Contact Us    Contact Us     |     Feedback
MOBILE VIEW  | 

THIAMINE

Export To Excel

Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Thiamine is a water soluble B vitamin that functions as a cofactor for the enzyme pyruvate dehydrogenase, which links anaerobic glycolysis to the Kreb's cycle.

Specific Substances

    1) Thiamine chloride
    2) Thiamine hydrochloride
    3) Molecular Formula: C(12)H(17)CIN(4)OS,HCL
    4) CAS 59-43-8 (thiamine)
    5) CAS 67-03-8 (thiamine hydrochloride)

Available Forms Sources

    A) FORMS
    1) Thiamine hydrochloride 100 mg in 2 mL vial as an injection for multiple dose use (Prod Info thiamine hydrochloride injection, 2006).
    2) Thiamine hydrochloride (vitamin B1) is available in 100 mg tablet as a vitamin supplement (Prod Info VITAMIN B-1 oral tablet, 2004).
    B) USES
    1) ALCOHOL WITHDRAWAL SYNDROME: Thiamine is recommended for patients with suspected alcohol withdrawal or chronic alcohol use. Thiamine propyl disulfide may be used when oral intake is appropriate (Hoffman, 2006). Thiamine may be given intramuscularly or intravenously when oral intake is not possible. Ethanol abuse is the most common cause of thiamine deficiency in Western countries (Doyon & Roberts, 1994).
    a) INCIDENCE: 12.5% of individuals that abuse alcohol can be thiamine deficient, as compared to 0.8% to 22% of the general population (Doyon & Roberts, 1994).
    2) ALTERED MENTAL STATUS: Thiamine is included in the initial treatment of a patient with an altered mental status; however immediate improvement in mental status is not expected to result from thiamine administration (Buylaert, 2000). However, if nutritional deficiencies (ie, chronic alcoholism, Wernicke's encephalopathy) are present, thiamine may be beneficial.
    a) Despite a lack of critical evidence to support the use of thiamine in patients with altered mental status, its routine use is still supported. It can potentially prevent delayed deterioration secondary to nutritional deficiency in individuals at risk (eg, chronic alcoholics, Wernicke's encephalopathy) (Hoffman, 2006; Hoffman & Goldfrank, 1995).
    3) ETHYLENE GLYCOL POISONING: Thiamine is recommended as a supplement in patients with ethylene glycol poisoning with standard doses usually given (Hoffman, 2006).
    4) WERNICKE'S ENCEPHALOPATHY (WE): One of the major organ systems affected by thiamine deficiency is the central nervous system (includes peripheral neuropathy, Wernicke's encephalopathy, and Wernicke-Korsakoff syndrome) (Doyon & Roberts, 1994). Intravenous thiamine is used for the emergent treatment of WE. The characteristic features of WE include oculomotor abnormalities, ataxia, and global confusion. This disorder can commonly occur concomitantly with Korsakoff's psychosis. Although this condition is a rare form of altered mental status, 100 mg of thiamine by IV bolus can start to treat WE (None Listed, 2007). Improvement can usually be observed within hours of thiamine administration (Doyon & Roberts, 1994). If the patient does not improve within 72 hours they may be at risk for developing Wernicke-Korsakoff syndrome (characterized by retrograde amnesia, impaired ability to learn, and confabulation); recovery is only anticipated in 50% of individuals (Doyon & Roberts, 1994).
    a) BARIATRIC SURGERY: Although not typical, bariatric surgery has produced Wernicke's encephalopathy (WE), which has responded rapidly to thiamine administration (Al-Fahad et al, 2006). Parenteral thiamine is the treatment of choice (Singh & Kumar, 2007). Patients undergoing surgery may be at increased risk due to alterations in stomach size, persistent vomiting, partial malabsorption produced by the surgery leading to WE (Al-Fahad et al, 2006).
    b) Based on a review of the literature, 32 cases of WE have been reported following obesity surgery (including vertical banded gastroplasty, Roux-en-Y gastric bypass, gastric partitioning, and gastric plication), with cases occurring as early as 2 weeks after surgery up to 78 weeks later. However, most cases (n=18) occurred within 4 to 12 weeks of surgery (Singh & Kumar, 2007).
    5) BERIBERI is a form of thiamine deficiency that affects the cardiovascular ("wet" beriberi) system. This form involves peripheral vasodilatation, biventricular heart failure, and peripheral edema. The response to thiamine is usually rapid (Doyon & Roberts, 1994).
    6) OTHER: Thiamine deficiency can potentially occur in individuals experiencing any of the following disorders or conditions: anorexia nervosa, hyperemesis of pregnancy, post surgical, parenteral nutrition administration, and acquired immunodeficiency syndrome (Hoffman & Goldfrank, 1995). In addition, patients on chronic diuretic therapy (eg, the elderly) may be at increased risk to develop a thiamine deficiency (McCabe-Sellers et al, 2005).
    a) CASE REPORT: A 13-year-old with diabetic ketoacidosis and encephalopathy was initially treated with an insulin drip and isotonic fluids and was metabolically and hemodynamically stable within 24 hours. However, persistent encephalopathy did not improve until parenteral thiamine was given (thiamine deficiency was confirmed by laboratory studies). Within 30 minutes the patient was alert and talking and responding to commands (Clark et al, 2006).
    7) Thiamine (vitamin B-1) when given as a vitamin supplement has been used for energy metabolism and nervous system function (Prod Info VITAMIN B-1 oral tablet, 2004). The daily requirement is somewhat dependent on total energy intake, with a minimum requirement of 0.5 mg/4200 Joules (Hoffman & Goldfrank, 1995).

Overview

Life Support

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

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) USES: Thiamine, a water soluble vitamin B1 supplement, is used as a vitamin supplement and has been used in the treatment of thiamine deficiency, alcohol withdrawal syndrome, Wernicke's encephalopathy, ethylene glycol poisoning, and the treatment of beriberi. Thiamine (vitamin B-1) when given as a vitamin supplement has been used for energy metabolism and nervous system function.
    B) PHARMACOLOGY: Thiamine combines with adenosine triphosphate (ATP) to form thiamine pyrophosphate (ie, cocarboxylase), a coenzyme. Thiamine's role in carbohydrate metabolism is the decarboxylation of pyruvic acid in the blood and alpha-ketoacids to acetaldehyde and carbon dioxide. An increase in pyruvic acid blood concentrations indicates vitamin B1 deficiency.
    C) TOXICOLOGY: Exposure to thiamine is not anticipated to produce significant symptoms; excessive intake is usually excreted in the urine.
    D) EPIDEMIOLOGY: Thiamine is widely used; serious toxicity is not expected.
    E) WITH THERAPEUTIC USE
    1) ADVERSE EVENTS: PARENTERAL: Rare reports of anaphylactoid reaction (ie, respiratory distress, pruritus, shock and abdominal pain) have been reported, usually after multiple large parenteral doses of 25 to 100 mg of thiamine for more than 7 days.
    2) OTHER events have included injection site pain following intravenous administration. There are very few adverse events reported with parenteral administration. ORAL: Adverse events are not usually reported following oral supplementation, even following high doses of 300 mg/day for several weeks.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: PARENTERAL: Single parenteral doses of 100 to 500 mg have been given with no toxic effects reported. Parenteral thiamine does contain aluminum and potential toxicity may occur following excessive exposure or in patients with renal impairment. ORAL: Toxicity is uncommon following oral supplementation; excessive doses are usually excreted rapidly in the urine.
    2) SEVERE TOXICITY: Severe toxicity has not been reported.
    0.2.20) REPRODUCTIVE
    A) Thiamine is classified by the manufacturer as FDA pregnancy category A.

Laboratory Monitoring

    A) No routine laboratory tests are indicated; obtain tests as indicated.
    B) Monitor for clinical evidence of an anaphylactoid reaction (angioedema, urticaria, hypotension, wheezing) as necessary.
    C) Thiamine levels are not usually clinically available.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) Treatment is symptomatic and supportive. See PARENTERAL overview for further information.
    0.4.6) PARENTERAL EXPOSURE
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Treatment is symptomatic and supportive; significant toxicity is not anticipated.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) Severe toxicity is not anticipated because of thiamine's low toxicity profile. ANAPHYLAXIS: Rare reports of anaphylaxis have occurred with parenteral thiamine administration. MILD/MODERATE: Give antihistamines with or without inhaled beta agonists, corticosteroids or epinephrine. SEVERE: Oxygen, aggressive airway management, antihistamines, epinephrine, corticosteroids, ECG monitoring, and IV fluids.
    C) DECONTAMINATION
    1) PREHOSPITAL: Decontamination is not necessary because of the low risk of toxicity.
    2) HOSPITAL: Decontamination is usually not indicated unless other more toxic coingestants are suspected.
    D) AIRWAY MANAGEMENT
    1) Airway management is usually not necessary; aggressive airway support is needed if anaphylaxis develops.
    E) ALUMINIUM INTOXICATION
    1) Parenteral thiamine hydrochloride contains aluminum; prolonged or excessive doses of thiamine hydrochloride may produce toxicity in patients, including premature neonates, at risk (eg renal failure).
    F) PATIENT DISPOSITION
    1) HOME CRITERIA: Asymptomatic adults with an inadvertent ingestion of several extra doses, and asymptomatic children with inadvertent minor ingestions can be managed at home.
    2) OBSERVATION CRITERIA: Patients with a deliberate overdose and those who are symptomatic should be referred to a healthcare facility for observation. Patients that remain asymptomatic can be discharged.
    3) ADMISSION CRITERIA: Patients with persistent symptoms should be admitted to the hospital.
    4) CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.
    G) PITFALLS
    1) Serious hypersensitivity/anaphylaxis may be more likely to occur following repeated parenteral administration or in patients with impaired renal function (ie, premature neonates). Aluminum toxicity (CNS and bone toxicity) may develop following repeated parenteral administration in patients with renal insufficiency.
    H) PHARMACOLOGY
    1) Thiamine is a water soluble B vitamin. Metabolism is rapid and any excess is excreted in the urine. Thiamine is distributed in all tissues with the highest concentrations occurring in the liver, brain, kidney and heart. If thiamine intake exceeds normal amounts, tissue stores increase by 2 to 3 times. Following parenteral administration, absorption of thiamine is rapid and complete.

Range Of Toxicity

    A) TOXICITY: Limited overdose data. PARENTERAL: Single parenteral doses of 100 to 500 mg have produced no toxic effects. However, doses above 30 mg 3 times daily are poorly utilized. As body tissues become saturated with thiamine, it is excreted in the urine as pyrimidine. ORAL: Toxicity is uncommon following oral thiamine; long-term supplementation of greater than 3 grams daily has been known to produce toxicity.
    B) THERAPEUTIC: BERIBERI: ADULT: 10 to 20 mg IM 3 times daily for up to 2 weeks along with a multivitamin containing 5 to 10 mg thiamine daily for one month. PEDIATRIC: 10 to 25 mg IM or IV or 10 to 50 mg/day orally for 2 weeks, then 5 to 10 mg orally for one month. NEURITIS OF PREGNANCY (secondary to severe vomiting): ADULT: 5 to 10 mg IM daily. WERNICKE-KORSAKOFF SYNDROME: Initial: 100 mg IV followed by 50 to 100 mg IM daily until patient is able to tolerate a balanced diet. DIETARY SUPPLEMENT: 100 mg orally daily.

Clinical Effects

Summary Of Exposure

    A) USES: Thiamine, a water soluble vitamin B1 supplement, is used as a vitamin supplement and has been used in the treatment of thiamine deficiency, alcohol withdrawal syndrome, Wernicke's encephalopathy, ethylene glycol poisoning, and the treatment of beriberi. Thiamine (vitamin B-1) when given as a vitamin supplement has been used for energy metabolism and nervous system function.
    B) PHARMACOLOGY: Thiamine combines with adenosine triphosphate (ATP) to form thiamine pyrophosphate (ie, cocarboxylase), a coenzyme. Thiamine's role in carbohydrate metabolism is the decarboxylation of pyruvic acid in the blood and alpha-ketoacids to acetaldehyde and carbon dioxide. An increase in pyruvic acid blood concentrations indicates vitamin B1 deficiency.
    C) TOXICOLOGY: Exposure to thiamine is not anticipated to produce significant symptoms; excessive intake is usually excreted in the urine.
    D) EPIDEMIOLOGY: Thiamine is widely used; serious toxicity is not expected.
    E) WITH THERAPEUTIC USE
    1) ADVERSE EVENTS: PARENTERAL: Rare reports of anaphylactoid reaction (ie, respiratory distress, pruritus, shock and abdominal pain) have been reported, usually after multiple large parenteral doses of 25 to 100 mg of thiamine for more than 7 days.
    2) OTHER events have included injection site pain following intravenous administration. There are very few adverse events reported with parenteral administration. ORAL: Adverse events are not usually reported following oral supplementation, even following high doses of 300 mg/day for several weeks.
    F) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: PARENTERAL: Single parenteral doses of 100 to 500 mg have been given with no toxic effects reported. Parenteral thiamine does contain aluminum and potential toxicity may occur following excessive exposure or in patients with renal impairment. ORAL: Toxicity is uncommon following oral supplementation; excessive doses are usually excreted rapidly in the urine.
    2) SEVERE TOXICITY: Severe toxicity has not been reported.

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) HYPOTENSIVE EPISODE
    1) WITH THERAPEUTIC USE
    a) Hypotension, circulatory collapse, and shock may occur as a result of a hypersensitivity or life-threatening anaphylaxis following parenteral thiamine administration (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013). This is a rare event.

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) PULMONARY EDEMA
    1) WITH THERAPEUTIC USE
    a) Pulmonary edema may occur as a result of a hypersensitivity or life-threatening anaphylaxis following parenteral thiamine administration (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013). This is a rare event.

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) ANAPHYLAXIS
    1) WITH THERAPEUTIC USE
    a) Anaphylactoid reactions, with respiratory distress, pruritus, bradycardia, hypotension, shock, tightness of the throat, nausea, sweating, abdominal pain have been reported, usually after multiple large doses of 25 to 100 mg given at intervals of more than 7 days. Although earlier studies suggested that reactions occurred with equal frequency by intravenous (IV), intramuscular (IM), or subcutaneous (SC) routes, more recent findings suggest an increased risk for serious anaphylactic reactions with intravenous administration following repeated doses (Sechi & Serra, 2007). These reactions were frequently preceded by SNEEZING or transient pruritus (Morinville et al, 1998; Fernandez et al, 1997; Steinberg, 1938; Laws, 1941; Schiff, 1941; Jolliffe, 1941; Eisenstadt, 1942; Leitner, 1943; Stein & Morgenstern, 1944; Reingold & Webb, 1946; Yudkin, 1959; Acharya et al, 1969). Six fatalities were reported up to 1968 (Pollitt, 1968). In a study of 989 patients given 1070 doses of 100 mg IV thiamine by rapid push, a systemic reaction, consisting of transient generalized pruritus, occurred in one patient, for an incidence of 0.093% (Wrenn et al, 1989).
    b) CAUSE: Anaphylactoid reactions that have occurred following thiamine administration are thought to be IgE-mediated (Johri et al, 2000). Anaphylaxis usually occurs after multiple parenteral dosages (Johri et al, 2000; Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).
    c) TESTING: If hypersensitivity is suspected, administer one-hundredth of the dose intradermally and observe for 30 minutes. If no reaction occurs, a full dose can be given and observe again for 30 minutes. Anaphylaxis is still possible; therapy should be readily available (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).
    d) TREATMENT: A 28-year-old woman developed severe anaphylaxis (dyspnea, cough, abdominal burning, dizziness, hypotension and near loss of consciousness) following a third dose of an intravenous multivitamin therapy containing thiamine. She was successfully treated with epinephrine and symptoms resolved within one hour (Morinville et al, 1998).
    e) INCIDENCE: Anaphylactic reactions appear to occur more frequently with intravenous injections compared to intramuscular administration (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013; Sechi & Serra, 2007; None Listed, 2007). However, the estimated risk is extremely low with anaphylactic reactions occurring in 2 to 4 cases per million intravenous injections, and 1 case per 5 million intramuscular injections (None Listed, 2007).

Reproductive

    3.20.1) SUMMARY
    A) Thiamine is classified by the manufacturer as FDA pregnancy category A.
    3.20.3) EFFECTS IN PREGNANCY
    A) PREGNANCY CATEGORY
    1) Thiamine is classified by the manufacturer as FDA pregnancy category A (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).
    B) FETAL RISK
    1) Studies in pregnant women have not shown that thiamine administration during pregnancy can increase the risk of fetal abnormalities. The risk of fetal harm appears remote when thiamine is used during pregnancy. However, the potential benefit of thiamine, as compared to the potential risk, should be evaluated with each individual (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).
    3.20.4) EFFECTS DURING BREAST-FEEDING
    A) LACK OF INFORMATION
    1) It is not known if thiamine is excreted in human milk (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS59-43-8 (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) No routine laboratory tests are indicated; obtain tests as indicated.
    B) Monitor for clinical evidence of an anaphylactoid reaction (angioedema, urticaria, hypotension, wheezing) as necessary.
    C) Thiamine levels are not usually clinically available.

Methods

    A) Although thiamine levels can be measured directly or functionally by measuring the erythrocyte transketolase activity at baseline and in response to thiamine diphosphate, the tests are usually not clinically available (Hoffman, 2006).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.2) DISPOSITION/PARENTERAL EXPOSURE
    6.3.2.1) ADMISSION CRITERIA/PARENTERAL
    A) Patients with persistent symptoms should be admitted to the hospital.
    6.3.2.2) HOME CRITERIA/PARENTERAL
    A) Asymptomatic adults with an inadvertent ingestion of several extra doses, and asymptomatic children with inadvertent minor ingestions can be managed at home.
    6.3.2.3) CONSULT CRITERIA/PARENTERAL
    A) Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.
    6.3.2.5) OBSERVATION CRITERIA/PARENTERAL
    A) Patients with a deliberate overdose and those who are symptomatic should be referred to a healthcare facility for observation. Patients that remain asymptomatic can be discharged.

Monitoring

    A) No routine laboratory tests are indicated; obtain tests as indicated.
    B) Monitor for clinical evidence of an anaphylactoid reaction (angioedema, urticaria, hypotension, wheezing) as necessary.
    C) Thiamine levels are not usually clinically available.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) Decontamination is generally not necessary because of a low toxicity profile. Consider gastrointestinal decontamination if a mixed ingestion involving a more toxic substance.
    6.5.3) TREATMENT
    A) SUPPORT
    1) Treatment is symptomatic and supportive; significant toxicity is unlikely to develop. See PARENTERAL exposure for further information.

Range Of Toxicity

Summary

    A) TOXICITY: Limited overdose data. PARENTERAL: Single parenteral doses of 100 to 500 mg have produced no toxic effects. However, doses above 30 mg 3 times daily are poorly utilized. As body tissues become saturated with thiamine, it is excreted in the urine as pyrimidine. ORAL: Toxicity is uncommon following oral thiamine; long-term supplementation of greater than 3 grams daily has been known to produce toxicity.
    B) THERAPEUTIC: BERIBERI: ADULT: 10 to 20 mg IM 3 times daily for up to 2 weeks along with a multivitamin containing 5 to 10 mg thiamine daily for one month. PEDIATRIC: 10 to 25 mg IM or IV or 10 to 50 mg/day orally for 2 weeks, then 5 to 10 mg orally for one month. NEURITIS OF PREGNANCY (secondary to severe vomiting): ADULT: 5 to 10 mg IM daily. WERNICKE-KORSAKOFF SYNDROME: Initial: 100 mg IV followed by 50 to 100 mg IM daily until patient is able to tolerate a balanced diet. DIETARY SUPPLEMENT: 100 mg orally daily.

Therapeutic Dose

    7.2.1) ADULT
    A) ALTERED MENTAL STATUS
    1) PARENTERAL: Administer 100 mg thiamine IV or IM. Immediate improvement is unlikely to occur in the unconscious patient, but it can provide some long-term protection for individuals at risk of thiamine deficiency, especially chronic alcoholics who may develop Wernicke's encephalopathy (Hoffman, 2006; Buylaert, 2000).
    B) ETHYLENE GLYCOL POISONING
    1) Thiamine is recommended as a supplement in patients with ethylene glycol poisoning; standard doses (100 mg IV) are usually given. Rationale for treatment suggests that a minor pathway for the elimination of glyoxylic acid involves its conversion to alpha-hydroxy-B-ketoadipate by alpha-ketoglutarate:glyoxylate carboligase, a thiamine and magnesium requiring enzyme (Hoffman, 2006).
    C) ALCOHOL WITHDRAWAL SYNDROME
    1) For patients with suspected alcohol withdrawal or chronic alcohol use that may be at risk for nutritional deficiency, give 100 mg of thiamine orally, IM or IV. Absorption of oral formulations may be inconsistent (Hoffman, 2006).
    a) PROPHYLACTIC TREATMENT: 250 mg thiamine IM once daily for 3 to 5 consecutive days for patients with severe alcohol withdrawal (Sechi & Serra, 2007).
    D) BERIBERI
    1) BACKGROUND: Clinical manifestations of thiamine deficiency include: severe cardiac failure known as Shoshin beriberi, peripheral neuropathy known as "dry" beriberi, severe cardiac failure known as "wet" beriberi, and Wernicke's encephalopathy (Pereira et al, 1984).
    2) "Wet" beriberi with myocardial failure is an emergency cardiac condition and thiamine should be administered slowly by the IV route (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).
    3) BERIBERI: 10 to 20 mg are given IM 3 times daily for up to 2 weeks; an oral multivitamin containing 5 to 10 mg of thiamine administered once daily for one month is also recommended to achieve body tissue saturation (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).
    E) WERNICKE'S ENCEPHALOPATHY
    1) Thiamine hydrochloride has been given for the treatment of Wernicke-Korsakoff syndrome by IV at an initial dose of 100 mg, followed by IM doses of 50 to 100 mg daily until the patient is consuming a regular, balanced diet (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).
    2) Treatment should include a minimum of 500 mg thiamine (dissolved in 100 mL of normal saline) via an infusion over 30 minutes 3 times per day for 2 to 3 days. If an effective response is observed, continue with 250 mg thiamine IV or IM daily for 3 to 5 days until clinical improvement stops. Treatment of suspected Wernicke's encephalopathy should also include intravenous glucose administration (Sechi & Serra, 2007).
    a) If there is NO response supplementation may be stopped within 2 to 3 days (Sechi & Serra, 2007).
    F) NEURITIS IN PREGNANCY
    1) DOSE: (Secondary to severe vomiting) 5 to 10 mg IM daily (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).
    G) THIAMINE DEFICIENCY
    1) MARGINAL THIAMINE STATUS WHEN DEXTROSE IS BEING ADMINISTERED: Recommended dose is 100 mg in each of the first few liters of IV fluid to avoid precipitating heart failure (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).
    2) POOR NUTRITION: For those with poor nutrition or malnutrition the suggested oral supplementation can be as high as 300 mg/day for several weeks. Parenteral administration should be used only for severe cases (None Listed, 2007).
    3) The benefit of prophylactic vitamin B1 administration in individuals in good health (ie, adequate nutritional status) has not been established (None Listed, 2007).
    4) The suggested Recommended Dietary Allowance (RDA) for adults are listed below (Prod Info thiamine oral tablets, 2005):
    1) MALE
    a) 15 to 18 years: 1.5 mg
    b) 19 to 24 years: 1.5 mg
    c) 25 to 50 years: 1.4 to 1.5 mg
    d) 50+ years: 1.2 mg
    2) FEMALE
    a) 15 to 18 years: 1.1 mg
    b) 19 to 24 years: 1.1 mg
    c) 25 to 50 years: 1.0 to 1.1 mg
    d) 50+ years: 1.0 mg
    7.2.2) PEDIATRIC
    A) RECOMMENDED DIETARY ALLOWANCE
    1) Recommended Dietary Allowance for pediatric patients:
    1) 0 to 6 months: 0.2 mg/day
    2) 7 to 12 months: 0.3 mg/day
    3) 1 to 3 years: 0.5 mg/day
    4) 4 to 8 years: 0.6 mg/day
    5) 9 to 13 years: 0.9 mg/day
    6) Males: 14 to 18 years: 1.2 mg/day
    7) Females: 14 to 18 years: 1 mg/day
    B) INFANTILE BERIBERI
    1) SEVERE: If collapse occurs, doses of 25 mg may cautiously be given via the IV route (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).
    2) MILD: May respond to ORAL therapy (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).

Minimum Lethal Exposure

    A) SUMMARY
    1) PARENTERAL: Limited data. There have been rare reports of deaths following parenteral administration of thiamine hydrochloride. Reingold and Webb (1946) reported that an individual died after receiving 4 IV injections (100 mg/dose) of thiamine over a period of one month (Haley & Flesher, 1946).

Maximum Tolerated Exposure

    A) PARENTERAL: Single parenteral doses of 100 to 500 mg have produced no toxic effects. However, doses above 30 mg 3 times daily are poorly utilized. As body tissues become saturated with thiamine, it is excreted in the urine as pyrimidine (Prod Info thiamine HCl intramuscular injection solution, intravenous injection solution, 2013).
    B) ORAL: Toxicity is uncommon following oral thiamine; long-term supplementation of greater than 3 grams daily has been known to produce toxicity (Prod Info thiamine oral tablets, 2005).

Workplace Standards

    A) ACGIH TLV Values for CAS59-43-8 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    B) NIOSH REL and IDLH Values for CAS59-43-8 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    C) Carcinogenicity Ratings for CAS59-43-8 :
    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 CAS59-43-8 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

Toxicity Information

    7.7.1) TOXICITY VALUES

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Thiamine combines with adenosine triphosphate (ATP) to form thiamine pyrophosphate (ie, cocarboxylase), a coenzyme. Thiamine's role in carbohydrate metabolism is the decarboxylation of pyruvic acid in the blood and alpha-ketoacids to acetaldehyde and carbon dioxide. An increase in pyruvic acid blood concentrations indicates vitamin B1 deficiency (Prod Info thiamine hydrochloride injection, 2006).
    1) The need for thiamine is greater when alterations in the diet result in an increase in carbohydrates. Depletion of vitamin B1 can occur over 3 weeks of total absence of thiamine in the diet (Prod Info thiamine hydrochloride injection, 2006).

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) 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.
    5) 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.
    6) 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.
    7) 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.
    8) 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.
    9) 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.
    10) 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.
    11) 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.
    12) AIHA: 2006 Emergency Response Planning Guidelines and Workplace Environmental Exposure Level Guides Handbook, American Industrial Hygiene Association, Fairfax, VA, 2006.
    13) Acharya V, Store SD, & Golwalla AF: Anaphylaxis following ingestion of aneurine hydrochloride. Indian Med Assoc J 1969; 52:84.
    14) Al-Fahad T, Ismael A, Soliman MO, et al: Very early onset of Wernicke's encephalopathy after gastric bypass. Obes Surg 2006; 16(5):671-672.
    15) American Conference of Governmental Industrial Hygienists : ACGIH 2010 Threshold Limit Values (TLVs(R)) for Chemical Substances and Physical Agents and Biological Exposure Indices (BEIs(R)), American Conference of Governmental Industrial Hygienists, Cincinnati, OH, 2010.
    16) Buylaert WA: Coma induced by intoxication. Acta Neurol Belg 2000; 100(4):221-224.
    17) Clark JA, Burny I, Sarnaik AP, et al: Acute thiamine deficiency in diabetic ketoacidosis: diagnosis and management. Pediatr Crit Care Med 2006; 7(6):595-599.
    18) 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.
    19) Davis RE, Icke GC, Thom J, et al: Intestinal absorption in man compared with folate and pyridoxal and its subsequent urinary excretion. J Nutr Sci Vitaminol 1984; 30:475-482.
    20) Doyon S & Roberts JR: Reappraisal of the "coma cocktail". dextrose, flumazenil, naloxone, and thiamine. Emerg Med Clin North Am 1994; 12(2):301-316.
    21) 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/.
    22) Eisenstadt WS: Hypersensitivity to thiamine hydrochloride. Minn Med 1942; 25:861-863.
    23) Fernandez M, Barcelo M, Munoz C, et al: Anaphylaxis to thiamine (vitamin B1). Allergy 1997; 52(9):958-960.
    24) Haley TJ & Flesher AM: A toxicity study of thiamine hydrochloride. Science 1946; 104(2711):567-568.
    25) Hardman JG, Gilman AG, & Limberd LEHardman JG, Gilman AG, & Limberd LE (Eds): Goodman & Gilman's The Pharmacological Basis Of Therapeutics, 8th. Pergamon Press, New York, NY, 1996.
    26) Hoffman RS & Goldfrank LR: The poisoned patient with altered consciousness. controversies in the use of a 'coma cocktail'. JAMA 1995; 274(7):562-569.
    27) Hoffman RS: Antidotes in depth: thiamine hydrochloride. In: Flomembaum NE, Howland MA, Goldfrank LR, et al, eds. Goldfrank's Toxicologic Emergencies, 8th ed. McGraw Hill, New York, NY, 2006, pp 1162-1166.
    28) 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.
    29) 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.
    30) 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.
    31) 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.
    32) 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.
    33) 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.
    34) 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.
    35) 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.
    36) Johri S, Shetty S, Soni A, et al: Anaphylaxis from intravenous thiamine--long forgotten?. Am J Emerg Med 2000; 18(5):642-643.
    37) Jolliffe N: Treatment of neuropsychiatric disorders with vitamins. JAMA 1941; 117:1496-1502.
    38) Khetrapal TK: Toxicity of parenterally administered thiamine hydrochloride. Burma.Med J 1962; 10:9-14.
    39) Laws CL: Sensitization to thiamine hydrochloride. JAMA 1941; 117:176.
    40) Leitner ZA: Untoward effects of vitamin B1. Lancet 1943; 2:474-475.
    41) Lieberman P, Nicklas R, Randolph C, et al: Anaphylaxis-a practice parameter update 2015. Ann Allergy Asthma Immunol 2015; 115(5):341-384.
    42) Lieberman P, Nicklas RA, Oppenheimer J, et al: The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126(3):477-480.
    43) McCabe-Sellers BJ, Sharkey JR, & Browne BA: Diuretic medication therapy use and low thiamin intake in homebound older adults. J Nutr Elder. 2005; 24(4):57-71.
    44) Morinville V, Jeannet-Peter N, & Hauser C: Anaphylaxis to parenteral thiamine (vitamin B1). Schweiz.Med Wochenschr 1998; 128(44):1743-1744.
    45) Morrison AB & Campbell JA: Factors influencing the excretion of oral test doses of thiamine and riboflavin by human subjects. J Nutr 1960; 72:435-440.
    46) NFPA: Fire Protection Guide to Hazardous Materials, 13th ed., National Fire Protection Association, Quincy, MA, 2002.
    47) 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.
    48) 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.
    49) 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.
    50) 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.
    51) 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.
    52) 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.
    53) 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.
    54) 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.
    55) 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.
    56) 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.
    57) 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.
    58) 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.
    59) 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.
    60) 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.
    61) 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.
    62) 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.
    63) 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.
    64) 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.
    65) 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.
    66) 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.
    67) 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.
    68) 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.
    69) 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.
    70) 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.
    71) 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.
    72) 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.
    73) 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.
    74) 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.
    75) 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.
    76) 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.
    77) 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.
    78) 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.
    79) 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.
    80) 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.
    81) 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.
    82) 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.
    83) 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.
    84) 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.
    85) 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.
    86) 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.
    87) 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.
    88) 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.
    89) 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.
    90) 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.
    91) 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.
    92) 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.
    93) 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.
    94) 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.
    95) 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.
    96) 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.
    97) 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.
    98) 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.
    99) 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.
    100) 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.
    101) 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.
    102) 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.
    103) 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.
    104) 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.
    105) 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.
    106) 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.
    107) 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.
    108) 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.
    109) 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.
    110) 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.
    111) 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.
    112) 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.
    113) 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.
    114) 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.
    115) 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.
    116) 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.
    117) 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.
    118) 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.
    119) 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.
    120) 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.
    121) 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.
    122) 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.
    123) 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.
    124) 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.
    125) 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.
    126) 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.
    127) National Research Council : Acute exposure guideline levels for selected airborne chemicals, 5, National Academies Press, Washington, DC, 2007.
    128) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 6, National Academies Press, Washington, DC, 2008.
    129) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 7, National Academies Press, Washington, DC, 2009.
    130) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 8, National Academies Press, Washington, DC, 2010.
    131) None Listed: Alcohol withdrawal syndrome: how to predict, prevent, diagnose and treat it. Prescrire Int 2007; 16(87):24-31.
    132) Nowak RM & Macias CG : Anaphylaxis on the other front line: perspectives from the emergency department. Am J Med 2014; 127(1 Suppl):S34-S44.
    133) Pereira VG, Masuda Z, Katz A, et al: Shoshin beriberi: report of two successfully treated patients with hemodynamic documentation. Am J Cardiol 1984; 53:1467.
    134) Pollitt NT: Large intravenous dosage of thiamine. JAMA 1968; 203:153.
    135) Product Information: VITAMIN B-1 oral tablet, thiamin hcl oral tablet. Nature's Bounty,Inc., Bohemia, NY, 2004.
    136) Product Information: diphenhydramine HCl intravenous injection solution, intramuscular injection solution, diphenhydramine HCl intravenous injection solution, intramuscular injection solution. Hospira, Inc. (per DailyMed), Lake Forest, IL, 2013.
    137) Product Information: thiamine HCl intramuscular injection solution, intravenous injection solution, thiamine HCl intramuscular injection solution, intravenous injection solution. Fresenius Kabi USA, LLC (per Dailymed), Lake Zurich, IL, 2013.
    138) Product Information: thiamine hydrochloride injection, thiamine hydrochloride injection. Abraxis Pharmaceutical Products, Schaumburg, IL, 2006.
    139) Product Information: thiamine oral tablets, thiamine oral tablets. Sallamander Concepts, Pretoria, South Africa, 2005.
    140) Reingold IM & Webb FR: Sudden death following intravenous injection of thiamine hydrochloride. JAMA 1946; 130:491-492.
    141) Schiff L: Collapse following parenteral administration of solution of thiamine hydrochloride. JAMA 1941; 117:609.
    142) Sechi G & Serra A: Wernicke's encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol 2007; 6(5):442-455.
    143) Singh S & Kumar A: Wernicke encephalopathy after obesity surgery: a systematic review. Neurology 2007; 68(11):807-811.
    144) Stein W & Morgenstern M: Sensitization to thiamine hydrochloride:Report of another case. Ann Intern Med 1944; 70:826-828.
    145) Steinberg CL: Untoward effects resulting from the use of large doses of vitamin B1. Am J Dig Dis 1938; 5:680-681.
    146) Tallaksen CME, Sande A, Bohmer T, et al: Kinetics of thiamin and thiamin phosphate esters in human blood, plasma and urine after 50 mg intravenously or orally. Eur J Clin Pharmacol 1993; 44:73-78.
    147) 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.
    148) 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.
    149) 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-.
    150) 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.
    151) 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.
    152) 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.
    153) 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.
    154) 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-.
    155) U.S. Occupational Safety, and Health Administration (OSHA): Process safety management of highly hazardous chemicals. 29 CFR 2010 2010; 29(1910.119):348-.
    156) 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.
    157) Vanden Hoek,TL; Morrison LJ; Shuster M; et al: Part 12: Cardiac Arrest in Special Situations 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. American Heart Association. Dallas, TX. 2010. Available from URL: http://circ.ahajournals.org/cgi/reprint/122/18_suppl_3/S829. As accessed 2010-10-21.
    158) Wrenn KD, Murphy F, & Slovis CM: A toxicity study of parenteral thiamine hydrochloride. Ann Emerg Med 1989; 18:867-870.
    159) Yudkin J: Aneurine. Practioner 1959; 182:30.