2 8.2, HCO3 2.4 mEq/L, anion gap 27.8 mEq/L) with no osmolal gap. Hemodialysis was performed to control this acidosis. On the second day, the hemoglobin fell from 11.9 to 8.9 g/dL and hematuria was noted, concurrently with maximal urinary levels of butoxyacetic acid. Urinary oxalate excretion remained unchanged and renal function was unimpaired. Half-life of EGBE for this patient was computed at 210 minutes (Gijsenbergh et al, 1989).
    3) ORAL: An 87-year-old woman presented in coma after ingestion of an unknown amount of a disinfectant cleaner containing 6.5% EGBE. Initial laboratory results included metabolic acidosis and an ethylene glycol level of 110 mg/dL. Ethanol therapy was begun 3 hours after admission. Hemodialysis was attempted, but discontinued due to ventricular tachycardia. Complications included prolonged acidosis, hypotension, arrhythmias, hepatic and renal failure, and DIC. The patient had a cardiac arrest and died 3 days after admission (Litovitz et al, 1990).
    4) ORAL: A 53-year-old chronic alcoholic was admitted 10 hours after ingestion of 500 mL of a household cleaner containing 9.1% EGBE (total EGBE 45.5 mL). Shortly, he became comatose and hypotensive (BP 60/30 mmHg). Abnormal laboratory findings included lactic acidosis and hypoxia (anion gap 34; pH 7.05; PaO2 26.8 mmHg), hypokalemia (2.1 mmol/L), and elevated liver function tests (ASAT 105 U/L; ammonia 83 mcmol/L). Physical examination showed crackles in both lungs. Chest radiograph revealed diffuse pulmonary edema. Hemodynamic data were consistent with ARDS. Treatment included supportive care for shock (colloids, epinephrine), which was stabilized in 12 hours; sodium bicarbonate for acidosis, which was corrected in 4 hours; and hemodialysis for 3 six-hour sessions. The patient was discharged after full recovery on the 15th day (Bauer et al, 1992).

Range Of Toxicity

Summary

    A) TOXICITY: Severe toxicity has been described in adults who ingested 30 to 63.5 mL of pure EGBE. Children ingesting small amounts (less than 10 mL) of dilute household products (less than 10% ethylene glycol butyl ether) generally do not develop evidence of poisoning. The threshold limit value weighted average for an 8 hour shift (TLV-TWA) is 20 ppm, 700 ppm is considered immediately dangerous to life and health.

Maximum Tolerated Exposure

    A) The threshold limit value weighted average for an 8 hour shift (TLV-TWA) is 20 ppm (American Conference of Governmental Industrial Hygienists, 2010); 700 ppm is considered immediately dangerous to life and health (National Institute for Occupational Safety and Health, 2007).
    B) ROUTE OF EXPOSURE
    1) INHALATION
    a) No clinical signs of adverse effects nor subjective complaints occurred among 7 male volunteers exposed to 20 parts per million for 2 hours (Johanson et al, 1986).
    b) Exposure of human beings to high concentrations of ethylene glycol monobutyl ether vapors, in the range of 300 to 600 parts per million, for several hours, would be expected to cause respiratory and eye irritation, narcosis, and possibly damage to the kidney and liver (Clayton & Clayton, 1981).
    c) Deaths that occur promptly from inhalation in animals are generally attributed to narcosis, but if death is delayed several days, it is likely to be caused by pneumonitis, pulmonary congestion, and/or kidney injury (Clayton & Clayton, 1981; Hathaway et al, 1996).
    2) ORAL
    a) ADULT TOXICITY
    1) Severe toxicity (coma, acidosis) was noted in a 50-year-old woman who ingested 250 to 500 milliliters of a 12 percent solution, equivalent to 30 to 60 milliliters of pure EGBE (Rambourg-Schepens et al, 1988).
    2) Severe toxicity (coma, acidosis, anemia, hematuria) was reported in a 23-year-old woman following ingestion of 500 milliliters of a window cleaner containing 12.7% EGBE. The total dose ingested was estimated to be 63.5 milliliters of pure EGBE or 0.89 gram/kilogram. Due to prompt gastric lavage, the authors estimated that one-half of this amount was actually absorbed (Gijsenbergh et al, 1989).
    3) Severe toxicity (coma, acidosis, hypotension, acute lung injury/ARDS) was reported in a 53-year-old man following ingestion of 500 milliliters of a 9.1 percent solution (equivalent to 45.5 milliliters of pure EGBE) (Bauer et al, 1992).
    b) PEDIATRIC TOXICITY
    1) No symptoms developed in 24 children ingesting 5 to 300 milliliters of glass cleaner (0.5 to 9.9% ethylene glycol butyl ether). The 2 children ingesting more than 15 milliliters (approximately 3 milliliters EGBE in a 14-month-old and 24 milliliters in a 2-year-old) were treated with gastric emptying. All others were followed at home following simple dilution (Dean & Krenzelok, 1992).
    c) Toxic hazard rating is between classes 3 & 4 with probable oral lethal dose of at least 50 to 500 milligrams per kilogram or the equivalent of 1 mL/kg or 1 ounce of pure EGBE for a 70 kilogram person (HSDB , 2000).
    3) DERMAL
    a) Prolonged and repeated contact of EGBE with the skin of rabbits failed to cause more than a very mild simple irritation (Clayton & Clayton, 1981).
    b) In guinea pigs, the percutaneous absorption of aqueous solutions of EGBE was greater than percutaneous absorption of undiluted EGBE(Johanson & Ferstrom, 1988) .
    c) The percutaneous absorption of EGBE was investigated in 12 exposure experiments with five male volunteers. Exposure of four fingers to liquid butoxyethanol corresponds roughly to being exposed to butoxyethanol vapor at 20 parts per million (Johanson & Ferstrom, 1988).

Workplace Standards

    A) ACGIH TLV Values for CAS111-76-2 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Editor's Note: The listed values are recommendations or guidelines developed by ACGIH(R) to assist in the control of health hazards. They should only be used, interpreted and applied by individuals trained in industrial hygiene. Before applying these values, it is imperative to read the introduction to each section in the current TLVs(R) and BEI(R) Book and become familiar with the constraints and limitations to their use. Always consult the Documentation of the TLVs(R) and BEIs(R) before applying these recommendations and guidelines.
    a) Adopted Value
    1) 2-Butoxyethanol (EGBE)
    a) TLV:
    1) TLV-TWA: 20 ppm
    2) TLV-STEL:
    3) TLV-Ceiling:
    b) Notations and Endnotes:
    1) Carcinogenicity Category: A3
    2) Codes: Not Listed
    3) Definitions:
    a) A3: Confirmed Animal Carcinogen with Unknown Relevance to Humans: The agent is carcinogenic in experimental animals at a relatively high dose, by route(s) of administration, at site(s), of histologic type(s), or by mechanism(s) that may not be relevant to worker exposure. Available epidemiologic studies do not confirm an increased risk of cancer in exposed humans. Available evidence does not suggest that the agent is likely to cause cancer in humans except under uncommon or unlikely routes or levels of exposure.
    c) TLV Basis - Critical Effect(s): Eye and URT irr
    d) Molecular Weight: 118.17
    1) For gases and vapors, to convert the TLV from ppm to mg/m(3):
    a) [(TLV in ppm)(gram molecular weight of substance)]/24.45
    2) For gases and vapors, to convert the TLV from mg/m(3) to ppm:
    a) [(TLV in mg/m(3))(24.45)]/gram molecular weight of substance
    e) Additional information:

    B) NIOSH REL and IDLH Values for CAS111-76-2 (National Institute for Occupational Safety and Health, 2007):
    1) Listed as: 2-Butoxyethanol
    2) REL:
    a) TWA: 5 ppm (24 mg/m(3))
    b) STEL:
    c) Ceiling:
    d) Carcinogen Listing: (Not Listed) Not Listed
    e) Skin Designation: [skin]
    1) Indicates the potential for dermal absorption; skin exposure should be prevented as necessary through the use of good work practices and gloves, coveralls, goggles, and other appropriate equipment.
    f) Note(s):
    3) IDLH:
    a) IDLH: 700 ppm
    b) Note(s): Not Listed

    C) Carcinogenicity Ratings for CAS111-76-2 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): A3 ; Listed as: 2-Butoxyethanol (EGBE)
    a) A3 :Confirmed Animal Carcinogen with Unknown Relevance to Humans: The agent is carcinogenic in experimental animals at a relatively high dose, by route(s) of administration, at site(s), of histologic type(s), or by mechanism(s) that may not be relevant to worker exposure. Available epidemiologic studies do not confirm an increased risk of cancer in exposed humans. Available evidence does not suggest that the agent is likely to cause cancer in humans except under uncommon or unlikely routes or levels of exposure.
    2) EPA (U.S. Environmental Protection Agency, 2011): Not likely to be carcinogenic to humans ; Listed as: Ethylene glycol monobutyl ether (EGBE) (2-Butoxyethanol)
    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): 3 ; Listed as: 2-Butoxyethanol
    a) 3 : The agent (mixture or exposure circumstance) is not classifiable as to its carcinogenicity to humans. This category is used most commonly for agents, mixtures and exposure circumstances for which the evidence of carcinogenicity is inadequate in humans and inadequate or limited in experimental animals. Exceptionally, agents (mixtures) for which the evidence of carcinogenicity is inadequate in humans but sufficient in experimental animals may be placed in this category when there is strong evidence that the mechanism of carcinogenicity in experimental animals does not operate in humans. Agents, mixtures and exposure circumstances that do not fall into any other group are also placed in this category.
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed ; Listed as: 2-Butoxyethanol
    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 CAS111-76-2 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Listed as: 2-Butoxyethanol
    2) Table Z-1 for 2-Butoxyethanol:
    a) 8-hour TWA:
    1) ppm: 50
    a) Parts of vapor or gas per million parts of contaminated air by volume at 25 degrees C and 760 torr.
    2) mg/m3: 240
    a) Milligrams of substances per cubic meter of air. When entry is in this column only, the value is exact; when listed with a ppm entry, it is approximate.
    3) Ceiling Value:
    4) Skin Designation: Yes
    5) Notation(s): Not Listed

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) References: RTECS, 2000 OHM/TADS, 1991 Lewis, 1996
    1) LD50- (ORAL)MOUSE:
    a) 1230 mg/kg
    2) LD50- (INHALATION)RAT:
    a) 2900 mg/kg
    3) LD50- (ORAL)RAT:
    a) 1480 mg/kg
    b) 470 mg/kg

Pharmacology Toxicology

Toxicologic Mechanism

    A) Hemolytic anemia in animals is presumed to be due to butoxyaldehyde and butoxyacetic acid metabolites (Ghanayem et al, 1987) 1989, 1990; (Bartnik et al, 1987).
    B) Inhibition of alcohol and aldehyde dehydrogenases resulted in protection of rats against butyl-ether-induced hemolytic anemia and concomitant changes in the kinetics of butoxyacetic acid (Ghanayem et al, 1987) 1989, 1990).
    C) The exact mode by which 2-butoxyethanol induces hematological effects has yet to be determined (Hughes et al, 2001 ).

Physicochemical

Physical Characteristics

    A) Ethylene glycol monobutyl ether is a mobile colorless liquid with a mild ethereal odor (CHRIS , 1991; HSDB , 2000).

Molecular Weight

    A) 118.18 (ITI, 1988)

References

General Bibliography

    1) 40 CFR 372.28: Environmental Protection Agency - Toxic Chemical Release Reporting, Community Right-To-Know, Lower thresholds for chemicals of special concern. National Archives and Records Administration (NARA) and the Government Printing Office (GPO). Washington, DC. Final rules current as of Apr 3, 2006.
    2) 40 CFR 372.65: Environmental Protection Agency - Toxic Chemical Release Reporting, Community Right-To-Know, Chemicals and Chemical Categories to which this part applies. National Archives and Records Association (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Apr 3, 2006.
    3) 49 CFR 172.101 - App. B: Department of Transportation - Table of Hazardous Materials, Appendix B: List of Marine Pollutants. National Archives and Records Administration (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Aug 29, 2005.
    4) 49 CFR 172.101: Department of Transportation - Table of Hazardous Materials. National Archives and Records Administration (NARA) and the Government Printing Office (GPO), Washington, DC. Final rules current as of Aug 11, 2005.
    5) 62 FR 58840: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 1997.
    6) 65 FR 14186: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.
    7) 65 FR 39264: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.
    8) 65 FR 77866: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2000.
    9) 66 FR 21940: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2001.
    10) 67 FR 7164: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2002.
    11) 68 FR 42710: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2003.
    12) 69 FR 54144: Notice of the National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances - Proposed AEGL Values, Environmental Protection Agency, NAC/AEGL Committee. National Archives and Records Administration (NARA) and the Government Publishing Office (GPO), Washington, DC, 2004.
    13) ACGIH: Documentation of the Threshold Limit Values and Biological Exposure Indices, 6th ed, Am Conference of Govt Ind Hyg, Inc, Cincinnati, OH, 1991, pp 162-163.
    14) AIHA: 2006 Emergency Response Planning Guidelines and Workplace Environmental Exposure Level Guides Handbook, American Industrial Hygiene Association, Fairfax, VA, 2006.
    15) American Conference of Governmental Industrial Hygienists : ACGIH 2010 Threshold Limit Values (TLVs(R)) for Chemical Substances and Physical Agents and Biological Exposure Indices (BEIs(R)), American Conference of Governmental Industrial Hygienists, Cincinnati, OH, 2010.
    16) Ansell-Edmont: SpecWare Chemical Application and Recommendation Guide. Ansell-Edmont. Coshocton, OH. 2001. Available from URL: http://www.ansellpro.com/specware. As accessed 10/31/2001.
    17) Artigas A, Bernard GR, Carlet J, et al: The American-European consensus conference on ARDS, part 2: ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling.. Am J Respir Crit Care Med 1998; 157:1332-1347.
    18) Barceloux DG, Bond GR, Krenzelok EP, et al: American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning. J Toxicol Clin Toxicol 2002; 40(4):415-446.
    19) Bartnik FG, Reddy AX, & Klecak G: Percutaneous absorption, metabolism, and hemolytic activity of n-butoxyethanol. Fundam Appl Toxicol 1987; 8:59-70.
    20) Bata Shoe Company: Industrial Footwear Catalog, Bata Shoe Company, Belcamp, MD, 1995.
    21) Battistella M: Fomepizole as an antidote for ethylene glycol poisoning. Ann Pharmacother 2002; 36:1085-1089.
    22) Bauer P, Weber M, & Mur JM: Transient non-cardiogenic pulmonary edema following massive ingestion of ethylene glycol butyl ether. Int Care Med 1992; 18:250-251.
    23) Best Manufacturing: ChemRest Chemical Resistance Guide. Best Manufacturing. Menlo, GA. 2002. Available from URL: http://www.chemrest.com. As accessed 10/8/2002.
    24) Best Manufacturing: Degradation and Permeation Data. Best Manufacturing. Menlo, GA. 2004. Available from URL: http://www.chemrest.com/DomesticPrep2/. As accessed 04/09/2004.
    25) Borron SW, Megarbane B, & Baud FJ: Fomepizole in treatment of uncomplicated ethylene glycol poisoning. Lancet 1999; 354:831.
    26) Boss Manufacturing Company: Work Gloves, Boss Manufacturing Company, Kewanee, IL, 1998.
    27) Brent J, McMartin K, & Phillips S: Fomepizole for the treatment of ethylene glycol poisoning. Methylpyrazole for toxic alcohols study group. N Engl J Med 1999; 40:832-838.
    28) Brower RG, Matthay AM, & Morris A: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Eng J Med 2000; 342:1301-1308.
    29) Browning RG & Curry SC: Effect of glycol ethers on plasma osmolality. Human Exp Toxicol 1992; 11:488-490.
    30) Budavari S: The Merck Index, 12th ed, Merck & Co, Inc, Whitehouse Station, NJ, 1996, pp 258.
    31) Burgess JL, Kirk M, Borron SW, et al: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med 1999; 34(2):205-212.
    32) Burkhart K & Donovan JW: Butoxyethanol intoxication and hemodialysis (abstract). J Toxicol-Clin Toxicol 1998; 36:517.
    33) CHRIS : CHRIS Hazardous Chemical Data. US Department of Transportation, US Coast Guard. Washington, DC (Internet Version). Edition expires 1990; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    34) CHRIS : CHRIS Hazardous Chemical Data. US Department of Transportation, US Coast Guard. Washington, DC (Internet Version). Edition expires 1991; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    35) Carpenter CP, Pozzani UC, & Weil CS: The toxicity of butyl cellosolve solvent. Arch Ind Health 1956; 14:114-131.
    36) Cataletto M: Respiratory Distress Syndrome, Acute(ARDS). In: Domino FJ, ed. The 5-Minute Clinical Consult 2012, 20th ed. Lippincott Williams & Wilkins, Philadelphia, PA, 2012.
    37) ChemFab Corporation: Chemical Permeation Guide Challenge Protective Clothing Fabrics, ChemFab Corporation, Merrimack, NH, 1993.
    38) Chemical Manufacturers Association: Glycol Ethers Program Panel Research Status Report, Chemical Manufacturers Association, Washington, DC, 1985, pp 5.
    39) Clayton GD & Clayton FE: Patty's Industrial Hygiene and Toxicology, Vol 2, John Wiley & Sons, New York, NY, 1981.
    40) Clayton GD & Clayton FE: Patty's Industrial Hygiene and Toxicology, Vol 2C Toxicology, 3rd ed, John Wiley & Sons, New York, NY, 1982, pp 3931-3939.
    41) Clayton GD & Clayton FE: Patty's Industrial Hygiene and Toxicology, Vol 2D, Toxicology, 4th ed, John Wiley & Sons, New York, NY, 1994, pp 2795-2804.
    42) Comasec Safety, Inc.: Chemical Resistance to Permeation Chart. Comasec Safety, Inc.. Enfield, CT. 2003. Available from URL: http://www.comasec.com/webcomasec/english/catalogue/mtabgb.html. As accessed 4/28/2003.
    43) Comasec Safety, Inc.: Product Literature, Comasec Safety, Inc., Enfield, CT, 2003a.
    44) DFG: List of MAK and BAT Values 2002, Report No. 38, Deutsche Forschungsgemeinschaft, Commission for the Investigation of Health Hazards of Chemical Compounds in the Work Area, Wiley-VCH, Weinheim, Federal Republic of Germany, 2002.
    45) Dean BS & Krenzelok EP: Clinical evaluation of pediatric ethylene glycol monobutyl ether poisonings. Clin Toxicol 1992; 30:557-563.
    46) Doe JE: Environ Health Perspect 1984; 57:199-206.
    47) Druteika DP, Zed PJ, & Ensom MHH: Role of fomepizole in the management of ethylene glycol toxicity. Pharmacother 2002; 22:365-372.
    48) DuPont: DuPont Suit Smart: Interactive Tool for the Selection of Protective Apparel. DuPont. Wilmington, DE. 2002. Available from URL: http://personalprotection.dupont.com/protectiveapparel/suitsmart/smartsuit2/na_english.asp. As accessed 10/31/2002.
    49) DuPont: Permeation Guide for DuPont Tychem Protective Fabrics. DuPont. Wilmington, DE. 2003. Available from URL: http://personalprotection.dupont.com/en/pdf/tyvektychem/pgcomplete20030128.pdf. As accessed 4/26/2004.
    50) DuPont: Permeation Test Results. DuPont. Wilmington, DE. 2002a. Available from URL: http://www.tyvekprotectiveapprl.com/databases/default.htm. As accessed 7/31/2002.
    51) ECETOC: The toxicology of glycol ethers and its relevance to man: an updating of ECETOC technical report no 4, report no 17. European Centre for Ecotoxicology and Toxicology of Chemicals, 1985.
    52) EPA: Search results for Toxic Substances Control Act (TSCA) Inventory Chemicals. US Environmental Protection Agency, Substance Registry System, U.S. EPA's Office of Pollution Prevention and Toxics. Washington, DC. 2005. Available from URL: http://www.epa.gov/srs/.
    53) ERG: Emergency Response Guidebook. A Guidebook for First Responders During the Initial Phase of a Dangerous Goods/Hazardous Materials Incident, U.S. Department of Transportation, Research and Special Programs Administration, Washington, DC, 2004.
    54) Ekins BR, Rollins DE, & Duffy DP: Standardized treatment of severe methanol poisoning with ethanol and hemodialysis. West J Med 1985; 142:337-340.
    55) Felgenhauer N, Zilker TH, & Von Clarmann M: A case of a severe ethylene glycol monobutyl ether poisoning (abstract), European Association of Poisons Centres and Clinical Toxicologist Scientific Meeting, Birmingham, UK, 1993.
    56) Ghanayem BI & Sullivan CA: Assessment of the haemolytic activity of 2-butoxyethanol and its major metabolite, butoxyacetic acid, in various mammals including humans. Human Exp Toxicol 1993; 12:305-311.
    57) Ghanayem BI, Burka LT, & Matthews HB: Metabolic basis of ethylene glycol monobutyl ether (2-butoxyethanol) toxicity: role of alcohol and aldehyde dehydrogenases. J Pharmacol Exp Ther 1987; 242:222-231.
    58) Ghanayem BI, Sanders JM, & Clark AM: Effects of dose, age, inhibition of metabolism and elimination on the toxicokinetics of 2-butoxyethanol and its metabolites. J Pharmacol Exp Ther 1990; 253:136-143.
    59) Ghanayem BI: Investigation of the mechanisms of 2-butoxyethanol-induced hemolytic anemia in rats and assessment of human risk in vitro. Biochem Pharmacol 1989; 38:1679-1984.
    60) Gijsenbergh FP, Jenco M, & Veulemans H: Acute butylgycol intoxication: A case report. Human Toxicol 1989; 8:243-245.
    61) Gollapudi BB, Barber ED, & Lawlor TE: Re-examination of the mutagenicity of ethylene glycol monobutyl ether to Salmonella tester strain TA97A. Mutat Res 1996; 370:61-64.
    62) Grant D: Toxicol Appl Pharmacol 1985; 77:187-200.
    63) Grant WM & Schuman JS: Toxicology of the Eye, 4th ed, Charles C Thomas, Springfield, IL, 1993.
    64) Groeseneken D, Veulemans H, & Masschelein R: An improved method for the determination in urine of alkoxyacetic acids. Int Arch Occup Environ Health 1989; 61:249-254.
    65) Groeseneken D, Veulemans H, & Masschelein R: Respiratory uptake and elimination of ethylene glycol monoethyl ether after experimental human exposure. Br J Ind Med 1986a; 43:544-549.
    66) Groeseneken D, van Vlem E, & Veulemans H: Gas chromatographic determination of methoxyacetic and ethoxyacetic acid in urine. Br J Ind Med 1986b; 43:62-65.
    67) Gualtieri JF, DeBoer L, Harris CR, et al: Repeated ingestion of 2-butoxyethanol: case report and literature review. J Toxicol - Clin Toxicol 2003; 41:57-62.
    68) Guardian Manufacturing Group: Guardian Gloves Test Results. Guardian Manufacturing Group. Willard, OH. 2001. Available from URL: http://www.guardian-mfg.com/guardianmfg.html. As accessed 12/11/2001.
    69) HSDB : Hazardous Substances Data Bank. National Library of Medicine. Bethesda, MD (Internet Version). Edition expires 1991; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    70) HSDB : Hazardous Substances Data Bank. National Library of Medicine. Bethesda, MD (Internet Version). Edition expires 2000; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    71) Haas CF: Mechanical ventilation with lung protective strategies: what works?. Crit Care Clin 2011; 27(3):469-486.
    72) Harbison RD: Hamilton & Hardy's Industrial Toxicology, 5th ed, Mosby, St. Louis, MO, 1998.
    73) Hardin BD: Environ Health Perspect 1984; 57:69-74.
    74) Hathaway GJ, Proctor NH, & Hughes JP: Chemical Hazards of the Workplace, 4th ed, Van Nostrand Reinhold Company, New York, NY, 1996.
    75) Hoflack JC, Lambolez L, & Elias Z: Mutagenicity of ethylene glycol ethers and of their metabolites in Salmonella typhimurium his. Mutat Res 1995; 341:281-287.
    76) Howland MA: Ethanol. In: Nelson LS, Hoffman RS, Lewin NA, et al, eds. Goldfrank's Toxicologic Emergencies, 9th ed. McGraw Hill Medical, New York, NY, 2011, pp 1419-1422.
    77) Hughes K, Meek ME, & Walker M: 2-butoxyethanol: Hazard characterization and exposure-response analysis. Environ Carcino & Ecotox Revs 2001 ; C19:77-104.
    78) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: 1,3-Butadiene, Ethylene Oxide and Vinyl Halides (Vinyl Fluoride, Vinyl Chloride and Vinyl Bromide), 97, International Agency for Research on Cancer, Lyon, France, 2008.
    79) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Formaldehyde, 2-Butoxyethanol and 1-tert-Butoxypropan-2-ol, 88, International Agency for Research on Cancer, Lyon, France, 2006.
    80) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Household Use of Solid Fuels and High-temperature Frying, 95, International Agency for Research on Cancer, Lyon, France, 2010a.
    81) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Smokeless Tobacco and Some Tobacco-specific N-Nitrosamines, 89, International Agency for Research on Cancer, Lyon, France, 2007.
    82) IARC Working Group on the Evaluation of Carcinogenic Risks to Humans : IARC Monographs on the Evaluation of Carcinogenic Risks to Humans: Some Non-heterocyclic Polycyclic Aromatic Hydrocarbons and Some Related Exposures, 92, International Agency for Research on Cancer, Lyon, France, 2010.
    83) IARC: List of all agents, mixtures and exposures evaluated to date - IARC Monographs: Overall Evaluations of Carcinogenicity to Humans, Volumes 1-88, 1972-PRESENT. World Health Organization, International Agency for Research on Cancer. Lyon, FranceAvailable from URL: http://monographs.iarc.fr/monoeval/crthall.html. As accessed Oct 07, 2004.
    84) ICAO: Technical Instructions for the Safe Transport of Dangerous Goods by Air, 2003-2004. International Civil Aviation Organization, Montreal, Quebec, Canada, 2002.
    85) ILC Dover, Inc.: Ready 1 The Chemturion Limited Use Chemical Protective Suit, ILC Dover, Inc., Frederica, DE, 1998.
    86) ITI: Toxic and Hazardous Industrial Chemicals Safety Manual, The International Technical Information Institute, Tokyo, JP, 1988.
    87) International Agency for Research on Cancer (IARC): IARC monographs on the evaluation of carcinogenic risks to humans: list of classifications, volumes 1-116. International Agency for Research on Cancer (IARC). Lyon, France. 2016. Available from URL: http://monographs.iarc.fr/ENG/Classification/latest_classif.php. As accessed 2016-08-24.
    88) International Agency for Research on Cancer: IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. World Health Organization. Geneva, Switzerland. 2015. Available from URL: http://monographs.iarc.fr/ENG/Classification/. As accessed 2015-08-06.
    89) Johanson G & Boman A: Percutaneous absorption of 2-butoxyethanol vapour in human subjects. Br J Ind Med 1991; 48:788-792.
    90) Johanson G & Ferstrom P: Influence of water on percutaneous absorption of 2-butoxyethanol in guinea pigs. Scand J Environ Health 1988; 14:95-100.
    91) Johanson G & Johnsson S: Gas chromatographic determiniation of butoxyacetic acid in human blood after exposure to 2-butoxyethanol. Arch Toxicol 1991; 65:433-435.
    92) Johanson G, Wallen M, & Byfalt Nordqvist M: Elimination kinetics of 2-butoxyethanol in the perfused rat liver - dose dependence and effect of ethanol. Toxicol Appl Pharmacol 1986; 83:315-320.
    93) Johanson G: Urine butoxyacetic acid as a therapeutic guide. Clin Toxicol 1993; 31:501-502.
    94) Kappler, Inc.: Suit Smart. Kappler, Inc.. Guntersville, AL. 2001. Available from URL: http://www.kappler.com/suitsmart/smartsuit2/na_english.asp?select=1. As accessed 7/10/2001.
    95) Kimberly-Clark, Inc.: Chemical Test Results. Kimberly-Clark, Inc.. Atlanta, GA. 2002. Available from URL: http://www.kc-safety.com/tech_cres.html. As accessed 10/4/2002.
    96) Kollef MH & Schuster DP: The acute respiratory distress syndrome. N Engl J Med 1995; 332:27-37.
    97) Kraut JA & Madias NE: Metabolic acidosis: pathophysiology, diagnosis and management. Nat Rev Nephrol 2010; 6(5):274-285.
    98) LaCrosse-Rainfair: Safety Products, LaCrosse-Rainfair, Racine, WI, 1997.
    99) Lewis RJ: Sax's Dangerous Properties of Industrial Materials, 9th ed, Van Nostrand Reinhold Company, New York, NY, 1996.
    100) Litovitz TL, Bailey KM, & Schmitz BF: 1990 Annual report of the American Association of Poison Control Centers National Data Collection System (case 70). Am J Emerg Med 1990; 9:461-509.
    101) Lund ME, Banner W Jr, & Finley PR: Effect of alcohols and selected solvents on serum osmolality measurements. J Toxicol Clin Toxicol 1983; 20:115-132.
    102) Lund ME, Banner W Jr, & Finley PR: Effect of alcohols and selected solvents on serum osmolality measurements. J Toxicol Clin Toxicol 1983a; 20:115-132.
    103) MAPA Professional: Chemical Resistance Guide. MAPA North America. Columbia, TN. 2003. Available from URL: http://www.mapaglove.com/pro/ChemicalSearch.asp. As accessed 4/21/2003.
    104) MAPA Professional: Chemical Resistance Guide. MAPA North America. Columbia, TN. 2004. Available from URL: http://www.mapaglove.com/ProductSearch.cfm?id=1. As accessed 6/10/2004.
    105) Mar-Mac Manufacturing, Inc: Product Literature, Protective Apparel, Mar-Mac Manufacturing, Inc., McBee, SC, 1995.
    106) Marigold Industrial: US Chemical Resistance Chart, on-line version. Marigold Industrial. Norcross, GA. 2003. Available from URL: www.marigoldindustrial.com/charts/uschart/uschart.html. As accessed 4/14/2003.
    107) McCoy HG, Cipolle RJ, & Ehlers SM: Severe methanol poisoning: application of a pharmacokinetic model for ethanol therapy and hemodialysis. Am J Med 1979; 67:804-807.
    108) McGregor DB: Environ Health Perspect 1984; 57:97-103.
    109) McKinney PE, Palmer RB, & Blackwell W: Butoxyethanol ingestion with prolonged hyperchloremic metabolic acidosis treated with ethanol therapy. Clin Toxicol 2000; 38:787-793.
    110) Medinsky MA, Singh G, & Bechtold WE: Disposition of three glycol ethers administered in drinking water to male F344/N rats. Toxicol Appl Pharmacol 1990; 102:443-455.
    111) Memphis Glove Company: Permeation Guide. Memphis Glove Company. Memphis, TN. 2001. Available from URL: http://www.memphisglove.com/permeation.html. As accessed 7/2/2001.
    112) Montgomery Safety Products: Montgomery Safety Products Chemical Resistant Glove Guide, Montgomery Safety Products, Canton, OH, 1995.
    113) NFPA: Fire Protection Guide to Hazardous Materials, 10th ed, National Fire Protection Association, Quincy, MA, 1991.
    114) NFPA: Fire Protection Guide to Hazardous Materials, 13th ed., National Fire Protection Association, Quincy, MA, 2002.
    115) NHLBI ARDS Network: Mechanical ventilation protocol summary. Massachusetts General Hospital. Boston, MA. 2008. Available from URL: http://www.ardsnet.org/system/files/6mlcardsmall_2008update_final_JULY2008.pdf. As accessed 2013-08-07.
    116) NIOSH: Current Intelligence Bulletin 39, Glycol Ethers, US Department of Health and Human Services, Public Health Service, Centers for Disease Control, No. 83-112, National Institute for Occupational Safety and Health, Cincinnati, OH, 1983.
    117) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 1, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2001.
    118) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 2, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2002.
    119) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 3, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2003.
    120) NRC: Acute Exposure Guideline Levels for Selected Airborne Chemicals - Volume 4, Subcommittee on Acute Exposure Guideline Levels, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission of Life Sciences, National Research Council. National Academy Press, Washington, DC, 2004.
    121) Nagano K: Environ Health Perspect 1984; 57:75-84.
    122) Nagano K: Sangyo Igaku 1979; 21:29-35.
    123) Nagano Y: Rodo Eisei 1977; 18:24-27.
    124) Naradzay J & Barish RA: Approach to ophthalmologic emergencies. Med Clin North Am 2006; 90(2):305-328.
    125) Nat-Wear: Protective Clothing, Hazards Chart. Nat-Wear. Miora, NY. 2001. Available from URL: http://www.natwear.com/hazchart1.htm. As accessed 7/12/2001.
    126) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2,3-Trimethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d68a&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    127) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2,4-Trimethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006m. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d68a&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    128) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2-Butylene Oxide (Proposed). United States Environmental Protection Agency. Washington, DC. 2008d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648083cdbb&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    129) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,2-Dibromoethane (Proposed). United States Environmental Protection Agency. Washington, DC. 2007g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064802796db&disposition=attachment&contentType=pdf. As accessed 2010-08-18.
    130) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 1,3,5-Trimethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d68a&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    131) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for 2-Ethylhexyl Chloroformate (Proposed). United States Environmental Protection Agency. Washington, DC. 2007b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648037904e&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    132) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Acrylonitrile (Proposed). United States Environmental Protection Agency. Washington, DC. 2007c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648028e6a3&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    133) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Adamsite (Proposed). United States Environmental Protection Agency. Washington, DC. 2007h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    134) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Agent BZ (3-quinuclidinyl benzilate) (Proposed). United States Environmental Protection Agency. Washington, DC. 2007f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803ad507&disposition=attachment&contentType=pdf. As accessed 2010-08-18.
    135) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Allyl Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2008. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648039d9ee&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    136) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Aluminum Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    137) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Arsenic Trioxide (Proposed). United States Environmental Protection Agency. Washington, DC. 2007m. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480220305&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    138) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Automotive Gasoline Unleaded (Proposed). United States Environmental Protection Agency. Washington, DC. 2009a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cc17&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    139) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Biphenyl (Proposed). United States Environmental Protection Agency. Washington, DC. 2005j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064801ea1b7&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    140) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Bis-Chloromethyl Ether (BCME) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006n. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648022db11&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    141) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Boron Tribromide (Proposed). United States Environmental Protection Agency. Washington, DC. 2008a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803ae1d3&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    142) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Bromine Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2007d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648039732a&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    143) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Bromoacetone (Proposed). United States Environmental Protection Agency. Washington, DC. 2008e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809187bf&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    144) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Calcium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    145) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Carbonyl Fluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2008b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803ae328&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    146) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Carbonyl Sulfide (Proposed). United States Environmental Protection Agency. Washington, DC. 2007e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648037ff26&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    147) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Chlorobenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2008c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064803a52bb&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    148) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Cyanogen (Proposed). United States Environmental Protection Agency. Washington, DC. 2008f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809187fe&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    149) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Dimethyl Phosphite (Proposed). United States Environmental Protection Agency. Washington, DC. 2009. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cbf3&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    150) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Diphenylchloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    151) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethyl Isocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648091884e&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    152) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethyl Phosphorodichloridate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480920347&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    153) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethylbenzene (Proposed). United States Environmental Protection Agency. Washington, DC. 2008g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809203e7&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    154) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ethyldichloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    155) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Germane (Proposed). United States Environmental Protection Agency. Washington, DC. 2008j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963906&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    156) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Hexafluoropropylene (Proposed). United States Environmental Protection Agency. Washington, DC. 2006. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064801ea1f5&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    157) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Ketene (Proposed). United States Environmental Protection Agency. Washington, DC. 2007. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ee7c&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    158) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Magnesium Aluminum Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    159) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Magnesium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    160) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Malathion (Proposed). United States Environmental Protection Agency. Washington, DC. 2009k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064809639df&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    161) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Mercury Vapor (Proposed). United States Environmental Protection Agency. Washington, DC. 2009b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a8a087&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    162) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyl Isothiocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963a03&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    163) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyl Parathion (Proposed). United States Environmental Protection Agency. Washington, DC. 2008l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963a57&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    164) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyl tertiary-butyl ether (Proposed). United States Environmental Protection Agency. Washington, DC. 2007a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064802a4985&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    165) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methylchlorosilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2005. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5f4&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    166) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyldichloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    167) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Methyldichlorosilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2005a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c646&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    168) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Mustard (HN1 CAS Reg. No. 538-07-8) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006a. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6cb&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    169) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Mustard (HN2 CAS Reg. No. 51-75-2) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006b. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6cb&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    170) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Mustard (HN3 CAS Reg. No. 555-77-1) (Proposed). United States Environmental Protection Agency. Washington, DC. 2006c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6cb&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    171) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Tetroxide (Proposed). United States Environmental Protection Agency. Washington, DC. 2008n. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648091855b&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    172) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Nitrogen Trifluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2009l. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963e0c&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    173) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Parathion (Proposed). United States Environmental Protection Agency. Washington, DC. 2008o. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480963e32&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    174) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Perchloryl Fluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2009c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e268&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    175) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Perfluoroisobutylene (Proposed). United States Environmental Protection Agency. Washington, DC. 2009d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e26a&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    176) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phenyl Isocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008p. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096dd58&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    177) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phenyl Mercaptan (Proposed). United States Environmental Protection Agency. Washington, DC. 2006d. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020cc0c&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    178) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phenyldichloroarsine (Proposed). United States Environmental Protection Agency. Washington, DC. 2007k. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020fd29&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    179) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phorate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008q. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096dcc8&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    180) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phosgene (Draft-Revised). United States Environmental Protection Agency. Washington, DC. 2009e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a8a08a&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    181) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Phosgene Oxime (Proposed). United States Environmental Protection Agency. Washington, DC. 2009f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e26d&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    182) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Potassium Cyanide (Proposed). United States Environmental Protection Agency. Washington, DC. 2009g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cbb9&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    183) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Potassium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005c. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    184) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Propargyl Alcohol (Proposed). United States Environmental Protection Agency. Washington, DC. 2006e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ec91&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    185) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Selenium Hexafluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2006f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ec55&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    186) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Silane (Proposed). United States Environmental Protection Agency. Washington, DC. 2006g. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d523&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    187) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Sodium Cyanide (Proposed). United States Environmental Protection Agency. Washington, DC. 2009h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7cbb9&disposition=attachment&contentType=pdf. As accessed 2010-08-15.
    188) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Sodium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    189) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Strontium Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005f. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    190) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Sulfuryl Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2006h. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020ec7a&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    191) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tear Gas (Proposed). United States Environmental Protection Agency. Washington, DC. 2008s. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096e551&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    192) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tellurium Hexafluoride (Proposed). United States Environmental Protection Agency. Washington, DC. 2009i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7e2a1&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    193) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tert-Octyl Mercaptan (Proposed). United States Environmental Protection Agency. Washington, DC. 2008r. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096e5c7&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    194) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Tetramethoxysilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2006j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d632&disposition=attachment&contentType=pdf. As accessed 2010-08-17.
    195) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Trimethoxysilane (Proposed). United States Environmental Protection Agency. Washington, DC. 2006i. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d632&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    196) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Trimethyl Phosphite (Proposed). United States Environmental Protection Agency. Washington, DC. 2009j. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=0900006480a7d608&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    197) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Trimethylacetyl Chloride (Proposed). United States Environmental Protection Agency. Washington, DC. 2008t. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648096e5cc&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    198) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for Zinc Phosphide (Proposed). United States Environmental Protection Agency. Washington, DC. 2005e. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020c5ed&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    199) National Advisory Committee for Acute Exposure Guideline Levels for Hazardous Substances: Acute Exposure Guideline Levels (AEGLs) for n-Butyl Isocyanate (Proposed). United States Environmental Protection Agency. Washington, DC. 2008m. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=09000064808f9591&disposition=attachment&contentType=pdf. As accessed 2010-08-12.
    200) National Heart,Lung,and Blood Institute: Expert panel report 3: guidelines for the diagnosis and management of asthma. National Heart,Lung,and Blood Institute. Bethesda, MD. 2007. Available from URL: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.
    201) National Institute for Occupational Safety and Health: NIOSH Pocket Guide to Chemical Hazards, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Cincinnati, OH, 2007.
    202) National Research Council : Acute exposure guideline levels for selected airborne chemicals, 5, National Academies Press, Washington, DC, 2007.
    203) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 6, National Academies Press, Washington, DC, 2008.
    204) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 7, National Academies Press, Washington, DC, 2009.
    205) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 8, National Academies Press, Washington, DC, 2010.
    206) Neese Industries, Inc.: Fabric Properties Rating Chart. Neese Industries, Inc.. Gonzales, LA. 2003. Available from URL: http://www.neeseind.com/new/TechGroup.asp?Group=Fabric+Properties&Family=Technical. As accessed 4/15/2003.
    207) Nelson BK: Environ Health Perspect 1984; 57:261-271.
    208) North: Chemical Resistance Comparison Chart - Protective Footwear . North Safety. Cranston, RI. 2002. Available from URL: http://www.linkpath.com/index2gisufrm.php?t=N-USA1. As accessed April 30, 2004.
    209) North: eZ Guide Interactive Software. North Safety. Cranston, RI. 2002a. Available from URL: http://www.northsafety.com/feature1.htm. As accessed 8/31/2002.
    210) OHM/TADS : Oil and Hazardous Materials/Technical Assistance Data System. US Environmental Protection Agency. Washington, DC (Internet Version). Edition expires 1991; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    211) Osterhoudt KC: Fomepizole therapy for pediatric butoxyethanol intoxication. J Toxicol - Clin Toxicol 2002; 40:929-930.
    212) Pappas SC & Silverman M: Treatment of methanol poisoning with ethanol and hemodialysis. Can Med Assoc J 1982; 126:1391-1394.
    213) Peate WF: Work-related eye injuries and illnesses. Am Fam Physician 2007; 75(7):1017-1022.
    214) Playtex: Fits Tough Jobs Like a Glove, Playtex, Westport, CT, 1995.
    215) Product Information: ANTIZOL(R) IV injection, fomepizole IV injection. Jazz Pharmaceuticals,Inc, Palo Alto, CA, 2006.
    216) RTECS : Registry of Toxic Effects of Chemical Substances. National Institute for Occupational Safety and Health. Cincinnati, OH (Internet Version). Edition expires 1991; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    217) Rambourg-Schepens MO, Buffet M, & Bertault R: Severe ethylene glycol butyl ether poisoning. Kinetics and metabolic pattern. Human Toxicol 1988; 7:187-189.
    218) Rambourg-Schepens MO, Buffet M, & Bertault R: Severe ethylene glycol butyl ether poisoning. Kinetics and metabolic pattern. Human Toxicol 1988a; 7:187-189.
    219) Rettenmeier AW, Hennigs R, & Wodarz R: Determination of butoxyacetic acid and n-butoxyacetyl- glutamine in urine of lacquerers exposed to 2-butoxyethanol. Int Arch Occup Environ Health 1993; 65(1 Suppl):S151-S153.
    220) River City: Protective Wear Product Literature, River City, Memphis, TN, 1995.
    221) Romer KG, Bagle F, & Freundt KJ: Ethanol-induced accumulation of ethylene glycol monoalkyl ethers in rats. Drug Chem Toxicol 1985; 8:255-264.
    222) S Sweetman : Martindale: The Complete Drug Reference. Pharmaceutical Press. London, England (Internet Version). Edition expires 2002; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    223) Safety 4: North Safety Products: Chemical Protection Guide. North Safety. Cranston, RI. 2002. Available from URL: http://www.safety4.com/guide/set_guide.htm. As accessed 8/14/2002.
    224) Samuels DM: Arch Toxicol (Suppl) 1984; 7:167-170.
    225) Sax NI & Lewis RJ: Hawley's Condensed Chemical Dictionary, 11th ed, Van Nostrand Reinhold Co, New York, NY, 1987, pp 1566.
    226) Sax NI & Lewis RJ: Dangerous Properties of Industrial Materials, 7th ed, Van Nostrand Reinhold Co, New York, NY, 1989, pp 624.
    227) Servus: Norcross Safety Products, Servus Rubber, Servus, Rock Island, IL, 1995.
    228) Sivilotti MLA, Burns MJ, & McMartin KE: Toxicokinetics of ethylene glycol during fomepizole therapy: implications for management. Ann Emerg Med 2000; 36:114-125.
    229) Smallwood AW, DeBord KE, & Lowry LK: Analysis of ethylene glycol monoalkyl ethers and their proposed metabolites in blood and urine. Environ Health Perspect 1984; 57:249-253.
    230) Standard Safety Equipment: Product Literature, Standard Safety Equipment, McHenry, IL, 1995.
    231) Stolbach A & Hoffman RS: Respiratory Principles. In: Nelson LS, Hoffman RS, Lewin NA, et al, eds. Goldfrank's Toxicologic Emergencies, 9th ed. McGraw Hill Medical, New York, NY, 2011.
    232) Tingley: Chemical Degradation for Footwear and Clothing. Tingley. South Plainfield, NJ. 2002. Available from URL: http://www.tingleyrubber.com/tingley/Guide_ChemDeg.pdf. As accessed 10/16/2002.
    233) Trelleborg-Viking, Inc.: Chemical and Biological Tests (database). Trelleborg-Viking, Inc.. Portsmouth, NH. 2002. Available from URL: http://www.trelleborg.com/protective/. As accessed 10/18/2002.
    234) Trelleborg-Viking, Inc.: Trellchem Chemical Protective Suits, Interactive manual & Chemical Database. Trelleborg-Viking, Inc.. Portsmouth, NH. 2001.
    235) Tyl RW, Millicovsky G, & Dodd DE: A teratologic evaluation of ethylene glycol monobutyl ether in Fischer 344 rats and New Zealand white rabbits following inhalation exposure. Environ Health Perspect 1984; 57:47-68.
    236) U.S. Department of Energy, Office of Emergency Management: Protective Action Criteria (PAC) with AEGLs, ERPGs, & TEELs: Rev. 26 for chemicals of concern. U.S. Department of Energy, Office of Emergency Management. Washington, DC. 2010. Available from URL: http://www.hss.doe.gov/HealthSafety/WSHP/Chem_Safety/teel.html. As accessed 2011-06-27.
    237) U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project : 11th Report on Carcinogens. U.S. Department of Health and Human Services, Public Health Service, National Toxicology Program. Washington, DC. 2005. Available from URL: http://ntp.niehs.nih.gov/INDEXA5E1.HTM?objectid=32BA9724-F1F6-975E-7FCE50709CB4C932. As accessed 2011-06-27.
    238) U.S. Environmental Protection Agency: Discarded commercial chemical products, off-specification species, container residues, and spill residues thereof. Environmental Protection Agency's (EPA) Resource Conservation and Recovery Act (RCRA); List of hazardous substances and reportable quantities 2010b; 40CFR(261.33, e-f):77-.
    239) U.S. Environmental Protection Agency: Integrated Risk Information System (IRIS). U.S. Environmental Protection Agency. Washington, DC. 2011. Available from URL: http://cfpub.epa.gov/ncea/iris/index.cfm?fuseaction=iris.showSubstanceList&list_type=date. As accessed 2011-06-21.
    240) U.S. Environmental Protection Agency: List of Radionuclides. U.S. Environmental Protection Agency. Washington, DC. 2010a. Available from URL: http://www.gpo.gov/fdsys/pkg/CFR-2010-title40-vol27/pdf/CFR-2010-title40-vol27-sec302-4.pdf. As accessed 2011-06-17.
    241) U.S. Environmental Protection Agency: List of hazardous substances and reportable quantities. U.S. Environmental Protection Agency. Washington, DC. 2010. Available from URL: http://www.gpo.gov/fdsys/pkg/CFR-2010-title40-vol27/pdf/CFR-2010-title40-vol27-sec302-4.pdf. As accessed 2011-06-17.
    242) U.S. Environmental Protection Agency: The list of extremely hazardous substances and their threshold planning quantities (CAS Number Order). U.S. Environmental Protection Agency. Washington, DC. 2010c. Available from URL: http://www.gpo.gov/fdsys/pkg/CFR-2010-title40-vol27/pdf/CFR-2010-title40-vol27-part355.pdf. As accessed 2011-06-17.
    243) U.S. Occupational Safety and Health Administration: Part 1910 - Occupational safety and health standards (continued) Occupational Safety, and Health Administration's (OSHA) list of highly hazardous chemicals, toxics and reactives. Subpart Z - toxic and hazardous substances. CFR 2010 2010; Vol6(SEC1910):7-.
    244) U.S. Occupational Safety, and Health Administration (OSHA): Process safety management of highly hazardous chemicals. 29 CFR 2010 2010; 29(1910.119):348-.
    245) United States Environmental Protection Agency Office of Pollution Prevention and Toxics: Acute Exposure Guideline Levels (AEGLs) for Vinyl Acetate (Proposed). United States Environmental Protection Agency. Washington, DC. 2006. Available from URL: http://www.regulations.gov/search/Regs/contentStreamer?objectId=090000648020d6af&disposition=attachment&contentType=pdf. As accessed 2010-08-16.
    246) Wells Lamont Industrial: Chemical Resistant Glove Application Chart. Wells Lamont Industrial. Morton Grove, IL. 2002. Available from URL: http://www.wellslamontindustry.com. As accessed 10/31/2002.
    247) Willson DF, Truwit JD, Conaway MR, et al: The adult calfactant in acute respiratory distress syndrome (CARDS) trial. Chest 2015; 148(2):356-364.
    248) Wilson DF, Thomas NJ, Markovitz BP, et al: Effect of exogenous surfactant (calfactant) in pediatric acute lung injury. A randomized controlled trial. JAMA 2005; 293:470-476.
    249) Workrite: Chemical Splash Protection Garments, Technical Data and Application Guide, W.L. Gore Material Chemical Resistance Guide, Workrite, Oxnard, CA, 1997.