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ALUM

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Alum compounds consist of aluminum ammonium sulfate, aluminum potassium sulfate, sodium aluminum sulfate and aluminum sulfate anhydrous. These compounds are generally classified as astringents and have slightly acidic properties. They are mucous membrane irritants and neurotoxic agents when absorbed systemically.

Specific Substances

    A) Ammonium aluminum sulfate
    1) Ammonia alum
    2) Ammonium alum
    Aluminum sulfate anhydrous
    1) Cake alum
    2) Concentrated alum
    3) Papermaker's alum
    4) Patent alum
    5) Pearl alum
    6) Pickle alum
    Potassium aluminum sulfate dodecahydrate
    1) Alum flour
    2) Alum meal
    3) Crude lump alum
    4) Cube alum
    5) Kalinite
    6) Potash alum
    7) Potassium alum
    8) Rock alum
    9) CAS 7784-24-9
    Potassium aluminum sulfate, anhydrous
    1) Burnt alum
    2) Dried alum
    3) Exsiccated alum
    Sodium aluminum sulfate
    1) Alum baking powder
    2) Porous alum
    3) Soda alum
    GENERAL TERMS
    1) DIALUMINUM TRISULFATE SOLUTION
    2) ALUMINUM ALUM SOLUTION
    3) ALUMINUM SULFATE (3:2)
    4) ALUMINUM SULFATE, SOLID
    5) ALUMINUM TRISULFATE SOLUTION
    6) CAKE ALUM SOLUTION
    7) DIALUMINUM SULFATE SOLUTION
    8) DIALUMINUM SULPHATE SOLUTION
    9) PICKEL ALUM
    10) ALAUN (GERMAN)
    11) SULFURIC ACID, ALUMINUM SALT SOLUTION
    12) ALUM SULFATE SOLUTION
    13) ALUM SOLUTION

    1.2.1) MOLECULAR FORMULA
    1) O12-S3.2Al

Available Forms Sources

    A) FORMS
    1) Aluminum sulfate is an odorless, white to light gray solid which occurs as lustrous crystals, pieces, granules, or in powder form (Budavari, 1996; CHRIS , 1992; HSDB , 1999).
    2) The commercial product is also known as CAKE ALUM or PATENT ALUM. It is about 99.5% pure (Budavari, 1996).
    B) USES
    1) Some baking powders may contain sodium alum. Styptic pencils consist of potassium alum fused with a small amount of potassium nitrate. Powdered or lump alum is available for topical astringent purposes. Dried alum is used for water purification.
    2) Alum is used in fabric and printing dyeing, in tanning, hardening gelatin, clarifying sugar, hardening plaster, copper plating, as a mordant, and reagent (Budavari, 1996).
    3) This compound is used in tanning leather; in sizing paper; as a mordant in dyeing; in purifying water; in the manufacture of aluminum resinate; in fire-proofing and waterproofing cloth; in clarifying oils and fats; in treating sewage; in waterproofing concrete; in deodorizing and decolorizing petroleum; in antiperspirants; in agricultural pesticides; in the manufacture of aluminum salts (Budavari, 1996).
    4) Aluminum sulfate is applied to soil, especially in the western US, to make it less alkaline. In the eastern US, it is used to produce an acid condition for such plants as rhododendrons, azaleas, camellias, and blueberries (HSDB , 1999).

Overview

Life Support

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

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) Alums are acidic compounds which cause irritation in eyes, on mucous membranes, in the respiratory tract, and on abraded skin. Symptoms following ingestion reflect irritant properties and can range from mild cramping and nausea to severe vomiting and hemorrhagic gastroenteritis depending on the concentration and the amount ingested. Anhydrous aluminum sulfate and dried alum are more irritating than other alums.
    B) Patients with renal failure may more readily accumulate toxic levels of aluminum which can result in encephalopathy and seizures.
    0.2.4) HEENT
    A) Inhalation of dust or mist is irritating to the eyes, nose, mouth and respiratory tract.
    0.2.6) RESPIRATORY
    A) Inhalation is irritating and may cause airway congestion. Symptoms are usually transient. Respiratory depression has been reported in patients with severe aluminum encephalopathy.
    0.2.7) NEUROLOGIC
    A) Aluminum accumulates in brain tissue and is a neurotoxic agent. Ataxia and seizures have been reported following ingestions and in patients with compromised renal function receiving bladder irrigations.
    B) Mental status changes, including obtundation, lethargy and confusion, may occur.
    0.2.8) GASTROINTESTINAL
    A) Ingestions of small amounts of alum may cause dryness and a puckering sensation of mucous membranes in the mouth and throat. Rectal enemas containing 1% ammonium alum caused mild cramping and nausea in the majority of patients.
    B) Ingestions of large doses may cause more severe gastrointestinal symptoms or vomiting and diarrhea. Solutions greater than 20% may produce gingival necrosis and fatal hemorrhagic gastroenteritis, although this is not well documented.
    0.2.9) HEPATIC
    A) Liver damage has been reported in acute and chronic toxicity.
    B) Liver necrosis has been reported in animal studies.
    0.2.10) GENITOURINARY
    A) Renal necrosis has been reported in animal studies.
    B) Vaginal mucosal erosions have been reported following instillation of concentrated intravaginal alum.
    0.2.11) ACID-BASE
    A) Metabolic acidosis has been reported.
    0.2.14) DERMATOLOGIC
    A) Concentrated solutions may irritate abraded skin.
    B) Anesthesia of the fingers may occur from prolonged contact.
    0.2.20) REPRODUCTIVE
    A) An increase in talipes was reported for infants of mothers exposed to excessive aluminum sulfate levels in drinking water.

Laboratory Monitoring

    A) Monitor serum aluminum levels in symptomatic patients, or following large exposures, especially in patients with renal dysfunction.
    B) Monitor hepatic and renal function in substantial ingestions.
    C) Monitor for CNS effects, especially in larger exposures and in patients with renal dysfunction.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) Ingestions of small quantities or dilute solutions are unlikely to produce major toxicity, and dilution may be all that is required.
    B) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting.
    C) Do not induce vomiting or give bicarbonate to neutralize.
    D) Consider aspiration of gastric contents with a small flexible nasogastric tube after large ingestions of high concentration alum compounds. The risk of mucosal injury may outweigh the potential benefits.
    E) Observe patients with ingestion carefully for the possible development of esophageal or gastrointestinal tract irritation or burns. If signs or symptoms of esophageal irritation or burns are present, consider endoscopy to determine the extent of injury.
    F) SEIZURES: Administer a benzodiazepine; DIAZEPAM (ADULT: 5 to 10 mg IV initially; repeat every 5 to 20 minutes as needed. CHILD: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed) or LORAZEPAM (ADULT: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist. CHILD: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue).
    1) Consider phenobarbital or propofol if seizures recur after diazepam 30 mg (adults) or 10 mg (children greater than 5 years).
    2) Monitor for hypotension, dysrhythmias, respiratory depression, and need for endotracheal intubation. Evaluate for hypoglycemia, electrolyte disturbances, and hypoxia.
    G) DEFEROXAMINE MESYLATE DOSE ADULT/CHILD
    1) ACUTE IRON INTOXICATION: ADULT: Administer deferoxamine by continuous IV infusion at a rate of 15 mg/kg/hour. It can be titrated up to a rate of 40 mg/kg/hour for patients with life-threatening iron toxicity, although hypotension may occur with higher doses, and the rate should be decreased if this develops. CHILD: Administer deferoxamine by continuous IV infusion at a rate of 15 mg/kg/hour. Infusion rates up to 35 mg/kg/hour have been used in children with severe overdoses without adverse effects, although hypotension may occur with higher doses, and the rate should be decreased if this develops. DURATION: Continuous infusion is generally 12 hours in patients with moderate poisoning, up to 24 hours in patients with severe poisoning. The patient should be titrated off the infusion if clinically improving. If the patient worsens as the deferoxamine is titrated off, it should be restarted. Infusions of greater than 24 hours have been associated with acute lung injury and should be avoided.
    0.4.3) INHALATION EXPOSURE
    A) INHALATION: Move patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer oxygen and assist ventilation as required. Treat bronchospasm with an inhaled beta2-adrenergic agonist. Consider systemic corticosteroids in patients with significant bronchospasm.
    0.4.4) EYE EXPOSURE
    A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Range Of Toxicity

    A) MINIMUM LETHAL DOSE - Fatalities are not well documented but have been reported following ingestions of 30 grams in an adult and 2 to 4 grams in children. Death was attributed to severe gastrointestinal irritation.

Clinical Effects

Summary Of Exposure

    A) Alums are acidic compounds which cause irritation in eyes, on mucous membranes, in the respiratory tract, and on abraded skin. Symptoms following ingestion reflect irritant properties and can range from mild cramping and nausea to severe vomiting and hemorrhagic gastroenteritis depending on the concentration and the amount ingested. Anhydrous aluminum sulfate and dried alum are more irritating than other alums.
    B) Patients with renal failure may more readily accumulate toxic levels of aluminum which can result in encephalopathy and seizures.

Heent

    3.4.1) SUMMARY
    A) Inhalation of dust or mist is irritating to the eyes, nose, mouth and respiratory tract.
    3.4.3) EYES
    A) IRRITATION - Dust and mist is irritating to eyes (HSDB , 1999). Irritation resolved in a day or two (Grant & Schuman, 1993). Aqueous 1% solutions have been used therapeutically in the eye (Grant & Schuman, 1993).
    3.4.5) NOSE
    A) IRRITATION - Inhalation of dust or mist is irritating.
    3.4.6) THROAT
    A) IRRITATION - Inhalation of dust or mist is irritating to respiratory tract and mouth. Ingestion produces a feeling of dryness and puckering of mucous membranes of the mouth and throat (FDA, 1982).

Respiratory

    3.6.1) SUMMARY
    A) Inhalation is irritating and may cause airway congestion. Symptoms are usually transient. Respiratory depression has been reported in patients with severe aluminum encephalopathy.
    3.6.2) CLINICAL EFFECTS
    A) IRRITATION SYMPTOM
    1) Inhalation of dust or mist is irritating and may cause airway congestion and constriction in rare instances. Symptoms are usually transient.
    B) ACUTE RESPIRATORY INSUFFICIENCY
    1) CASE REPORT - Respiratory depression has been reported in an 87-year-old male following 48 hours of bladder irrigation with 9.6 liters of 1% alum solution. Toxic serum levels peaked at 7,014 nmol/L of aluminum (Shoskes et al, 1992).

Neurologic

    3.7.1) SUMMARY
    A) Aluminum accumulates in brain tissue and is a neurotoxic agent. Ataxia and seizures have been reported following ingestions and in patients with compromised renal function receiving bladder irrigations.
    B) Mental status changes, including obtundation, lethargy and confusion, may occur.
    3.7.2) CLINICAL EFFECTS
    A) SEIZURE
    1) Ataxia and seizures have been reported following ingestion of concentrated solutions (greater than 20%) (Gosselin et al, 1984).
    2) CASE REPORT - Three episodes of tonic-clonic seizures were reported in a 30-year-old male following 400 liters of 1% alum bladder irrigation for hemorrhagic cystitis. Plasma aluminum levels were in the toxic range (Murphy et al, 1992).
    3) CASE REPORT - Myoclonus and obtundation were reported in a 31-year-old female with renal failure and hemorrhagic cystitis who was receiving 1% alum bladder irrigations and developed toxic levels. Despite deferoxamine chelation therapy, her mental status declined and she died as a result of an intracerebral bleed (Perazella & Brown, 1993).
    B) TOXIC ENCEPHALOPATHY
    1) Aluminum-induced encephalopathy (confusion, dysarthria, asterixis, seizure, coma) has been reported in several patients following several days to weeks of bladder irrigation with alum (usual concentration is 1%). Most of these patients had some degree of renal insufficiency at the time of treatment, which may promote accumulation of neurotoxic quantities of aluminum. It has been speculated that aluminum may also penetrate into the systemic circulation via a hemorrhagic bladder. Irrigation with alum in these patients may lead to markedly elevated serum aluminum levels, temporally associated with an acute encephalopathy. Symptoms appear to be reversible when serum aluminum concentrations are reduced (Nakamura et al, 2000; Phelps et al, 1999).
    2) CASE REPORT - Lethargy and obtundation were reported in an 81-year-old male following bladder irrigation with 1% alum for hemorrhagic cystitis due to bladder carcinoma. Serum aluminum level was 294 mcg/L (normal = 0-20 mcg/L). No seizures occurred and EEG remained normal. Treatment included charcoal hemoperfusion and deferoxamine (Sing et al, 1993).
    3) CASE REPORT - Lethargy and respiratory depression occurred in an 87-year-old male with bladder cancer following an irrigation with 1% alum (9.6 liters over 48 hr, equivalent to 96 grams aluminum sulfate or 9.6 grams free aluminum). Serum aluminum level peaked at 7,014 nmol/L. The patient died the day after discontinuing alum (Shoskes et al, 1992).
    4) CASE REPORT - Murphy et al (1992) report a case of decreased mental status, lethargy and disorientation in a 30-year-old male with cyclophosphamide-induced hemorrhagic cystitis treated with 400 liters of 1% alum bladder irrigation over 7 days. Plasma alum level of 1.48 mmol/L (normal 0.1-0.37 mmol/L) was reported.
    5) CASE REPORT - A 15-year-old girl with acute lymphoblastic leukemia developed euphoria, lip smacking, eye rolling, impaired short term memory, and nominal aphasia after receiving intravesical 1% alum irrigation for 12 days (total 19 grams aluminum). Serum aluminum concentration was 14 micrograms/liter, bone marrow biopsy demonstrated aluminum deposition and EEG revealed diffuse bilateral slowing with bursts of fast activity. Symptoms resolved with discontinuation of the alum and treatment with deferoxamine (Kanwar et al, 1996).
    C) AMNESIA
    1) CASE SERIES - McMillan et al (1993) have reported on patients who accidentally drank aluminum sulfate contaminated water and later presented with cognitive impairments. Ten patients evaluated 8 and 26 months following the poisoning showed evidence of memory and information processing impairment. It is unclear whether this is due to acute neurotoxic effects of alum or perhaps psychological stress.
    2) CASE SERIES - In a retrospective study of 55 people exposed to drinking water contaminated with aluminum sulfate (Camelford water incident: 20 tons of aluminum sulfate accidentally emptied into a treated water reservoir), Altmann et al (1999) concluded that this group sustained considerable damage to cerebral function, not related to anxiety, as investigated 3 years after the incident. Other authors have disputed these results, stating a biased self selection of cases, improper study design and methodological flaws, and absence of physiological measures of absorption of aluminum and other toxins at the time of the incident (David, 2000; Esmonde, 2000; McMillan, 2000; Murray et al, 2000).

Gastrointestinal

    3.8.1) SUMMARY
    A) Ingestions of small amounts of alum may cause dryness and a puckering sensation of mucous membranes in the mouth and throat. Rectal enemas containing 1% ammonium alum caused mild cramping and nausea in the majority of patients.
    B) Ingestions of large doses may cause more severe gastrointestinal symptoms or vomiting and diarrhea. Solutions greater than 20% may produce gingival necrosis and fatal hemorrhagic gastroenteritis, although this is not well documented.
    3.8.2) CLINICAL EFFECTS
    A) APTYALISM
    1) Ingestion of small amounts of alum may cause dryness and a puckering sensation of mucous membranes in the mouth and throat (FDA, 1982).
    B) GASTRITIS
    1) Rectal enemas containing 1% ammonium alum caused mild cramping and nausea in the majority of patients (Wyatt, 1966). Ingestion of large doses may cause more severe gastrointestinal symptoms of vomiting and diarrhea (FDA, 1982; CHRIS , 1992).
    C) GASTROENTERITIS
    1) Concentrated solutions (greater than 20%) have produced gingival necrosis and fatal hemorrhagic gastroenteritis, although this is not well documented (Gosselin et al, 1984).

Hepatic

    3.9.1) SUMMARY
    A) Liver damage has been reported in acute and chronic toxicity.
    B) Liver necrosis has been reported in animal studies.
    3.9.2) CLINICAL EFFECTS
    A) LIVER DAMAGE
    1) CASE REPORT - A liver biopsy revealed diffuse hepatocellular swelling accompanied by portal venous dilatation and portal triaditis, with no necrosis, cholestasis, or hemorrhage, in a 23-year-old female who chronically ingested baking powder, up to 7 oz/day. Sodium bicarbonate and calcium sulfate and phosphate are also main constituents of baking powder and probably contributed to this adverse event (Barton et al, 1992).
    B) HEPATIC FAILURE
    1) CASE REPORT - Liver failure associated with acute toxic aluminum levels was reported in an 81-year-old male treated with 1% alum bladder irrigations for hemorrhagic cystitis (Sing et al, 1993).
    3.9.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) HEPATIC NECROSIS
    a) Central liver necrosis has been observed in animal poisonings (Gosselin et al, 1984).

Genitourinary

    3.10.1) SUMMARY
    A) Renal necrosis has been reported in animal studies.
    B) Vaginal mucosal erosions have been reported following instillation of concentrated intravaginal alum.
    3.10.2) CLINICAL EFFECTS
    A) VAGINITIS
    1) Alum douche has been used in conjunction with sitz baths in certain ethnic groups as a healing method for the perineal area. In one case, a 17-year-old girl instilled alum crystals, instead of a less concentrated douche solution, vaginally and experienced vulvar edema and gray-yellow charring of the vaginal mucosa with areas of ulceration (Hahn et al, 2001).
    3.10.3) ANIMAL EFFECTS
    A) ANIMAL STUDIES
    1) NEPHRITIS
    a) Nephritis has been observed in animal poisonings (Gosselin et al, 1984).

Acid-Base

    3.11.1) SUMMARY
    A) Metabolic acidosis has been reported.
    3.11.2) CLINICAL EFFECTS
    A) ACIDOSIS
    1) CASE REPORT - Mild metabolic acidosis was reported in an elderly male after treatment with 9.6 liters of 1% alum solution in a bladder irrigation. Compromised kidney function and bladder carcinoma were underlying factors, probably resulting in increased sulfate ion retention (Shoskes et al, 1992).

Hematologic

    3.13.2) CLINICAL EFFECTS
    A) DISSEMINATED INTRAVASCULAR COAGULATION
    1) CASE REPORT - Death from disseminated intravascular coagulation (DIC) was reported in an 81-year-old male with prostate and bladder cancer who had received 1% alum bladder irrigations and developed acute toxic aluminum levels (Sing et al, 1993).

Dermatologic

    3.14.1) SUMMARY
    A) Concentrated solutions may irritate abraded skin.
    B) Anesthesia of the fingers may occur from prolonged contact.
    3.14.2) CLINICAL EFFECTS
    A) SKIN IRRITATION
    1) Concentrated solutions may irritate abraded skin. Solutions of 5% to 10% have been used to harden the epidermis in patients with soft corns or sore feet (JEF Reynolds , 1988). Crystalline alum-containing deodorants have been reported to cause an irritant dermatitis (erythematous, pruritic eruption) several days after commencing use of this product (Gallego et al, 1999).
    B) ANESTHESIA OF SKIN
    1) Anesthesia of the fingers (acroanesthesia) may occur from prolonged contact with alum (White, 1934).

Musculoskeletal

    3.15.2) CLINICAL EFFECTS
    A) DISORDER OF BONE
    1) BONE UPTAKE - Aluminum lines in bone biopsy specimens have been reported in two individuals exposed to high levels of aluminum in their drinking water for one month, then biopsied 7 months later. This indicated that aluminum can be absorbed from the gut, and excess levels can be deposited in bone. Although both patients exhibited acute oral irritation at the time of exposure, no clinical signs associated with bone were noted (Eastwood et al, 1990).
    2) Aluminum deposition has been demonstrated in bone biopsy specimens taken from a patient who developed aluminum encephalopathy after intravesical alum instillation (Kanwar et al, 1996).
    B) JOINT PAIN
    1) Painful joints were reported more frequently in a population exposed to alum in contaminated drinking water (relative risk 2.0, 95% CI 1.2 to 3.2) (Rowland et al, 1990).

Reproductive

    3.20.1) SUMMARY
    A) An increase in talipes was reported for infants of mothers exposed to excessive aluminum sulfate levels in drinking water.
    3.20.2) TERATOGENICITY
    A) SKELETAL MALFORMATION
    1) ALUMINUM SULFATE - 88 women exposed during pregnancy to excessive aluminum sulfate levels in drinking water were compared to 2 groups of unexposed controls. Outcome of pregnancy, fetal viability and birthweight parameters were the same for the three groups. The only significant difference found was an increase in talipes reported for infants of exposed mothers (4 cases vs one control) (Golding et al, 1991).

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS10043-01-3 (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004):
    1) Not Listed

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor serum aluminum levels in symptomatic patients, or following large exposures, especially in patients with renal dysfunction.
    B) Monitor hepatic and renal function in substantial ingestions.
    C) Monitor for CNS effects, especially in larger exposures and in patients with renal dysfunction.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Monitor serum aluminum levels in symptomatic patients or after large exposures, particularly when renal dysfunction is present. A normal level is less than 40 mcg/L.
    2) Monitor hepatic and renal function in substantial ingestions.
    3) Monitor serum electrolytes in symptomatic patients or after large exposures.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Monitoring

    A) Monitor serum aluminum levels in symptomatic patients, or following large exposures, especially in patients with renal dysfunction.
    B) Monitor hepatic and renal function in substantial ingestions.
    C) Monitor for CNS effects, especially in larger exposures and in patients with renal dysfunction.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    B) ACTIVATED CHARCOAL
    1) Activated charcoal may induce vomiting and obscure endoscopy findings. It is not recommended after ingestion of high concentration alum compounds.
    6.5.2) PREVENTION OF ABSORPTION
    A) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    B) GASTRIC LAVAGE
    1) Do not induce vomiting or give bicarbonate to neutralize. Passing a small, flexible nasogastric or orogastric tube into the stomach to aspirate gastric contents is controversial; the potential benefits must be weighed against the risk of worsening mucosal damage.
    C) ACTIVATED CHARCOAL
    1) Activated charcoal may induce vomiting and obscure endoscopy findings. It is not recommended for use after ingestion of high concentrations of alum.
    6.5.3) TREATMENT
    A) IRRITATION SYMPTOM
    1) Observe patients with ingestion carefully for the possible development of esophageal or gastrointestinal tract irritation or burns. If signs or symptoms of esophageal irritation or burns are present, consider endoscopy to determine the extent of injury.
    B) SEIZURE
    1) SUMMARY
    a) Attempt initial control with a benzodiazepine (eg, diazepam, lorazepam). If seizures persist or recur, administer phenobarbital or propofol.
    b) Monitor for respiratory depression, hypotension, and dysrhythmias. Endotracheal intubation should be performed in patients with persistent seizures.
    c) Evaluate for hypoxia, electrolyte disturbances, and hypoglycemia (or, if immediate bedside glucose testing is not available, treat with intravenous dextrose).
    2) DIAZEPAM
    a) ADULT DOSE: Initially 5 to 10 mg IV, OR 0.15 mg/kg IV up to 10 mg per dose up to a rate of 5 mg/minute; may be repeated every 5 to 20 minutes as needed (Brophy et al, 2012; Prod Info diazepam IM, IV injection, 2008; Manno, 2003).
    b) PEDIATRIC DOSE: 0.1 to 0.5 mg/kg IV over 2 to 5 minutes; up to a maximum of 10 mg/dose. May repeat dose every 5 to 10 minutes as needed (Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008).
    c) Monitor for hypotension, respiratory depression, and the need for endotracheal intubation. Consider a second agent if seizures persist or recur after repeated doses of diazepam .
    3) NO INTRAVENOUS ACCESS
    a) DIAZEPAM may be given rectally or intramuscularly (Manno, 2003). RECTAL DOSE: CHILD: Greater than 12 years: 0.2 mg/kg; 6 to 11 years: 0.3 mg/kg; 2 to 5 years: 0.5 mg/kg (Brophy et al, 2012).
    b) MIDAZOLAM has been used intramuscularly and intranasally, particularly in children when intravenous access has not been established. ADULT DOSE: 0.2 mg/kg IM, up to a maximum dose of 10 mg (Brophy et al, 2012). PEDIATRIC DOSE: INTRAMUSCULAR: 0.2 mg/kg IM, up to a maximum dose of 7 mg (Chamberlain et al, 1997) OR 10 mg IM (weight greater than 40 kg); 5 mg IM (weight 13 to 40 kg); INTRANASAL: 0.2 to 0.5 mg/kg up to a maximum of 10 mg/dose (Loddenkemper & Goodkin, 2011; Brophy et al, 2012). BUCCAL midazolam, 10 mg, has been used in adolescents and older children (5-years-old or more) to control seizures when intravenous access was not established (Scott et al, 1999).
    4) LORAZEPAM
    a) MAXIMUM RATE: The rate of intravenous administration of lorazepam should not exceed 2 mg/min (Brophy et al, 2012; Prod Info lorazepam IM, IV injection, 2008).
    b) ADULT DOSE: 2 to 4 mg IV initially; repeat every 5 to 10 minutes as needed, if seizures persist (Manno, 2003; Brophy et al, 2012).
    c) PEDIATRIC DOSE: 0.05 to 0.1 mg/kg IV over 2 to 5 minutes, up to a maximum of 4 mg/dose; may repeat in 5 to 15 minutes as needed, if seizures continue (Brophy et al, 2012; Loddenkemper & Goodkin, 2011; Hegenbarth & American Academy of Pediatrics Committee on Drugs, 2008; Sreenath et al, 2009; Chin et al, 2008).
    5) PHENOBARBITAL
    a) ADULT LOADING DOSE: 20 mg/kg IV at an infusion rate of 50 to 100 mg/minute IV. An additional 5 to 10 mg/kg dose may be given 10 minutes after loading infusion if seizures persist or recur (Brophy et al, 2012).
    b) Patients receiving high doses will require endotracheal intubation and may require vasopressor support (Brophy et al, 2012).
    c) PEDIATRIC LOADING DOSE: 20 mg/kg may be given as single or divided application (2 mg/kg/minute in children weighing less than 40 kg up to 100 mg/min in children weighing greater than 40 kg). A plasma concentration of about 20 mg/L will be achieved by this dose (Loddenkemper & Goodkin, 2011).
    d) REPEAT PEDIATRIC DOSE: Repeat doses of 5 to 20 mg/kg may be given every 15 to 20 minutes if seizures persist, with cardiorespiratory monitoring (Loddenkemper & Goodkin, 2011).
    e) MONITOR: For hypotension, respiratory depression, and the need for endotracheal intubation (Loddenkemper & Goodkin, 2011; Manno, 2003).
    f) SERUM CONCENTRATION MONITORING: Monitor serum concentrations over the next 12 to 24 hours. Therapeutic serum concentrations of phenobarbital range from 10 to 40 mcg/mL, although the optimal plasma concentration for some individuals may vary outside this range (Hvidberg & Dam, 1976; Choonara & Rane, 1990; AMA Department of Drugs, 1992).
    6) OTHER AGENTS
    a) If seizures persist after phenobarbital, propofol or pentobarbital infusion, or neuromuscular paralysis with general anesthesia (isoflurane) and continuous EEG monitoring should be considered (Manno, 2003). Other anticonvulsants can be considered (eg, valproate sodium, levetiracetam, lacosamide, topiramate) if seizures persist or recur; however, there is very little data regarding their use in toxin induced seizures, controlled trials are not available to define the optimal dosage ranges for these agents in status epilepticus (Brophy et al, 2012):
    1) VALPROATE SODIUM: ADULT DOSE: An initial dose of 20 to 40 mg/kg IV, at a rate of 3 to 6 mg/kg/minute; may give an additional dose of 20 mg/kg 10 minutes after loading infusion. PEDIATRIC DOSE: 1.5 to 3 mg/kg/minute (Brophy et al, 2012).
    2) LEVETIRACETAM: ADULT DOSE: 1000 to 3000 mg IV, at a rate of 2 to 5 mg/kg/min IV. PEDIATRIC DOSE: 20 to 60 mg/kg IV (Brophy et al, 2012; Loddenkemper & Goodkin, 2011).
    3) LACOSAMIDE: ADULT DOSE: 200 to 400 mg IV; 200 mg IV over 15 minutes (Brophy et al, 2012). PEDIATRIC DOSE: In one study, median starting doses of 1.3 mg/kg/day and maintenance doses of 4.7 mg/kg/day were used in children 8 years and older (Loddenkemper & Goodkin, 2011).
    4) TOPIRAMATE: ADULT DOSE: 200 to 400 mg nasogastric/orally OR 300 to 1600 mg/day orally divided in 2 to 4 times daily (Brophy et al, 2012).
    C) DEFEROXAMINE
    1) In patients with evidence of aluminum encephalopathy after alum exposure (most commonly from intravesical irrigation) deferoxamine has been given alone and before and after charcoal hemoperfusion to decrease serum aluminum levels (Sing et al, 1993; Perazella & Brown, 1993; Kanwar et al, 1996). Aluminum-DFO complexes may have limited clearance by available hemodialysis membranes (Perazella & Brown, 1993).
    a) Deferoxamine and aluminoxamine are eliminated mainly via the kidney, with elimination half-lives significantly prolonged in patients with renal impairment. It has been suggested to administer deferoxamine in conjunction with hemodialysis in patients with renal insufficiency since deferoxamine alone may cause exacerbation of aluminum toxicity due to mobilization of aluminum from body storage sites into blood. An optimal deferoxamine dose for treatment of aluminum intoxication has not yet been clearly defined (Nakamura et al, 2000).
    2) DEFEROXAMINE MESYLATE DOSE ADULT/CHILD
    a) ACUTE IRON INTOXICATION: ADULT: Administer deferoxamine by continuous IV infusion at a rate of 15 mg/kg/hour. It can be titrated up to a rate of 40 mg/kg/hour for patients with life-threatening iron toxicity, although hypotension may occur with higher doses, and the rate should be decreased if this develops. CHILD: Administer deferoxamine by continuous IV infusion at a rate of 15 mg/kg/hour. Infusion rates up to 35 mg/kg/hour have been used in children with severe overdoses without adverse effects, although hypotension may occur with higher doses, and the rate should be decreased if this develops. DURATION: Continuous infusion is generally 12 hours in patients with moderate poisoning, up to 24 hours in patients with severe poisoning. The patient should be titrated off the infusion if clinically improving. If the patient worsens as the deferoxamine is titrated off, it should be restarted. Infusions of greater than 24 hours have been associated with acute lung injury and should be avoided.
    D) ENDOSCOPIC PROCEDURE
    1) There is little information available regarding the use of endoscopy, corticosteroids or surgery after ingestion of concentrated alum products. The following information is derived from experience with other caustic ingestions.
    2) SUMMARY: Obtain consultation concerning endoscopy as soon as possible, and perform endoscopy within the first 24 hours when indicated.
    3) INDICATIONS: Endoscopy should be performed in adults with a history of deliberate ingestion, adults with any signs or symptoms attributable to inadvertent ingestion, and in children with stridor, vomiting, or drooling after unintentional ingestion (Crain et al, 1984). Endoscopy should also be performed in children with dysphagia or refusal to swallow, significant oral burns, or abdominal pain after unintentional ingestion (Gaudreault et al, 1983; Nuutinen et al, 1994). Children and adults who are asymptomatic after accidental ingestion do not require endoscopy (Gupta et al, 2001; Lamireau et al, 2001; Gorman et al, 1992).
    4) RISKS: Numerous large case series attest to the relative safety and utility of early endoscopy in the management of caustic ingestion.
    a) REFERENCES: (Dogan et al, 2006; Symbas et al, 1983; Crain et al, 1984a; Gaudreault et al, 1983a; Schild, 1985; Moazam et al, 1987; Sugawa & Lucas, 1989; Previtera et al, 1990; Zargar et al, 1991; Vergauwen et al, 1991; Gorman et al, 1992)
    5) The risk of perforation during endoscopy is minimized by (Zargar et al, 1991):
    a) Advancing across the cricopharynx under direct vision
    b) Gently advancing with minimal air insufflation
    c) Never retroverting or retroflexing the endoscope
    d) Using a pediatric flexible endoscope
    e) Using extreme caution in advancing beyond burn lesion areas
    f) Most authors recommend endoscopy within the first 24 hours of injury, not advancing the endoscope beyond areas of severe esophageal burns, and avoiding endoscopy during the subacute phase of healing when tissue slough increases the risk of perforation (5 to 15 days after ingestion) (Zargar et al, 1991).
    6) GRADING
    a) Several scales for grading caustic injury exist. The likelihood of complications such as strictures, obstruction, bleeding, and perforation is related to the severity of the initial burn (Zargar et al, 1991):
    b) Grade 0 - Normal examination
    c) Grade 1 - Edema and hyperemia of the mucosa; strictures unlikely.
    d) Grade 2A - Friability, hemorrhages, erosions, blisters, whitish membranes, exudates and superficial ulcerations; strictures unlikely.
    e) Grade 2B - Grade 2A plus deep discreet or circumferential ulceration; strictures may develop.
    f) Grade 3A - Multiple ulcerations and small scattered areas of necrosis; strictures are common, complications such as perforation, fistula formation or gastrointestinal bleeding may occur.
    g) Grade 3B - Extensive necrosis through visceral wall; strictures are common, complications such as perforation, fistula formation, or gastrointestinal bleeding are more likely than with 3A.
    7) FOLLOW UP - If burns are found, follow 10 to 20 days later with barium swallow or esophagram.
    8) SCINTIGRAPHY - Scans utilizing radioisotope labelled sucralfate (technetium 99m) were performed in 22 patients with caustic ingestion and compared with endoscopy for the detection of esophageal burns. Two patients had minimal residual isotope activity on scanning but normal endoscopy and two patients had normal activity on scan but very mild erythema on endoscopy. Overall the radiolabeled sucralfate scan had a sensitivity of 100%, specificity of 81%, positive predictive value of 84% and negative predictive value of 100% for detecting clinically significant burns in this population (Millar et al, 2001). This may represent an alternative to endoscopy, particularly in young children, as no sedation is required for this procedure. Further study is required.
    9) MINIPROBE ULTRASONOGRAPHY - was performed in 11 patients with corrosive ingestion . Findings were categorized as grade 0 (distinct muscular layers without thickening, grade I (distinct muscular layers with thickening), grade II (obscured muscular layers with indistinct margins) and grade III (muscular layers that could not be differentiated). Findings were further categorized as to whether the worst appearing image involved part of the circumference (type a) or the whole circumference (type b). Strictures did not develop in patients with grade 0 (5 patients) or grade I (4 patients) lesions. Transient stricture formation developed in the only patient with grade IIa lesions, and stricture requiring repeated dilatation developed in the only patient with grade IIIb lesions (Kamijo et al, 2004).
    E) CORTICOSTEROID
    1) CORROSIVE INGESTION/SUMMARY: The use of corticosteroids for the treatment of caustic ingestion is controversial. Most animal studies have involved alkali-induced injury (Haller & Bachman, 1964; Saedi et al, 1973). Most human studies have been retrospective and generally involve more alkali than acid-induced injury and small numbers of patients with documented second or third degree mucosal injury.
    2) FIRST DEGREE BURNS: These burns generally heal well and rarely result in stricture formation (Zargar et al, 1989; Howell et al, 1992). Corticosteroids are generally not beneficial in these patients (Howell et al, 1992).
    3) SECOND DEGREE BURNS: Some authors recommend corticosteroid treatment to prevent stricture formation in patients with a second degree, deep-partial thickness burn (Howell et al, 1992). However, no well controlled human study has documented efficacy. Corticosteroids are generally not beneficial in patients with a second degree, superficial-partial thickness burn (Caravati, 2004; Howell et al, 1992).
    4) THIRD DEGREE BURNS: Some authors have recommended steroids in this group as well (Howell et al, 1992). A high percentage of patients with third degree burns go on to develop strictures with or without corticosteroid therapy and the risk of infection and perforation may be increased by corticosteroid use. Most authors feel that the risk outweighs any potential benefit and routine use is not recommended (Boukthir et al, 2004; Oakes et al, 1982; Pelclova & Navratil, 2005).
    5) CONTRAINDICATIONS: Include active gastrointestinal bleeding and evidence of gastric or esophageal perforation. Corticosteroids are thought to be ineffective if initiated more than 48 hours after a burn (Howell, 1987).
    6) DOSE: Administer daily oral doses of 0.1 milligram/kilogram of dexamethasone or 1 to 2 milligrams/kilogram of prednisone. Continue therapy for a total of 3 weeks and then taper (Haller et al, 1971; Marshall, 1979). An alternative regimen in children is intravenous prednisolone 2 milligrams/kilogram/day followed by 2.5 milligrams/kilogram/day of oral prednisone for a total of 3 weeks then tapered (Anderson et al, 1990).
    7) ANTIBIOTICS: Animal studies suggest that the addition of antibiotics can prevent the infectious complications associated with corticosteroid use in the setting of caustic burns. Antibiotics are recommended if corticosteroids are used or if perforation or infection is suspected. Agents that cover anaerobes and oral flora such as penicillin, ampicillin, or clindamycin are appropriate (Rosenberg et al, 1953).
    8) STUDIES
    a) ANIMAL
    1) Some animal studies have suggested that corticosteroid therapy may reduce the incidence of stricture formation after severe alkaline corrosive injury (Haller & Bachman, 1964; Saedi et al, 1973a).
    2) Animals treated with steroids and antibiotics appear to do better than animals treated with steroids alone (Haller & Bachman, 1964).
    3) Other studies have shown no evidence of reduced stricture formation in steroid treated animals (Reyes et al, 1974). An increased rate of esophageal perforation related to steroid treatment has been found in animal studies (Knox et al, 1967).
    b) HUMAN
    1) Most human studies have been retrospective and/or uncontrolled and generally involve small numbers of patients with documented second or third degree mucosal injury. No study has proven a reduced incidence of stricture formation from steroid use in human caustic ingestions (Haller et al, 1971; Hawkins et al, 1980; Yarington & Heatly, 1963; Adam & Brick, 1982).
    2) META ANALYSIS
    a) Howell et al (1992), analyzed reports concerning 361 patients with corrosive esophageal injury published in the English language literature since 1956 (10 retrospective and 3 prospective studies). No patients with first degree burns developed strictures. Of 228 patients with second or third degree burns treated with corticosteroids and antibiotics, 54 (24%) developed strictures. Of 25 patients with similar burn severity treated without steroids or antibiotics, 13 (52%) developed strictures (Howell et al, 1992).
    b) Another meta-analysis of 10 studies found that in patients with second degree esophageal burns from caustics, the overall rate of stricture formation was 14.8% in patients who received corticosteroids compared with 36% in patients who did not receive corticosteroids (LoVecchio et al, 1996).
    c) Another study combined results of 10 papers evaluating therapy for corrosive esophageal injury in humans published between January 1991 and June 2004. There were a total of 572 patients, all patients received corticosteroids in 6 studies, in 2 studies no patients received steroids, and in 2 studies, treatment with and without corticosteroids was compared. Of 109 patients with grade 2 esophageal burns who were treated with corticosteroids, 15 (13.8%) developed strictures, compared with 2 of 32 (6.3%) patients with second degree burns who did not receive steroids (Pelclova & Navratil, 2005).
    3) Smaller studies have questioned the value of steroids (Ferguson et al, 1989; Anderson et al, 1990), thus they should be used with caution.
    4) Ferguson et al (1989) retrospectively compared 10 patients who did not receive antibiotics or steroids with 31 patients who received both antibiotics and steroids in a study of caustic ingestion and found no difference in the incidence of esophageal stricture between the two groups (Ferguson et al, 1989).
    5) A randomized, controlled, prospective clinical trial involving 60 children with lye or acid induced esophageal injury did not find an effect of corticosteroids on the incidence of stricture formation (Anderson et al, 1990).
    a) These 60 children were among 131 patients who were managed and followed-up for ingestion of caustic material from 1971 through 1988; 88% of them were between 1 and 3 years old (Anderson et al, 1990).
    b) All patients underwent rigid esophagoscopy after being randomized to receive either no steroids or a course consisting initially of intravenous prednisolone (2 milligrams/kilogram per day) followed by 2.5 milligrams/kilogram/day of oral prednisone for a total of 3 weeks prior to tapering and discontinuation (Anderson et al, 1990).
    c) Six (19%), 15 (48%), and 10 (32%) of those in the treatment group had first, second and third degree esophageal burns, respectively. In contrast, 13 (45%), 5 (17%), and 11 (38%) of the control group had the same levels of injury (Anderson et al, 1990).
    d) Ten (32%) of those receiving steroids and 11 (38%) of the control group developed strictures. Four (13%) of those receiving steroids and 7 (24%) of the control group required esophageal replacement. All but 1 of the 21 children who developed strictures had severe circumferential burns on initial esophagoscopy (Anderson et al, 1990).
    e) Because of the small numbers of patients in this study, it lacked the power to reliably detect meaningful differences in outcome between the treatment groups (Anderson et al, 1990).
    6) ADVERSE EFFECTS
    a) The use of corticosteroids in the treatment of caustic ingestion in humans has been associated with gastric perforation (Cleveland et al, 1963) and fatal pulmonary embolism (Aceto et al, 1970).
    F) SURGICAL PROCEDURE
    1) In severe cases of gastrointestinal necrosis or perforation, emergent surgical consultation should be obtained. The need for gastric resection or laparotomy in the stable patient is controversial (Chodak & Passaro, 1978; Dilawari et al, 1984).
    2) LAPAROTOMY/LAPAROSCOPY - Early laparotomy or laparoscopy should be considered in patients with endoscopic evidence of severe esophageal or gastric burns after acid ingestion to evaluate for the presence of transmural gastric or esophageal necrosis (Estrera et al, 1986; Meredith et al, 1988; Wu & Lai, 1993). Emergent laparotomy should be strongly considered in any patient with hypotension, altered mental status, or acidemia (Hovarth et al, 1991).
    a) STUDY - In a retrospective study of patients with extensive transmural gastroesophageal necrosis after caustic ingestion, all 4 patients treated in the conventional manner (endoscopy, steroids, antibiotics, and repeated evaluation for the occurrence of esophagogastric necrosis and perforation) died, while all 3 patients treated with early laparotomy and immediate esophagogastric resection survived (Estrera et al, 1986).
    b) Wu & Lai (1993) reported the results of emergency surgical resection of the alimentary tract in 28 patients who had extensive corrosive injuries due to the ingestion of acids or other caustics. Operative mortality was most frequently associated with sepsis. Non-fatal bleeding, infections, biliary or bronchial fistulas were other noted complications. Morbidity and mortality were related to the severity of the damage and the extent of surgery required.
    1) Immediate postoperative management included antibiotics, extensive respiratory care, tracheobronchial toilet, maintenance of fluid, electrolyte and acid-base balance, and jejunostomy feeding or total parenteral nutrition.

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.

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).

Enhanced Elimination

    A) HEMOPERFUSION
    1) Charcoal hemoperfusion was used to treat toxic aluminum serum levels (Sing et al, 1993). Hemoperfusion clearance of aluminum was not determined in this case report.
    B) HEMODIALYSIS
    1) Hemodialysis is recommended for patients with renal insufficiency and with aluminum toxicity due to alum bladder irrigations. It has been suggested to administer deferoxamine prior (6 to 8 hours) to hemodialysis treatment. If dialysis is started too early after deferoxamine, aluminoximine will not be dialyzed effectively. The addition of charcoal hemoperfusion may aid in lowering peak serum levels of aluminum in these patients. Deferoxamine and aluminoxamine are effectively removed via hemodialysis, with elimination half-lives of about 2 hours and 2 to 4 hours, respectively. Thus, combination deferoxamine and hemodialysis may be optimal for the treatment of acute aluminum toxicity in these patients (Nakamura et al, 2000; Phelps et al, 1999).

Abstracts

Case Reports

    A) ADVERSE EFFECTS
    1) Lethargy, respiratory depression and mild metabolic acidosis occurred in an 87-year-old male with bladder cancer and compromised renal function following bladder irrigation with 1% alum (9.6 liters over 48 hr, equivalent to 96 grams aluminum sulfate or 9.6 grams free aluminum). Serum aluminum level peaked at 7,014 nmol/L. The patient died the day after discontinuing alum (Shoskes et al, 1992).
    2) Lethargy and obtundation were reported in an 81-year-old male following bladder irrigation with 1% alum for hemorrhagic cystitis. Underlying conditions included bladder and prostate carcinoma and renal impairment. Serum aluminum level was reported to be 294 mcg/L (normal = 0-20 mcg/L). No seizures occurred and EEG remained normal. Treatment included charcoal hemoperfusion and deferoxamine (Sing et al, 1993).
    3) In July, 1988, 20 tons of 8 percent aluminium sulphate solution were accidentally discharged into the water treatment works of an English town. Initial concentration (for 12 hours after dumping) of aluminium in the main water was estimated to be 1200 mg/L; dilution the next day resulted in a concentration of 109 mg/L and levels remained above normal for at least a month afterward. Local residents were primarily treated for burns and ulcers of the oral cavity; a large percentage of the fish in the local rivers died after the contaminated mains were flushed, but no other animals were affected (Allen & Sansom, 1989).

Range Of Toxicity

Summary

    A) MINIMUM LETHAL DOSE - Fatalities are not well documented but have been reported following ingestions of 30 grams in an adult and 2 to 4 grams in children. Death was attributed to severe gastrointestinal irritation.

Therapeutic Dose

    7.2.1) ADULT
    A) ROUTE OF ADMINISTRATION
    1) TOPICAL - Two percent potassium alum is used topically to suppress excessive sweating. Five to 10 percent alum solutions are used topically to harden epidermis, on soft corns, or as a foot soak. Fifteen percent alum in talc is used as a foot powder (FDA, 1982).
    2) IRRIGATION - 1% alum bladder irrigation solution may be used for the treatment of hemorrhagic cystitis (Perazella & Brown, 1993; Sing et al, 1993; Murphy et al, 1992; Shoskes et al, 1992).

Minimum Lethal Exposure

    A) CASE REPORTS
    1) Fatalities are not well documented, but have been reported to occur following ingestion of 30 grams in an adult (Gosselin et al, 1984) and 2 to 4 grams in children (Locket, 1957). Death was attributed to severe gastrointestinal irritation.
    2) An 87-year-old male with renal dysfunction and hemorrhagic cystitis died after receiving 96 grams aluminum sulfate (9.6 grams free aluminum) as a 1% alum bladder irrigation over 48 hours. Because an autopsy was refused by family, it could not be proven that end organ aluminum toxicity directly resulted in his death (Shoskes et al, 1992).

Maximum Tolerated Exposure

    A) GENERAL/SUMMARY
    1) The maximum tolerated human exposure to this agent has not been delineated.
    B) ROUTE OF EXPOSURE
    1) ORAL - In July 1988, 20 tons of 8% aluminum sulfate solution was accidentally discharged into the water treatment works of an English town. Initial concentration (for 12 hours after dumping) of aluminum in the main water was estimated to be 1200 mg/L; dilution the next day resulted in a concentration of 109 mg/L and levels remained above normal for at least a month afterward. Local residents were primarily treated for burns and ulcers of the oral cavity; a large percentage of the fish in the local rivers died after the contaminated mains were flushed, but no other animals were affected (Allen & Sansom, 1989).
    2) The following information is for ALUMS in general -
    a) Formulations of 0.2 to 15% alum are used therapeutically; they have been used as mouthwashes or gargles for the treatment of stomatitis or pharyngitis. Potassium alum (2%) is used topically to suppress excessive sweating. Five to 10% alum solutions are used topically to harden epidermis, on soft corns, or as a foot soak. Fifteen percent alum in talc is used as a foot powder (FDA, 1982).
    C) CASE REPORTS
    1) A 30-year-old male had 3 episodes of tonic-clonic seizures after receiving 40 grams of alum as a bladder irrigation over a 7 day period. He also had renal dysfunction which may have accounted for decreased aluminum excretion (Murphy et al, 1992).
    2) A 31-year-old female with acute renal failure received a total of 520 grams alum as a 1% bladder irrigation over a 7 day period and developed myoclonus and progressive obtundation (Perazella & Brown, 1993).
    3) A 15-year-old girl with acute lymphoblastic leukemia developed euphoria, lip smacking, eye rolling, impaired short term memory, and nominal aphasia after receiving intravesical 1% alum irrigation for 12 days (total 19 grams aluminum). Symptoms resolved with discontinuation of the alum and treatment with deferoxamine (Kanwar et al, 1996).

Serum Plasma Blood Concentrations

    7.5.2) TOXIC CONCENTRATIONS
    A) TOXIC CONCENTRATION LEVELS
    1) CASE REPORTS
    a) A plasma aluminum level of 1.48 micromoles/liter (normal 0.1 - 0.37 micro- moles/liter) was reported in a 30-year-old male who had received greater than 400 milliliters of 1% alum bladder irrigation over 7 days (Murphy et al, 1992).
    b) A serum aluminum level of 436 micrograms/liter (normal less than 40 micrograms/liter) was reported in a 31-year-old female following a total of 520 grams of aluminum from a 1% alum irrigation given intravesically over 7 days (Perazella & Brown, 1993).
    c) A peak serum aluminum level of 7,014 nanomoles/liter (toxic greater than 2000) was reported in an 87-year-old male following bladder irrigation with a total of 96 grams of aluminum sulfate (9.6 grams free aluminum) over 48 hours (Shoskes et al, 1992).
    d) A 15-year-old girl with acute lymphoblastic leukemia developed euphoria, lip smacking, eye rolling, impaired short term memory, and nominal aphasia after receiving intravesical 1% alum irrigation for 12 days (total 19 grams aluminum). Serum aluminum concentration was 14 micrograms/liter, bone marrow biopsy demonstrated aluminum deposition and EEG revealed diffuse bilateral slowing with bursts of fast activity. Symptoms resolved with discontinuation of the alum and treatment with deferoxamine (Kanwar et al, 1996).

Workplace Standards

    A) ACGIH TLV Values for CAS10043-01-3 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    B) NIOSH REL and IDLH Values for CAS10043-01-3 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    C) Carcinogenicity Ratings for CAS10043-01-3 :
    1) ACGIH (American Conference of Governmental Industrial Hygienists, 2010): Not Listed
    2) EPA (U.S. Environmental Protection Agency, 2011): Not Listed
    3) IARC (International Agency for Research on Cancer (IARC), 2016; International Agency for Research on Cancer, 2015; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2010a; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2008; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007; IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2006; IARC, 2004): Not Listed
    4) NIOSH (National Institute for Occupational Safety and Health, 2007): Not Listed
    5) MAK (DFG, 2002): Not Listed
    6) NTP (U.S. Department of Health and Human Services, Public Health Service, National Toxicology Project ): Not Listed

    D) OSHA PEL Values for CAS10043-01-3 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) References: HSDB, 1992 RTECS, 2002
    1) LD50- (INTRAPERITONEAL)MOUSE:
    a) 1735 mg/kg
    2) LD50- (ORAL)MOUSE:
    a) 6207 mg/kg
    b) 4210 mg/kg
    3) LD50- (ORAL)RAT:
    a) 1930 mg/kg

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Alums are weakly acidic compounds that produce astringent effects by precipitating protein.

Toxicologic Mechanism

    A) Aluminum accumulates in brain tissue producing neurotoxicity, including encephalopathy and seizures (McMillan et al, 1993; Perazella & Brown, 1993). Neurofibrillary degeneration of the cerebral gray matter has been documented, particularly in patients with chronic renal failure with toxic aluminum serum levels (Murphy et al, 1992).

Physicochemical

Physical Characteristics

    A) ALUMINUM SULFATE: It is an odorless, white to light gray solid, which occurs as lustrous crystals, pieces, granules, or in powder form (CHRIS, 2005; HSDB, 2005; Budavari, 1996) ; colorless in water (OHM/TADS, 2005); it has a sweet, mildly astringent taste (HSDB, 2005); the commercial product is also known as CAKE ALUM or PATENT ALUM. It is about 99.5% pure (Budavari, 1996).
    B) ANHYDROUS ALUMINUM POTASSIUM SULFATE: white powder; stryptic or astringent taste.
    C) POTASSIUM ALUM DODECAHYDRATE: Colorless, hard, large transparent crystals or white crystalline powder; sweet astringent taste.

Ph

    A) For an aqueous solution (1 g/1 mL H2O), pH is not less than 2.9 (HSDB, 2005).
    B) 2-10% solutions have a pH of 3-4 (Reynolds, 1998).
    C) ALUMINUM SULFATE, ANHYDROUS: 1:20 solution has a pH of 2.9 (potassium aluminum sulfate)
    D) POTASSIUM ALUM DODECAHYDRATE: pH of a 0.2 molar solution is 3.3 (Budavari, 1996).

Molecular Weight

    A) ALUMINUM SULFATE: 342.14 (Budavari, 1996)

Other

    A) ODOR THRESHOLD
    1) Currently not available (CHRIS , 2002)

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) AAR: Emergency Handling of Hazardous Materials in Surface Transportation, Bureau of Explosives, Association of American Railroads, Washington, DC, 1987.
    14) AIHA: 2006 Emergency Response Planning Guidelines and Workplace Environmental Exposure Level Guides Handbook, American Industrial Hygiene Association, Fairfax, VA, 2006.
    15) AMA Department of DrugsAMA Department of Drugs: AMA Evaluations Subscription, American Medical Association, Chicago, IL, 1992.
    16) Aceto T Jr, Terplan K, & Fiore RR: Chemical burns of the esophagus in children and glucocorticoid therapy. J Med 1970; 1:101-109.
    17) Adam JS & Brick HG: Pediatric caustic ingestion. Ann Otol Laryngol 1982; 91:656-658.
    18) Allen WM & Sansom BF: Accidental contamination of the public water supply at Lowermoor, Camelford: an assessment of the possible veterinary consequences. Vet Record 1989; 124:479-482.
    19) 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.
    20) Anderson KD, Touse TM, & Randolph JG: A controlled trial of corticosteroids in children with corrosive injury of the esophagus. N Engl J Med 1990; 323:637-640.
    21) 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.
    22) Barton JR, Riely CA, & Sibai BM: Baking powder pica mimicking preeclampsia. Am J Obstet Gynecol 1992; 167:98-99.
    23) Bata Shoe Company: Industrial Footwear Catalog, Bata Shoe Company, Belcamp, MD, 1995.
    24) Best Manufacturing: ChemRest Chemical Resistance Guide. Best Manufacturing. Menlo, GA. 2002. Available from URL: http://www.chemrest.com. As accessed 10/8/2002.
    25) Best Manufacturing: Degradation and Permeation Data. Best Manufacturing. Menlo, GA. 2004. Available from URL: http://www.chemrest.com/DomesticPrep2/. As accessed 04/09/2004.
    26) Boss Manufacturing Company: Work Gloves, Boss Manufacturing Company, Kewanee, IL, 1998.
    27) Boukthir S, Fetni I, Mrad SM, et al: [High doses of steroids in the management of caustic esophageal burns in children]. Arch Pediatr 2004; 11(1):13-17.
    28) Brophy GM, Bell R, Claassen J, et al: Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17(1):3-23.
    29) Budavari S: The Merck Index, 11th ed, Merck & Co, Inc, Rahway, NJ, 1989.
    30) Budavari S: The Merck Index, 12th ed, Merck & Co, Inc, Rahway, NJ, 1996.
    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) CHRIS : CHRIS Hazardous Chemical Data. US Department of Transportation, US Coast Guard. Washington, DC (Internet Version). Edition expires 1992; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    33) CHRIS : CHRIS Hazardous Chemical Data. US Department of Transportation, US Coast Guard. Washington, DC (Internet Version). Edition expires 2002; 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 2005; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    35) Caravati EM: Alkali. In: Dart RC, ed. Medical Toxicology, Lippincott Williams & Wilkins, Philadelphia, PA, 2004.
    36) Chamberlain JM, Altieri MA, & Futterman C: A prospective, randomized study comparing intramuscular midazolam with intravenous diazepam for the treatment of seizures in children. Ped Emerg Care 1997; 13:92-94.
    37) ChemFab Corporation: Chemical Permeation Guide Challenge Protective Clothing Fabrics, ChemFab Corporation, Merrimack, NH, 1993.
    38) Chin RF , Neville BG , Peckham C , et al: Treatment of community-onset, childhood convulsive status epilepticus: a prospective, population-based study. Lancet Neurol 2008; 7(8):696-703.
    39) Chodak GW & Passaro E: Acid ingestion: need for gastric resection. JAMA 1978; 239:229-226.
    40) Choonara IA & Rane A: Therapeutic drug monitoring of anticonvulsants state of the art. Clin Pharmacokinet 1990; 18:318-328.
    41) Cleveland WW, Chandler JR, & Lawson RB: Treatment of caustic burns of the esophagus. JAMA 1963; 186:182-183.
    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) Crain EF, Gershel JC, & Mezey AP: Caustic ingestions. Symptoms as predictors of esophageal injury. Am J Dis Child 1984a; 138(9):863-865.
    45) Crain EF, Gershel JC, & Mezey AP: Caustic ingestions; symptoms as predictors of esophageal injury. Am J Dis Child 1984; 138:863-865.
    46) 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.
    47) David A: Cerebral dysfunction after water pollution incident in Camelford. Results were biased by self selection of cases (letter). Br Med J 2000; 320:1337.
    48) Dilawari JB, Singh S, & Rao PN: Corrosive acid ingestion in man, a clinical and endoscopic study. Gut 1984; 25:183-187.
    49) Dogan Y, Erkan T, Cokugras FC, et al: Caustic gastroesophageal lesions in childhood: an analysis of 473 cases. Clin Pediatr (Phila) 2006; 45(5):435-438.
    50) 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.
    51) 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.
    52) DuPont: Permeation Test Results. DuPont. Wilmington, DE. 2002a. Available from URL: http://www.tyvekprotectiveapprl.com/databases/default.htm. As accessed 7/31/2002.
    53) 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/.
    54) 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.
    55) Eastwood JB, Levin GE, & Pazianas M: Aluminium deposition in bone after contamination of drinking water supply. Lancet 1990; 336:462-464.
    56) Esmonde TFG: Cerebral dysfunction after water pollution incident in Camelford. Study has several methodological errors (letter). Br Med J 2000; 320:1337-1338.
    57) Estrera A, Taylor W, & Mills LJ: Corrosive burns of the esophagus and stomach: a recommendation of an aggressive surgical approach. Ann Thorac Surg 1986; 41:276-283.
    58) FDA: Federal Register 47: 22902-22903, 47, Government Printing Office, Washington, DC, 1982, pp 22902-22903.
    59) Ferguson MK, Migliore M, & Staszak VM: Early evaluation and therapy for caustic esophageal injury. Am J Surg 1989; 157:116-120.
    60) Gallego H, Lewis EJ, & Crutchfield CE: Crystal deodorant dermatitis: irritant dermatitis to alum-containing deodorant. Cutis 1999; 64:65-66.
    61) Gaudreault P, Parent M, & McGuigan MA: Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics 1983; 71:761-770.
    62) Gaudreault P, Parent M, McGuigan MA, et al: Predictability of esophageal injury from signs and symptoms: a study of caustic ingestion in 378 children. Pediatrics 1983a; 71(5):767-770.
    63) Golding J, Rowland A, & Greenwood R: Aluminium sulphate in water in north Cornwall and outcome of pregnancy. Br Med J 1991; 302:1175-1177.
    64) Gorman RL, Khin-Maung-Gyi MT, & Klein-Schwartz W: Initial symptoms as predictors of esophageal injury in alkaline corrosive ingestions. Am J Emerg Med 1992; 10:89-94.
    65) Gosselin RE, Smith RP, & Hodge HC: Clinical Toxicology of Commercial Products, 5th ed, Williams & Wilkins, Baltimore, MD, 1984.
    66) Grant WM & Schuman JS: Toxicology of the Eye, 4th ed, Charles C Thomas, Springfield, IL, 1993.
    67) 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.
    68) Gupta SK, Croffie JM, & Fitzgerald JF: Is esophagogastroduodenoscopy necessary in all caustic ingestions?. J Ped Gastroenterol Nutr 2001; 32:50-53.
    69) HSDB : Hazardous Substances Data Bank. National Library of Medicine. Bethesda, MD (Internet Version). Edition expires 1992; 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 1999; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    71) HSDB : Hazardous Substances Data Bank. National Library of Medicine. Bethesda, MD (Internet Version). Edition expires 2005; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    72) Hahn I, O'Connor J, & Melville L: Intravaginal alum resulting in mucosal erosions (abstract). J Toxicol-Clin Toxicol 2001; 39:313-314.
    73) Haller JA & Bachman K: The comparative effect of current therapy on experimental caustic burns of the esophagus. Pediatrics 1964; 236-245.
    74) Haller JA, Andrews HG, & White JJ: Pathophysiology and management of acute corrosive burns of the esophagus. J Pediatr Surg 1971; 6:578-584.
    75) Hawkins DB, Demeter MJ, & Barnett TE: Caustic ingestion: controversies in management. A review of 214 cases. Laryngoscope 1980; 90:98-109.
    76) Hegenbarth MA & American Academy of Pediatrics Committee on Drugs: Preparing for pediatric emergencies: drugs to consider. Pediatrics 2008; 121(2):433-443.
    77) Hovarth OP, Olah T, & Zentai G: Emergency esophagogastrectomy for the treatment of hydrochloric acid injury. Ann Thorac Surg 1991; 52:98-101.
    78) Howell JM, Dalsey WC, & Hartsell FW: Steroids for the treatment of corrosive esophageal injury: a statistical analysis of past studies. Am J Emerg Med 1992; 10:421-425.
    79) Howell JM: Alkaline ingestions. Ann Emerg Med 1987; 15:820-825.
    80) Hvidberg EF & Dam M: Clinical pharmacokinetics of anticonvulsants. Clin Pharmacokinet 1976; 1:161.
    81) 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.
    82) 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.
    83) 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.
    84) 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.
    85) 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.
    86) 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.
    87) ICAO: Technical Instructions for the Safe Transport of Dangerous Goods by Air, 2003-2004. International Civil Aviation Organization, Montreal, Quebec, Canada, 2002.
    88) ILC Dover, Inc.: Ready 1 The Chemturion Limited Use Chemical Protective Suit, ILC Dover, Inc., Frederica, DE, 1998.
    89) 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.
    90) 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.
    91) JEF Reynolds : Martindale: The Extra Pharmacopeia. The Pharmaceutical Press. London, UK (Internet Version). Edition expires 1988; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    92) Kamijo Y, Kondo I, Kokuto M, et al: Miniprobe ultrasonography for determining prognosis in corrosive esophagitis. Am J Gastroenterol 2004; 99(5):851-854.
    93) Kanwar VS, Jenkins JJ, & Mandrell BN: Aluminum toxicity following intravesical alum irrigation for hemorrhagic cystitis. Med Ped Oncoloby 1996; 27:64-67.
    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) Knox WG, Scott JR, & Zintel HA: Bouginage and steroids used singly or in combination in experimental corrosive esophagitis. Ann Surg 1967; 166:930-941.
    97) LaCrosse-Rainfair: Safety Products, LaCrosse-Rainfair, Racine, WI, 1997.
    98) Lamireau T, Rebouissoux L, & Denis D: Accidental caustic ingestion in children: is endoscopy always mandatory?. J Ped Gastroenterol Nutr 2001; 33:81-84.
    99) Lewis RJ: Hawley's Condensed Chemical Dictionary, 13th ed, John Wiley & Sons, Inc, New York, NY, 1997.
    100) LoVecchio F, Hamilton R, & Sturman K: A meta-analysis of the use of steroids in the prevention of stricture formation from second degree caustic burns of the esophagus (abstract). J Toxicol-Clin Toxicol 1996; 35:579-580.
    101) Locket S: Clinical Toxicology, CV Mosby CO, St Louis, MO, 1957.
    102) Loddenkemper T & Goodkin HP: Treatment of Pediatric Status Epilepticus. Curr Treat Options Neurol 2011; Epub:Epub.
    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) Manno EM: New management strategies in the treatment of status epilepticus. Mayo Clin Proc 2003; 78(4):508-518.
    106) Mar-Mac Manufacturing, Inc: Product Literature, Protective Apparel, Mar-Mac Manufacturing, Inc., McBee, SC, 1995.
    107) 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.
    108) Marshall F II: Caustic burns of the esophagus: ten year results of aggressive care. South Med J 1979; 72:1236-1237.
    109) McMillan TM, Freemont AJ, & Herxheimer A: Camelford water poisoning accident: serial neuropsychological assessments and further observation on bone aluminium. Human & Experimental Toxicology 1993; 12:37-42.
    110) McMillan TM: Cerebral dysfunction after water pollution incident in Camelford. Study may prolong the agony (letter). Br Med J 2000; 320:1338.
    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) Meredith JW, Kon ND, & Thompson JN: Management of injuries from liquid lye ingestion. J Trauma 1988; 28:1173-1180.
    113) Millar AJW, Numanoglu A, & Mann M: Detection of caustid oesophageal injury tiwh technetium 99m-labelled sucralfate. J Ped SUrg 2001; 36:262-265.
    114) Moazam F, Talbert JL, & Miller D: Caustic ingestion and its sequelae in children. South Med J 1987; 80:187-188.
    115) Montgomery Safety Products: Montgomery Safety Products Chemical Resistant Glove Guide, Montgomery Safety Products, Canton, OH, 1995.
    116) Murphy CP, Cox RL, & Harden EA: Case report: Encephalopathy and seizures induced by intravesical alum irrigations. Bone Marrow Transplant 1992; 10:383-385.
    117) Murray V, Goodfellow F, & Bogle R: Cerebral dysfunction after water pollution incident in Camelford. Inappropriate study, inappropriate conclusions (letter). Br Med J 2000; 320:1338.
    118) NFPA: Fire Protection Guide to Hazardous Materials, 13th ed., National Fire Protection Association, Quincy, MA, 2002.
    119) 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.
    120) 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.
    121) 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.
    122) 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.
    123) Nakamura H, Rose PG, & Blumer JL: Acute encephalopathy due to aluminum toxicity successfully treated by combined intravenous deferoxamine and hemodialysis. J Clin Pharmacol 2000; 40:296-300.
    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) 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.
    208) North: eZ Guide Interactive Software. North Safety. Cranston, RI. 2002a. Available from URL: http://www.northsafety.com/feature1.htm. As accessed 8/31/2002.
    209) Nuutinen M, Uhari M, & Karvali T: Consequences of caustic ingestions in children. Acta Paediatr 1994; 83:1200-1205.
    210) OHM/TADS : Oil and Hazardous Materials/Technical Assistance Data System. US Environmental Protection Agency. Washington, DC (Internet Version). Edition expires 1992; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    211) OHM/TADS: Oil and Hazardous Materials Technical Assistance Data System. US Environmental Protection Agency. Washington, D.C. (Internet Version). Edition expires 2005; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    212) Oakes DD, Sherck JP, & Mark JBD: Lye ingestion. J Thorac Cardiovasc Surg 1982; 83:194-204.
    213) Peate WF: Work-related eye injuries and illnesses. Am Fam Physician 2007; 75(7):1017-1022.
    214) Pelclova D & Navratil T: Do corticosteroids prevent oesophageal stricture after corrosive ingestion?. Toxicol Rev 2005; 24(2):125-129.
    215) Perazella M & Brown E: Case reports: Acute aluminum toxicity and alum bladder irrigation in patients with renal failure. Am J Kidney Dis 1993; 21:44-46.
    216) Phelps KR, Naylor K, & Brien TP: Encephalopathy after bladder irrigation with alum: case report and literature review. Am J Med Sci 1999; 318:181-185.
    217) Playtex: Fits Tough Jobs Like a Glove, Playtex, Westport, CT, 1995.
    218) Previtera C, Giusti F, & Gugliemi M: Predictive value of visible lesions (cheeks, lips, oropharynx) in suspected caustic ingestion: may endoscopy reasonably be omitted in completely negative pediatric patients?. Pediatr Emerg Care 1990; 6:176-178.
    219) Product Information: diazepam IM, IV injection, diazepam IM, IV injection. Hospira, Inc (per Manufacturer), Lake Forest, IL, 2008.
    220) Product Information: lorazepam IM, IV injection, lorazepam IM, IV injection. Akorn, Inc, Lake Forest, IL, 2008.
    221) RTECS : Registry of Toxic Effects of Chemical Substances. National Institute for Occupational Safety and Health. Cincinnati, OH (Internet Version). Edition expires 1999; provided by Truven Health Analytics Inc., Greenwood Village, CO.
    222) Reyes HM, Lin CY, & Schluhk FF: Experimental treatment of corrosive esophageal burns. J Pediatr Surg 1974; 9:317-327.
    223) River City: Protective Wear Product Literature, River City, Memphis, TN, 1995.
    224) Rosenberg N, Kunderman PJ, & Vroman L: Prevention of experimental esophageal stricture by cortisone II. Arch Surg 1953; 66:593-598.
    225) Rowland A, Grainger R, & Smith RS: Water contamination in North Cornwall: a retrospective cohort study into the acute and short-term effects of the aluminum sulphate incident in July, 1998. J Royal Soc Health 1990; 110:166-172.
    226) Saedi S, Nyhus LM, & Gabrys BF: Pharmacological prevention of esophageal stricture: an experimental study in the cat. Am Surg 1973a; 39:465-469.
    227) Saedi S, Nyhust LM, & Gabrys BF: Pharmacological prevention of esophageal stricture: an experimental study in the cat. Am Surg 1973; 39:465-469.
    228) 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.
    229) Sax NI & Lewis RJ: Dangerous Properties of Industrial Materials, 7th ed, Van Nostrand Reinhold Company, New York, NY, 1989.
    230) Sax NI & Lewis RJ: Hawley's Condensed Chemical Dictionary, 11th ed, Van Nostrand Reinhold Company, New York, NY, 1987.
    231) Schild JA: Caustic ingestion in adult patients. Laryngoscope 1985; 95:1199-1201.
    232) Scott R, Besag FMC, & Neville BGR: Buccal midazolam and rectal diazepam for treatment of prolonged seizures in childhood and adolescence: a randomized trial. Lancet 1999; 353:623-626.
    233) Servus: Norcross Safety Products, Servus Rubber, Servus, Rock Island, IL, 1995.
    234) Shoskes DA, Radzinski CA, & Struthers NW: Aluminum toxicity and death following intravesical alum irrigation in a patient with renal impairment. Journal of Urology 1992; 147:697-699.
    235) Sing K, Ahmed S, & Moneer Y: Hyperaluminemia following bladder irrigation with alum: a case report (abstract 93). Vet Hum Toxicol 1993; 35:340.
    236) Sreenath TG, Gupta P, Sharma KK, et al: Lorazepam versus diazepam-phenytoin combination in the treatment of convulsive status epilepticus in children: A randomized controlled trial. Eur J Paediatr Neurol 2009; Epub:Epub.
    237) Standard Safety Equipment: Product Literature, Standard Safety Equipment, McHenry, IL, 1995.
    238) Sugawa C & Lucas CE: Caustic injury of the upper gastrointestinal tract in adults: a clinical and endoscopic study. Surgery 1989; 106:802-807.
    239) Symbas PN, Vlasis SE, & Hatcher CR Jr: Esophagitis secondary to ingestion of caustic material. Ann Thorac Surg 1983; 36:73-77.
    240) 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.
    241) 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.
    242) Trelleborg-Viking, Inc.: Trellchem Chemical Protective Suits, Interactive manual & Chemical Database. Trelleborg-Viking, Inc.. Portsmouth, NH. 2001.
    243) 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.
    244) 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.
    245) 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-.
    246) 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.
    247) 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.
    248) 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.
    249) 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.
    250) 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-.
    251) U.S. Occupational Safety, and Health Administration (OSHA): Process safety management of highly hazardous chemicals. 29 CFR 2010 2010; 29(1910.119):348-.
    252) 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.
    253) Vergauwen p, Moulin D, & Buts JP: Caustic burns of the upper digestive and respiratory tracts. Eur J Pediatr 1991; 150:700-703.
    254) 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.
    255) White RP: The Dermatogoses, 4th Ed, Lewis, London, England, 1934.
    256) Workrite: Chemical Splash Protection Garments, Technical Data and Application Guide, W.L. Gore Material Chemical Resistance Guide, Workrite, Oxnard, CA, 1997.
    257) Wu MH & Lai WW: Surgical management of extensive corrosive injuries of the alimentary tract. Surg Gynecol Obstetr 1993; 177:12-16.
    258) Wyatt GM: Comparison of ammonium alum and tannic acid as barium enema additives. JAMA 1966; 195:129-132.
    259) Yarington CT & Heatly CA: Steroids, antibiotics, and early esophagoscopy in caustic esophageal trauma. N Y State J Med 1963; 63:2960-2963.
    260) Zargar SA, Kochhar R, & Mehta S: The role of fiberoptic endoscopy in the management of corrosive ingestion and modified endoscopic classification of burns. Gastrointest Endosc 1991; 37:165-169.
    261) Zargar SA, Kochhar R, & Nagi B: Ingestion of corrosive acids: spectrum of injury to upper gastrointestinal tract and natural history. Gastroenterology 1989; 97:702-707.