NITRITES

Used in manufacture of diazo dyes, potassium salts, nitroso compounds, and nitrogen oxide; dyeing and printing textile fabrics; bleaching flax, silk, and linen; photography (ITI, 1988; Budavari, 1996)
Also used in meat curing, coloring, and preserving, where nitrites are legally present in amounts of up to 200 ppm (Baselt, 2000); in processing smoked chub (Budavari, 1996).
Used as reagents in analytical chemistry (Budavari, 1996).
Chemical in metal treatment and finishing operations; corrosion inhibitor; component of detinning solution and multi-purpose greases (HSDB , 2000).

MEDICINAL

SODIUM NITRITE

One gram tablets of sodium nitrite are supplied to medical and dental professionals as an adjunct to disinfectant fluids such as chlorhexidine. Sodium nitrite, a strong oxidizing agent, prevents rusting of the instruments being disinfected (Gowans, 1990).
Used in combination with amyl nitrite and sodium thiosulfate as an antidote for cyanide poisoning (Chen et al, 1933; Chen & Rose, 1952; Hall & Rumack, 1986). It may also be efficacious in hydrogen sulfide poisoning (Stine et al, 1976; Peters, 1981).
Formerly administered orally as a vasodilator for the treatment of angina pectoris (Baselt, 2000). This use has been rendered obsolete by the presence of more efficacious and less toxic vasodilators (Gilman et al, 1985).

FORMS

SODIUM NITRITE - Sterile sodium nitrite (300 milligrams/10 milliliter ampule) is available in the Cyanide Antidote Kit.

SOURCES

Nitrates are converted to nitrites by bacteria in the mouth. The kinetics of conversion are quite complex and are not directly related to the nitrate level in the medium or the amount of microbial growth (Tannenbaum et al, 1974).
HIGH INORGANIC NITRITE (KNO2, NaNO2) levels are found in well-water contaminated by septic tanks, municipal sewage, fertilizers, and feed lots where bacteria reduce nitrates to nitrites (Ellenhorn & Barceloux, 1988).

-CLINICAL EFFECTS

GENERAL CLINICAL EFFECTS

USES: Nitrites are commonly found in the manufacturing industry; they are used in the manufacture of diazo dyes, potassium salts, nitroso compounds, and nitrogen oxide, dyeing and printing textile fabrics, in photography, as reagents in analytical chemistry, as a key chemical in metal treatment and finishing operations, and bleaching flax, silk, and linen. Nitrites are also used in meat curing and preserving, and high inorganic nitrite (KNO2, NaNO2) levels may be found in well water contaminated by septic tanks, municipal sewage, fertilizers, and feed lots where bacteria reduce nitrates to nitrites. Medically, sodium nitrite is used as an adjunct to disinfectant fluids to prevent rusting of the instruments. Sodium nitrite is also used as an antidote to cyanide poisoning in combination with sodium thiosulfate. Please refer to "SODIUM NITRITE" management for more information.

PHARMACOLOGY: Sodium nitrite acts as a vasodilator and relaxes maximally contracted smooth muscles, especially at the level of the small blood vessels. In the setting of cyanide toxicity, sodium nitrite has its therapeutic effect by creating methemoglobin which scavenges cyanide and possibly by increasing hepatic blood flow. Nitrites oxidize normal (ferrous) hemoglobin to ferric hemoglobin (methemoglobin).

TOXICOLOGY: Toxic effects of sodium nitrite are caused by an extension of therapeutic mechanisms. Significant vasodilation may cause hypotension and end-organ hypoperfusion. Excess methemoglobinemia may lead to functional hypoxia. The toxic effects of other nitrites are similar to sodium nitrite's effects.

EPIDEMIOLOGY: Overdose is rare.

WITH POISONING/EXPOSURE

MILD TO MODERATE TOXICITY: Hypotension with syncope and tachycardia are common findings in toxicity. Cyanosis may also be noted due to methemoglobinemia. Other common symptoms include headache, nausea, vomiting, and abdominal pain.
SEVERE TOXICITY: In cases of severe toxicity, patients may develop severe hypotension, distributive shock, coronary ischemia, cerebrovascular disease, and seizures. Profound methemoglobinemia may lead to respiratory depression, and coma. Death due to nitrite poisoning is caused by uncontrolled vasodilation and hypoperfusion, or by profound methemoglobinemia and functional hypoxia.

POTENTIAL HEALTH HAZARDS - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)

Inhalation, ingestion or contact (skin, eyes) with vapors or substance may cause severe injury, burns or death.
Fire may produce irritating, corrosive and/or toxic gases.
Runoff from fire control or dilution water may cause pollution.

-FIRST AID

FIRST AID AND PREHOSPITAL TREATMENT

Prehospital gastrointestinal decontamination is generally not recommended because of the potential for CNS depression or persistent seizures and subsequent aspiration.

-MEDICAL TREATMENT

LIFE SUPPORT

Support respiratory and cardiovascular function.

SUMMARY

FIRST AID - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)

Move victim to fresh air.
Call 911 or emergency medical service.
Give artificial respiration if victim is not breathing.
Administer oxygen if breathing is difficult.
Remove and isolate contaminated clothing and shoes.
Contaminated clothing may be a fire risk when dry.
In case of contact with substance, immediately flush skin or eyes with running water for at least 20 minutes.
Keep victim warm and quiet.
Ensure that medical personnel are aware of the material(s) involved and take precautions to protect themselves.

-RANGE OF TOXICITY

MINIMUM LETHAL EXPOSURE

SPECIFIC SUBSTANCE

SODIUM NITRITE

The ESTIMATED LETHAL DOSE of sodium nitrite in adults is 2.6 grams (Ten Brink et al, 1982).
A 17-year-old female developed central cyanosis, tachycardia, tachypnea, and cardiac arrhythmias prior to her death following ingestion of a 1 gram tablet of sodium nitrite (Gowans, 1990).

MAXIMUM TOLERATED EXPOSURE

SUMMARY

ACCEPTABLE DAILY INTAKE (excluding infants under 6 months of age):

NITRITES: 0.4 mg/kg (WHO, 1965)
ADULTS: Estimated ingestion of 700 mg of sodium nitrite from the inadvertent dental addition of an anticorrosive agent to drinking water resulted in severe methemoglobinemia (49%) with full recovery after treatment with methylene blue (Bradberry et al, 1993).

-STANDARDS AND LABELS

SHIPPING REGULATIONS

SURFACE

DOT -- Table of Hazardous Materials and Special Provisions for UN/NA Number 2627 (49 CFR 172.101, 2005):

Hazardous materials descriptions and proper shipping name: Nitrites, inorganic, n.o.s

Symbol(s): Not Listed
Hazard class or Division: 5.1

5.1: Oxidizer. See 49 CFR section 173.127 for definitions.

Identification Number: UN2627
Packing Group: II

II: Packing Group II - indicates the degree of danger presented by the material is medium.

Label(s) required (if not excepted): 5.1

5.1: Oxidizer.

Special Provisions: 33, IB8, IP4, T3, TP33

33: Ammonium nitrites and mixtures of an inorganic nitrite with an ammonium salt are prohibited.
IB8: Authorized IBCs: Metal (11A, 11B, 11N, 21A, 21B, 21N, 31A, 31B and 31N); Rigid plastics (11H1, 11H2, 21H1, 21H2, 31H1 and 31H2); Composite (11HZ1, 11HZ2, 21HZ1, 21HZ2, 31HZ1 and 31HZ2); Fiberboard (11G); Wooden (11C, 11D and 11F); Flexible (13H1, 13H2, 13H3, 13H4, 13H5, 13L1, 13L2, 13L3, 13L4, 13M1 or 13M2).
IP4: Flexible, fiberboard or wooden IBCs must be sift-proof and water-resistant or be fitted with a sift-proof and water-resistant liner.
T3: Minimum test pressure (bar): 2.65; Minimum shell thickness (in mm-reference steel) (See sxn.178.274(d)): sxn.178.274(d)(2); Pressure-relief requirements (See sxn.178.275(g)): Normal; Bottom opening requirements (See sxn.178.275(d)): sxn.178.275(d)(2).
TP33: The portable tank instruction assigned for this substance applies for granular and powdered solids and for solids which are filled and discharged at temperatures above their melting point which are cooled and transported as a solid mass. Solid substances transported or offered for transport above their melting point are authorized for transportation in portable tanks conforming to the provisions of portable tank instruction T4 for solid substances of packing group III or T7 for solid substances of packing group II, unless a tank with more stringent requirements for minimum shell thickness, maximum allowable working pressure, pressure-relief devices or bottom outlets are assigned in which case the more stringent tank instruction and special provisions shall apply. Filling limits must be in accordance with portable tank special provision TP3. Solids meeting the defnintion of an elevated temperature material must be transported in accordance with the applicable requirements of this subchapter.

Packaging Authorizations (refer to 49 CFR 173.***):

Exceptions: 152
Non-bulk packaging: 212
Bulk packaging: None

Quantity Limitations:

Passenger aircraft or railcar: 5 kg
Cargo aircraft only: 25 kg

Vessel Stowage Requirements:

Vessel stowage location: A

A: The material may be stowed "on deck" or "under deck" on a cargo vessel and on a passenger vessel.

Vessel stowage other: 46, 56, 58, B101

46: Stow "away from" powdered metals.
56: Stow "separated from" ammonium compounds.
58: Stow "separated from" cyanides.
B101:

DOT -- Table of Hazardous Materials and Special Provisions for UN/NA Number 3219 (49 CFR 172.101, 2005):

Hazardous materials descriptions and proper shipping name: Nitrites, inorganic, aqueous solution, n.o.s

Symbol(s): Not Listed
Hazard class or Division: 5.1

5.1: Oxidizer. See 49 CFR section 173.127 for definitions.

Identification Number: UN3219
Packing Group: II

II: Packing Group II - indicates the degree of danger presented by the material is medium.

Label(s) required (if not excepted): 5.1

5.1: Oxidizer.

Special Provisions: IB1, T4, TP1

IB1: Authorized IBCs: Metal (31A, 31B and 31N). Additional Requirement: Only liquids with a vapor pressure less than or equal to 110 kPa at 50 °C (1.1 bar at 122 °F), or 130 kPa at55 °C (1.3 bar at 131 °F) are authorized.
T4: Minimum test pressure (bar): 2.65; Minimum shell thickness (in mm-reference steel) (See sxn.178.274(d)): sxn.178.274(d)(2); Pressure-relief requirements (See sxn.178.275(g)): Normal; Bottom opening requirements (See sxn.178.275(d)): sxn.178.275(d)(3).
TP1: The maximum degree of filling must not exceed the degree of filling determined by the following: [Degree of filling = 97/1+alpha(tr - tf)], where tr is the maximum mean bulk temperature during transport, and tf is the temperature in degrees celsius of the liquid during filling.

Packaging Authorizations (refer to 49 CFR 173.***):

Exceptions: 152
Non-bulk packaging: 202
Bulk packaging: 242

Quantity Limitations:

Passenger aircraft or railcar: 1 L
Cargo aircraft only: 5 L

Vessel Stowage Requirements:

Vessel stowage location: B

B: (i) The material may be stowed "on deck" or "under deck" on a cargo vessel and on a passenger vessel carrying a number of passengers limited to not more than the larger of 25 passengers, or one passenger per each 3 m of overall vessel length; and (ii) "On deck only" on passenger vessels in which the number of passengers specified in paragraph (k)(2)(i) of this section is exceeded.

Vessel stowage other: 46, 56, 58, B101

46: Stow "away from" powdered metals.
56: Stow "separated from" ammonium compounds.
58: Stow "separated from" cyanides.
B101:

Hazardous materials descriptions and proper shipping name: Nitrites, inorganic, aqueous solution, n.o.s

Symbol(s): Not Listed
Hazard class or Division: 5.1

5.1: Oxidizer. See 49 CFR section 173.127 for definitions.

Identification Number: UN3219
Packing Group: III

III: Packing Group III - indicates the degree of danger presented by the material is minor.

Label(s) required (if not excepted): 5.1

5.1: Oxidizer.

Special Provisions: IB2, T4, TP1

IB2: Authorized IBCs: Metal (31A, 31B and 31N); Rigid plastics (31H1 and 31H2); Composite (31HZ1). Additional Requirement: Only liquids with a vapor pressure less than or equal to 110 kPa at 50 °C (1.1 bar at 122 °F), or 130kPa at 55 °C (1.3 bar at 131 °F) are authorized.
T4: Minimum test pressure (bar): 2.65; Minimum shell thickness (in mm-reference steel) (See sxn.178.274(d)): sxn.178.274(d)(2); Pressure-relief requirements (See sxn.178.275(g)): Normal; Bottom opening requirements (See sxn.178.275(d)): sxn.178.275(d)(3).
TP1: The maximum degree of filling must not exceed the degree of filling determined by the following: [Degree of filling = 97/1+alpha(tr - tf)], where tr is the maximum mean bulk temperature during transport, and tf is the temperature in degrees celsius of the liquid during filling.

Packaging Authorizations (refer to 49 CFR 173.***):

Exceptions: 152
Non-bulk packaging: 203
Bulk packaging: 241

Quantity Limitations:

Passenger aircraft or railcar: 2.5 L
Cargo aircraft only: 30 L

Vessel Stowage Requirements:

Vessel stowage location: B

B: (i) The material may be stowed "on deck" or "under deck" on a cargo vessel and on a passenger vessel carrying a number of passengers limited to not more than the larger of 25 passengers, or one passenger per each 3 m of overall vessel length; and (ii) "On deck only" on passenger vessels in which the number of passengers specified in paragraph (k)(2)(i) of this section is exceeded.

Vessel stowage other: 46, 56, 58, B101

46: Stow "away from" powdered metals.
56: Stow "separated from" ammonium compounds.
58: Stow "separated from" cyanides.
B101:

ICAO International Shipping Name for UN2627 (ICAO, 2002):

Proper Shipping Name: Nitrites, inorganic, n.o.s.
UN Number: 2627

ICAO International Shipping Name for UN3219 (ICAO, 2002):

Proper Shipping Name: Nitrites, inorganic, aqueous solution, n.o.s.
UN Number: 3219

-PERSONAL PROTECTION

SUMMARY

RECOMMENDED PROTECTIVE CLOTHING - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)

Wear positive pressure self-contained breathing apparatus (SCBA).
Wear chemical protective clothing that is specifically recommended by the manufacturer. It may provide little or no thermal protection.
Structural firefighters' protective clothing will only provide limited protection.

-PHYSICAL HAZARDS

FIRE HAZARD

SUMMARY

POTENTIAL FIRE OR EXPLOSION HAZARDS - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)
- These substances will accelerate burning when involved in a fire.
- Some may decompose explosively when heated or involved in a fire.
- May explode from heat or contamination.
- Some will react explosively with hydrocarbons (fuels).
- May ignite combustibles (wood, paper, oil, clothing, etc.).
- Containers may explode when heated.
- Runoff may create fire or explosion hazard.

FIRE CONTROL/EXTINGUISHING AGENTS

SMALL FIRE PRECAUTIONS - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)
- Use water. Do not use dry chemicals or foams. CO2 or Halon® may provide limited control.
LARGE FIRE PRECAUTIONS - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)
- Flood fire area with water from a distance.
- Move containers from fire area if you can do it without risk.
- Do not move cargo or vehicle if cargo has been exposed to heat.
- Fight fire from maximum distance or use unmanned hose holders or monitor nozzles.
- Cool containers with flooding quantities of water until well after fire is out.
- ALWAYS stay away from tanks engulfed in fire.
- For massive fire, use unmanned hose holders or monitor nozzles; if this is impossible, withdraw from area and let fire burn.

REACTIVITY HAZARD

Sodium Nitrite: Incompatible with acetanilide, aminoguanidine salts, antipyrine, butadiene, caffeine citrate, chlorates, hypophosphites, iodides, mercury salts, morphine, oxidizing agents, permanganate, phenazone, phthalic acid, phthalic anhydride, reductants, sodium amide, sodium disulfite, sodium thiocyanate, sulfites, tannic acid, urea, wood, and vegetable astringents, decoctions, infusions, or tinctures (Reynolds, 1982; Budavari, 1989; Sax & Lewis, 1989).

Sodium Nitrite: Antagonistic to acetylcholine, epinephrine, and histamine (HSDB , 1992).

Sodium Nitrite: Hypotensive effect is potentiated by beta-adrenergic blockers and alcohol (HSDB , 1992).

Sodium Nitrite: Other nitrites potentiate hypotensive and/or anticholinergic effects of tricyclic antidepressants, antihistamines, and meperidine and related CNS depressants (HSDB , 1992).

EVACUATION PROCEDURES

SUMMARY

Editor's Note: This material is not listed in the Table of Initial Isolation and Protective Action Distances.
LARGE SPILL - PUBLIC SAFETY EVACUATION DISTANCES - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)
- Consider initial downwind evacuation for at least 100 meters (330 feet).
FIRE - PUBLIC SAFETY EVACUATION DISTANCES - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)
- If tank, rail car or tank truck is involved in a fire, ISOLATE for 800 meters (1/2 mile) in all directions; also, consider initial evacuation for 800 meters (1/2 mile) in all directions.
PUBLIC SAFETY MEASURES - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)
- CALL Emergency Response Telephone Number on Shipping Paper first. If Shipping Paper not available or no answer, refer to appropriate telephone number:
- For additional details see the section entitled "WHO TO CALL FOR ASSISTANCE" under the ERG Instructions.
- As an immediate precautionary measure, isolate spill or leak area in all directions for at least 50 meters (150 feet) for liquids and at least 25 meters (75 feet) for solids.
- Keep unauthorized personnel away.
- Stay upwind.
- Keep out of low areas.
- Ventilate closed spaces before entering.

CONTAINMENT/WASTE TREATMENT OPTIONS

SUMMARY

SPILL OR LEAK PRECAUTIONS - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)
- Keep combustibles (wood, paper, oil, etc.) away from spilled material.
- Do not touch damaged containers or spilled material unless wearing appropriate protective clothing.
- Stop leak if you can do it without risk.
- Do not get water inside containers.
RECOMMENDED PROTECTIVE CLOTHING - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)
- Wear positive pressure self-contained breathing apparatus (SCBA).
- Wear chemical protective clothing that is specifically recommended by the manufacturer. It may provide little or no thermal protection.
- Structural firefighters' protective clothing will only provide limited protection.

SMALL LEAK/SPILL

SMALL LIQUID SPILL PRECAUTIONS - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)
- Use a non-combustible material like vermiculite or sand to soak up the product and place into a container for later disposal.
SMALL DRY SPILL PRECAUTIONS - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)
- With clean shovel place material into clean, dry container and cover loosely; move containers from spill area.

LARGE LEAK/SPILL

LARGE SPILL PRECAUTIONS - EMERGENCY RESPONSE GUIDEBOOK, GUIDE 140 (ERG, 2004)
- Dike far ahead of liquid spill for later disposal.
- Following product recovery, flush area with water.

-PHYSICAL/CHEMICAL PROPERTIES

MOLECULAR WEIGHT

SODIUM NITRITE: 69 (Budavari, 1996; HSDB , 2000)

DESCRIPTION/PHYSICAL STATE

SODIUM NITRITE: odorless, white or slightly yellow hygroscopic granules, rods, or powder with a mild saline taste (Budavari, 1996; HSDB , 2000).

SODIUM NITRITE: 9 (aqueous solution) (Budavari, 1996; HSDB , 2000)

SPECIFIC GRAVITY

TEMPERATURE AND/OR PRESSURE NOT LISTED

SODIUM NITRITE, SOLID: 2.17 g/cm(3) (Budavari, 1996; HSDB , 2000)

SOLUBILITY

IN WATER

soluble in 1.5 parts cold water and 0.6 part boiling water (Budavari, 1996; HSDB , 2000)

-REFERENCES

GENERAL BIBLIOGRAPHY

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.

AMA Department of DrugsAMA Department of Drugs: AMA Evaluations Subscription, American Medical Association, Chicago, IL, 1992.

Askew GL, Finelli L, & Genese CA: Boilerbaisse: an outbreak of methemoglobinemia in New Jersey in 1992. Pediatrics 1994; 94:381-384.

Barton GMG: A fatal case of sodium nitrite poisoning. Lancet 1954; 1:190-191.

Baselt RC: Analytical Procedures for Therapeutic Drug Monitoring and Emergency Toxicology, Biomedical Publications, Davis, CA, 1980.

Baselt RC: Disposition of Toxic Drugs and Chemicals in Man, 5th ed, Chemical Toxicology Institute, Foster City, CA, 2000.

Beasley VR, Dorman DC, & Fikes JD: A Systems Affected Approach to Veterinary Toxicology, University of Illinois, Urbana, IL, 1989.

Berlin CM: The treatment of cyanide poisoning in children. Pediatrics 1970; 46:793-796.

Boermans HJ: Diagnosis of nitrate toxicosis in cattle, using biological fluids and a rapid ion chromatographic method. Am J Vet Res 1990; 51:491-495.

Bradberry SM, Gazzard BG, & Vale JA: Methaemoglobinaemia caused by accidental contamination of drinking water with sodium nitrite (abstract), European Association of Poisons Centres and Clinical Toxicologists Scientific Meeting, Birmingham, UK, 1993.

Brophy GM, Bell R, Claassen J, et al: Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17(1):3-23.

Budavari S: The Merck Index, 11th ed, Merck & Co, Inc, Rahway, NJ, 1989.

Budavari S: The Merck Index, 12th ed, Merck & Co, Inc, Whitehouse Station, NJ, 1996.

Burgess JL, Kirk M, Borron SW, et al: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med 1999; 34(2):205-212.

Burrows GE, Horn GW, & McNew RW: The prophylactic effect of corn supplementation on experimental nitrate intoxication in cattle. J Anim Sci 1987; 64:1682-1689.

Calabrese EJ, Moore GS, & Ho SC: Low erythrocyte glucose-6-phosphate dehydrogenase (G-6-PD) activity and susceptibility to nitrite-induced methemoglobinemia formation. Bull Environ Contam Toxicol 1980; 25:837-840.

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.

Chen KK & Rose CL: Nitrite and thiosulfate therapy in cyanide poisoning. JAMA 1952; 149:113-119.

Chen KK, Rose CL, & Clowes GHA: Methylene blue, nitrites, and sodium thiosulphate against cyanide poisoning. Proc Soc Exp Biol Med 1933; 31:250-251.

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.

Choi KK & Fung FW: Determination of nitrate and nitrite in meat products by using a nitrate ion-selective electrode. Analyst 1980; 105:241-245.

Choonara IA & Rane A: Therapeutic drug monitoring of anticonvulsants state of the art. Clin Pharmacokinet 1990; 18:318-328.

Chyka PA, Seger D, Krenzelok EP, et al: Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43(2):61-87.

Dunipace AJ, Beaven R, Noblitt T, et al: Mutagenic potential of toluidine blue evaluated in the Ames test. Mutat Res 1992; 279(4):255-259.

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.

Ellenhorn MJ & Barceloux DG: Medical Toxicology: Diagnosis and Treatment of Human Poisoning, Elsevier, New York, NY, 1988.

Elliot CG, Colby TV, & Kelly TM: Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal. Chest 1989; 96:672-674.

FDA: Poison treatment drug product for over-the-counter human use; tentative final monograph. FDA: Fed Register 1985; 50:2244-2262.

Fan AM, Willhite CC, & Book SA: Evaluation of the nitrate drinking water standard with reference to infant methemoglobinemia and potential reproductive toxicity. Regul Toxicol Pharmacol 1987; 7:135-148.

Forsyth RJ & Moulden A: Methaemoglobinaemia after ingestion of amyl nitrite. Arch Dis Child 1991; 66:152.

Gautami S, Rao RN, & Raghuram TC: Accidental acute fatal sodium nitrite poisoning. Clin Tox 1995; 33:131-133.

Ger J, Kao H, & Shih TS: Fatal toxic methemoglobinemia due to occupational exposure to methyl nitrite (abstract). Chin Med J (Taipei) 1996; 57:S78.

Gilman AG, Goodman LS, & Rall TW: The Pharmacological Basis of Therapeutics, 7th ed, MacMillan Publishing Company, New York, NY, 1985.

Golej J, Boigner H, Burda G, et al: Severe respiratory failure following charcoal application in a toddler. Resuscitation 2001; 49:315-318.

Gosselin RE, Smith RP, & Hodge HC: Clinical Toxicology of Commercial Products, 5th ed, Williams & Wilkins, Baltimore, MD, 1984.

Gowans WJ: Fatal methaemoglobinaemia in a dental nurse: a case of sodium nitrite poisoning. Br J Gen Pract 1990; 40:470-471.

Graff GR, Stark J, & Berkenbosch JW: Chronic lung disease after activated charcoal aspiration. Pediatrics 2002; 109:959-961.

Grant D & Butler WH: Chronic toxicity of sodium nitrite in the male F344 rat. Fd Chem Toxicol 1989; 27:565-571.

Grant WM & Schuman JS: Toxicology of the Eye, 4th ed, Charles C. Thomas, Springfield, IL, 1993.

Gruener N, Shuval HI, & Behroozi K: Methemoglobinemia induced by transplacental passage of nitrites in rats. Bull Environ Contam Toxicol 1973; 9:44-48.

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.

HSDB : Hazardous Substances Data Bank. National Library of Medicine. Bethesda, MD (Internet Version). Edition expires 2000; provided by Truven Health Analytics Inc., Greenwood Village, CO.

Hall AH & Rumack BH: Clinical Toxicology of Cyanide. Ann Emerg Med 1986; 15:1067-1074.

Hall AH, Kulig KW, & Rumack BH: Suspected cyanide poisoning in smoke inhalation: complications of sodium nitrite therapy. J Toxicol Clin Exp 1989a; 9:3-9.

Hall AH, Kulig KW, & Rumack BH: Toxic smoke inhalation. Am J Emerg Med 1989b; 7:121-122.

Hall AH: Systemic asphyxiants: cyanide and cyanogens, hydrogen sulfide, methemoglobin inducers, in: Rippe JM et al (eds): Intensive Care Medicine, 2nd ed, Little, Brown & Co, Boston, MA, 1991, pp 1248-1258.

Harris CR & Filandrinos D: Accidental administration of activated charcoal into the lung: aspiration by proxy. Ann Emerg Med 1993; 22:1470-1473.

Harrison MR: Toxic methemoglobinemia: A case of nitrobenzene and aniline poisoning treated by exchange transfusions. Anesthesia 1977; 32:270-272.

Hegenbarth MA & American Academy of Pediatrics Committee on Drugs: Preparing for pediatric emergencies: drugs to consider. Pediatrics 2008; 121(2):433-443.

Herman MI, Chyka PA, & Butlse AY: Methylene blue by intraosseous infusion for methemoglobinemia. Ann Emerg Med 1999; 33:111-113.

Hix WR & Wilson WR: Toluidine blue staining of the esophagus: a useful adjunct in the panendoscopic evaluation of patients with squamous cell carcinoma of the head and neck. Arch Otolaryngol Head Neck Surg 1987; 113(8):864-865.

Hjelt K, Lund JT, Scherling B, et al: Methaemoglobinaemia among neonates in a neonatal intensive care unit. Acta Paediatr 1995; 84(4):365-370.

Hoegl L, Thoma-Greber E, & Poppinger J: Butyl nitrite-induced acrocyanosis in an HIV-infected patient. Arch Dermatol 1999; 135:90-91.

Hoorn AJW: Dimethylglycine and chemically related amines tested for mutagenicity under potential nitrosation conditions. Mutat Res 1989; 222:343-350.

Howard JL: Current Veterinary Therapy: Food Animal Practice 2, Saunders, Philadelphia, PA, 1986.

Howland MA: Antidotes in Depth. In: Goldfrank LR, Flomenbaum N, Hoffman RS, et al, eds. Goldfrank's Toxicologic Emergencies. 8th ed., 8th ed. McGraw-Hill, New York, NY, 2006, pp 826-828.

Humphreys DJ: Veterinary Toxicology, 3rd ed, Bailliere Tindall, London, UK, 1988.

Hvidberg EF & Dam M: Clinical pharmacokinetics of anticonvulsants. Clin Pharmacokinet 1976; 1:161.

ICAO: Technical Instructions for the Safe Transport of Dangerous Goods by Air, 2003-2004. International Civil Aviation Organization, Montreal, Quebec, Canada, 2002.

ITI: Toxic and Hazardous Industrial Chemicals Safety Manual, The International Technical Information Institute, Tokyo, Japan, 1988.

Isaacson RL & Fahey JM: Some anatomical and behavioral consequences of acute sodium nitrite administration. Neurosci Res Commun 1987; 1:39-45.

Kaplan A, Smith C, & Promnitz DA: Methaemoglobinaemia due to accidental sodium nitrite poisoning. Report of 10 cases. S Afr Med J 1990; 77:300-301.

Kiese M , Lorcher W , Weger N , et al: Comparative studies on the effects of toluidine blue and methylene blue on the reduction of ferrihaemoglobin in man and dog. Eur J Clin Pharmacol 1972; 4(2):115-118.

Kikugawa K & Kato T: Formation of a mutagenic diazoquinone by interaction of phenol with nitrite. Food Chem Toxicol 1988; 26:209-214.

Kirby NG: Sodium nitrite poisoning treated by exchange transfusion. Lancet 1955; 1:594-595.

Kleinman ME, Chameides L, Schexnayder SM, et al: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 14: pediatric advanced life support. Circulation 2010; 122(18 Suppl.3):S876-S908.

Leman AD: Diseases of Swine 6, Iowa State University Press, Ames, IA, 1986.

Ley DH: Nitrite poisoning in herring gulls (Larus argentatus) and ring billed gulls (Larus delawarensis). J Wildlife Diseases 1986; 22:381-384.

Lindenmann J, Matzi V, Kaufmann P, et al: Hyperbaric oxygenation in the treatment of life-threatening isobutyl nitrite-induced methemoglobinemia--a case report. Inhal Toxicol 2006; 18(13):1047-1049.

Loddenkemper T & Goodkin HP: Treatment of Pediatric Status Epilepticus. Curr Treat Options Neurol 2011; Epub:Epub.

Manley CH: A fatal case of sodium nitrite poisoning. Analyst 1945; 70:50.

Manno EM: New management strategies in the treatment of status epilepticus. Mayo Clin Proc 2003; 78(4):508-518.

Marquez A & Todd M: Acute hemolytic anemia and agranulocytosis following intravenous administration of toluidine blue. Am Pract 1959; 10:1548-1550.

McQuiston TAC: Fatal poisoning by sodium nitrite. Lancet 1936; 2:1153-1154.

Metcalf WK: A biochemical change in the blood in pregnancy and malignant diseases. Phys Med Biol 1961; 5:259-269.

Mokhtar NM, El-Aaser AA, & El-Bolkainy MN: Effect of soybean feeding on experimental carcinogenesis - III. Carcinogenicity of nitrite and dibutylamine in mice: a Histopathological study. Eur J Cancer Clin Oncol 1988; 24:403-411.

Naidue SR & Rao PV: Case of nitrite poisoning. Br Med J 1936; 1:1300.

Naradzay J & Barish RA: Approach to ophthalmologic emergencies. Med Clin North Am 2006; 90(2):305-328.

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.

Nemec K: Antidotes in acute poisoning. Eur J Hosp Pharm Sci Pract 2011; 17(4):53-55.

None Listed: Position paper: cathartics. J Toxicol Clin Toxicol 2004; 42(3):243-253.

Nyakas C, Markel E, & Bohus B: Protective effect of the calcium antagonist nimodipine on discrimination learning deficits and impaired retention behavior caused by prenatal nitrite exposure in rats. Behav Brain Res 1990; 38:69-76.

Oppe TE: Methaemoglobinemia due to sodium nitrite. Lancet 1951; 1:1051.

Padberg LR & Martin T: Three fatal cases of nitrite poisoning. JAMA 1939; 113:1733.

Palmer AA: Fatal poisoning by sodium nitrite. Med J Aust 1933; 2:113-114.

Peate WF: Work-related eye injuries and illnesses. Am Fam Physician 2007; 75(7):1017-1022.

Peberdy MA , Callaway CW , Neumar RW , et al: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care science. Part 9: post–cardiac arrest care. Circulation 2010; 122(18 Suppl 3):S768-S786.

Peters JW: Hydrogen sulfide poisoning in a hospital setting. JAMA 1981; 246:1588-1589.

Pollack MM, Dunbar BS, & Holbrook PR: Aspiration of activated charcoal and gastric contents. Ann Emerg Med 1981; 10:528-529.

Product Information: PROVAYBLUE(TM) intravenous injection, methylene blue intravenous injection. American Regent (per FDA), Shirley, NY, 2016.

Product Information: diazepam IM, IV injection, diazepam IM, IV injection. Hospira, Inc (per Manufacturer), Lake Forest, IL, 2008.

Product Information: dopamine hcl, 5% dextrose IV injection, dopamine hcl, 5% dextrose IV injection. Hospira,Inc, Lake Forest, IL, 2004.

Product Information: lorazepam IM, IV injection, lorazepam IM, IV injection. Akorn, Inc, Lake Forest, IL, 2008.

Product Information: methylene blue 1% IV injection, methylene blue 1% IV injection. American Regent, Inc (per manufacturer), Shirley, NY, 2011.

Product Information: methylene blue 1% intravenous injection, methylene blue 1% intravenous injection. Akorn, Inc. (per manufacturer), Lake Forest, IL, 2011.

Product Information: norepinephrine bitartrate injection, norepinephrine bitartrate injection. Sicor Pharmaceuticals,Inc, Irvine, CA, 2005.

Rau NR, Nagaraj MV, Prakash PS, et al: Fatal pulmonary aspiration of oral activated charcoal. Br Med J 1988; 297:918-919.

Reynolds JEF: Martindale: The Extra Pharmacopoeia, 28th ed, The Pharmaceutical Press, London, England, 1982.

Robbiano L, Carlo P, & Finollo R: DNA damage induced in rats by oral administration of chlordiazepoxide plus sodium nitrite or of N-nitrosochlordiazepoxide. Toxicol Appl Pharmacol 1990; 102:186-190.

Robinson NE: Current Veterinary Therapy in Equine Medicine 2, Saunders, Philadelphia, PA, 1987.

Rodriguez FS, Miguez Santiyan MP, & Pedrera Zamorano JD: Evaluation of reagent strips for the rapid diagnosis of nitrite poisoning. J Anal Toxicol 1992; 16:63-64.

S Sweetman : Martindale: The Complete Drug Reference. London: Pharmaceutical Press. The Pharmaceutical Press. London, UK (Internet Version). Edition expires 2000; provided by Truven Health Analytics Inc., Greenwood Village, CO.

Sax NI & Lewis RJ: Dangerous Properties of Industrial Materials, 7th ed, Van Nostrand Reinhold Co, New York, NY, 1989.

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.

Sevier & Berbatis CG: Accidental sodium nitrite ingestion. Med J Aust 1976; 1:847.

Sheehy MH & Way JL: Nitrite intoxication: protection with methylene blue and oxygen. Toxicol Appl Pharmacol 1974; 30:221-226.

Shepherd G & Keyes DC: Methylene blue. In: Dart,RC, ed. Medical Toxicology, 3rd ed. 3rd ed, Philadelphia, PA, 2004, pp -.

Shih RD, Marcus SM, & Genese CA: The boiler room blues: two separate epidemics of methemoglobinemia due to contamination of potable water from boiler additives (abstracts). J Toxicol Clin Toxicol 1995; 33:507-508.

Singley TL III: Secondary methemoglobinemia due to the adulteration of fish with sodium nitrite. Ann Intern Med 1962; 57:800-803.

Smith RO, Alkaitis AA, & Shafer PR: Chemically-induced methemoglobinemias in the mouse. Biochem Pharmacol 1967; 16:317-328.

Smith RP & Gosselin RE: Current concepts about the treatment of selected poisonings. Ann Rev Pharm Tox 1976; 16:188-189.

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.

Standefer J, Jones J, & Street E: Death associated with nitrite ingestion: report of a case. J Forensic Sci 1979; 24:768-771.

Stanford SC , Stanford BJ , & Gillman PK : Risk of severe serotonin toxicity following co-administration of methylene blue and serotonin reuptake inhibitors: an update on a case report of post-operative delirium. J Psychopharmacol 2010; 24(10):1433-1438.

Stine RJ, Slosberg B, & Beachman BE: Hydrogen sulfide intoxication. Ann Intern Med 1976; 85:756.

Tannenbaum SR, Sinskey AJ, & Weisman M: Nitrite in human saliva. Its possible relationship to nitrosamine formation. J Nat Cancer Inst 1974; 53:79-84.

Ten Brink WA, Wiezer JH, & Luijpen AF: Nitrite poisoning caused by food contaminated with cooling fluid. J Toxicol Clin Toxicol 1982; 19:139-147.

Teunis BS, Leftwich EI, & Pierce LE: Acute methemoglobinemia and hemolytic anemia due to toluidine blue. Arch Surg 1970; 101:527-531.

Thayer & Huffaker RC: Determination of nitrate and nitrite by high-pressure liquid chromatography: comparison with other methods for nitrite determination. Anal Biochem 1980; 102:110-119.

Tsuda H & Hasegawa M: Malignant transformation of mouse BALB/c3T3 cells induced by NaNO2. Carcinogenesis 1990; 11:595-597.

U.S. Food and Drug Administration: FDA Drug Safety Communication: Serious CNS reactions possible when methylene blue is given to patients taking certain psychiatric medications. U.S. Food and Drug Administration. Silver Spring, MD. 2011. Available from URL: http://www.fda.gov/Drugs/DrugSafety/ucm263190.htm. As accessed 2011-07-26.

Vetter J: Neurocirculatory dystonia of retinal vessels. Klin Monatsbl Augenheilkd 1951; 118:165-171.

Viveiros DM & Tondat LM: Effects of sodium nitrite on DRL performance in the rat. Pharmacol Biochem Behav 1978; 8:125-127.

WHO: Technical Report No. 309:25, World Health Organization, Geneva, Switzerland, 1965.

Wang D, Huang WQ, & Wang HW: Mutagenicity and carcinogenicity studies of home-made "rust-proof cutting fluid". Teratogenesis Carcinog Mutagen 1988; 8:35-43.

Wax PM & Hoffman RS: Methemoglobinemia: an occupational hazard of phenylpropanolamine production. Clin Tox 1994; 32:299-303.

Wei JY & Reid PR: Quantitative determination of trinitroglycerin in human plasma circulation. 1979; 59:588-592.

Winek CL, Collom WD, & Martineau P: Toluidine blue intoxication. Clin Toxicol 1969; 2:1-3.

de Beer J, Heyndrickx A, & Timperman J: Suicidal poisoning by nitrite. Eur J Tox 1975; 8:247-251.

do Nascimento TS, Pereira RO, de Mello HL, et al: Methemoglobinemia: from diagnosis to treatment. Rev Bras Anestesiol 2008; 58(6):651-664.

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Information to evaluate chemical incidents

Information to evaluate chemical incidents

Information to evaluate chemical incidents