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BLASTICIDIN-S

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Blasticidin-S is a contact fungicidal aminocyclonucleoside antibiotic introduced from Japan in 1969. It is derived from Streptomyces griseochromogenes (Hayes, Jr, 1982; (Sax, 1984).

Specific Substances

    1) Blasticidin-S
    2) BLA-S
    3) Blaes-M
    4) JANTAJ: 11,1,58
    5) Molecular Formula: C17-H26-N8-O5
    6) CAS 2079-00-7
    7) BENZYLAMINOBENZENE SULPHONATE
    8) TOA BLA-S

Available Forms Sources

    A) FORMS
    1) Blasticidin S is available in emulsifiable concentrate 2% (20 g blasticidin benzylaminobenzenesulfonate/liter), wettable powder (40 g active agent/kg), and dusts (1.6 g active agent/kg) (Hayes, 1982). It is also supplied as 2 mL tube of a 10 mg/mL colorless solution in Hepes buffer, filtered to sterility (Tech Data, 2001).
    2) The commercial formulations generally contain the benzylaminobenzenesulfonate salt (Yamashita et al, 1987).
    B) SOURCES
    1) Blasticidin S is distributed by Nihon Noyaku Co, Ltd, and manufactured by Kaken Pharmaceutical Co, Ltd in Japan. It is also manufactured by Cayla in France for gene transfer research (Tech Data, 2001).
    C) USES
    1) Blasticidin is used primarily in Japan, Taiwan, Korea, Taiwan, and Central and South America in rice growing areas for control of rice blast disease.
    2) Blasticidin S is used for gene transfer research (Tech Data, 2001).

Overview

Life Support

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

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) DERMAL/INHALATION - There is limited experience with this agent. Symptoms reported in a field study where workers without protection were exposed to the dusting powder of 0.2% concentration for under 120 minutes have involved irritation. This includes corneal ulcers, keratitis, conjunctivitis, dyspnea, abdominal pain, and headache.
    B) ORAL - Toxic ingestions have resulted in significant hypotension, arrhythmias, aspiration pneumonitis, acrocyanosis, and coma. Immediate symptoms may include profuse vomiting and diarrhea, and sore throat. Death is due to pronounced hypotension following large intestinal fluid losses and aspiration pneumonitis.
    0.2.4) HEENT
    A) Conjunctivitis, keratitis, and corneal ulcers have been reported in workers exposed to this fungicide.
    B) Pharyngitis and pain were seen in workers exposed to blasticidin-S.
    1) Pharyngitis is a common complaint following ingestions.
    0.2.5) CARDIOVASCULAR
    A) Hypotension is a common clinical effect following profuse intestinal fluid losses.
    B) Tachyarrhythmias have been reported following suicidal ingestions.
    0.2.6) RESPIRATORY
    A) Dyspnea, coughing, and pulmonary edema were seen in workers exposed to the dusting powder of blasticidin-S.
    B) Aspiration pneumonitis has been reported following suicidal ingestions.
    0.2.7) NEUROLOGIC
    A) Headache was noted in one case series where workers were exposed for less than 120 minutes.
    B) A poisoning case associated with hyponatremia and CNS damage has been reported.
    C) Coma has been reported following suicidal ingestions.
    0.2.8) GASTROINTESTINAL
    A) Abdominal pain with nausea, vomiting and diarrhea have been reported. Profuse intestinal fluid losses may occur resulting in electrolyte imbalances and hypotension.
    0.2.9) HEPATIC
    A) Mild elevations of liver function tests have been reported following ingestions.
    0.2.12) FLUID-ELECTROLYTE
    A) Electrolyte imbalances may occur following intense fluid losses through vomiting and diarrhea.
    0.2.13) HEMATOLOGIC
    A) Hemoconcentration has been reported in severe cases of suicidal ingestions following a course of profuse intestinal fluid losses.
    0.2.14) DERMATOLOGIC
    A) Dermatitis has developed in workers exposed to blasticidin-S.
    B) Acrocyanosis has been reported following ingestions of Blasticidin- S.

Laboratory Monitoring

    A) Laboratory methods are generally not available for determination of blasticidin-S. No toxic levels have been established.
    B) Monitor fluid and electrolyte status.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting.
    B) EMESIS - Is not recommended as ingestion of blasticidin-S may cause protracted vomiting, shock and coma.
    C) GASTRIC LAVAGE: Consider after ingestion of a potentially life-threatening amount of poison if it can be performed soon after ingestion (generally within 1 hour). Protect airway by placement in the head down left lateral decubitus position or by endotracheal intubation. Control any seizures first.
    1) CONTRAINDICATIONS: Loss of airway protective reflexes or decreased level of consciousness in unintubated patients; following ingestion of corrosives; hydrocarbons (high aspiration potential); patients at risk of hemorrhage or gastrointestinal perforation; and trivial or non-toxic ingestion.
    D) ACTIVATED CHARCOAL: Administer charcoal as a slurry (240 mL water/30 g charcoal). Usual dose: 25 to 100 g in adults/adolescents, 25 to 50 g in children (1 to 12 years), and 1 g/kg in infants less than 1 year old.
    E) SODIUM POLYSTYRENE SULFONATE - Administration of polystyrenesulfonate (cation exchange resin) has been recommended because it showed a higher absorption capacity than activated charcoal.
    1) SODIUM POLYSTYRENE SULFONATE: ORAL: ADULT: Average daily adult dose is 15 g to 60 g. The dose is usually administered as a 15 g resin 1 to 4 times per day as needed in a small (20 mL to 100 mL) slurry of water or syrup.
    2) RECTAL: It may be given as a retention enema, although it is considered less effective than oral administration. DOSE: 30 to 50 g resin every 6 hours as a retention enema administered as a warm emulsion in 100 mL of an aqueous vehicle (eg, 20% Dextrose in Water).
    3) INFANT and SMALLER CHILDREN: ORAL or RECTAL: Use lower doses than adults; consider utilizing the exchange rate of 1 milliequivalent of excess potassium per gram of resin as the basis for the calculation.
    4) NEONATES: Sodium polystyrene sulfonate should NOT be given by the oral route to neonates.
    5) CAUTION: NEONATES and CHILDREN: Rectal administration should be performed with caution, as excessive dosage or inadequate dilution could result in impaction of the resin.
    F) Endotracheal intubation and ventilatory assistance with supplemental oxygen may be required if CNS and respiratory depression are present.
    G) Adequate administration of intravenous fluids with monitoring and replacement of electrolytes is the mainstay in treatment of oral exposures.
    H) HYPOTENSION: Infuse 10 to 20 mL/kg isotonic fluid. If hypotension persists, administer dopamine (5 to 20 mcg/kg/min) or norepinephrine (ADULT: begin infusion at 0.5 to 1 mcg/min; CHILD: begin infusion at 0.1 mcg/kg/min); titrate to desired response.
    0.4.3) INHALATION EXPOSURE
    A) INHALATION: Move patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer oxygen and assist ventilation as required. Treat bronchospasm with an inhaled beta2-adrenergic agonist. Consider systemic corticosteroids in patients with significant bronchospasm.
    B) ACUTE LUNG INJURY: Maintain ventilation and oxygenation and evaluate with frequent arterial blood gases and/or pulse oximetry monitoring. Early use of PEEP and mechanical ventilation may be needed.
    0.4.4) EYE EXPOSURE
    A) DECONTAMINATION: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, the patient should be seen in a healthcare facility.
    B) Irrigation with saline or water may not prevent keratitis. The addition of calcium salts to the irrigant has reduced the irritation in animals eyes as well as human workers.
    0.4.5) DERMAL EXPOSURE
    A) OVERVIEW
    1) DECONTAMINATION: Remove contaminated clothing and jewelry and place them in plastic bags. Wash exposed areas with soap and water for 10 to 15 minutes with gentle sponging to avoid skin breakdown. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Range Of Toxicity

    A) Toxic levels have not been established.
    B) 4.3 to 34.2% of blasticidin-S applicators developed ocular problems when it was used between 1962 and 1968.

Clinical Effects

Summary Of Exposure

    A) DERMAL/INHALATION - There is limited experience with this agent. Symptoms reported in a field study where workers without protection were exposed to the dusting powder of 0.2% concentration for under 120 minutes have involved irritation. This includes corneal ulcers, keratitis, conjunctivitis, dyspnea, abdominal pain, and headache.
    B) ORAL - Toxic ingestions have resulted in significant hypotension, arrhythmias, aspiration pneumonitis, acrocyanosis, and coma. Immediate symptoms may include profuse vomiting and diarrhea, and sore throat. Death is due to pronounced hypotension following large intestinal fluid losses and aspiration pneumonitis.

Vital Signs

    3.3.3) TEMPERATURE
    A) CASE SERIES - FEVER was noted in 4 of 17 workers exposed to the dusting powder (0.2% Blasticidin-S) for under 120 minutes (Hirono, 1974a). It was also reported in suicide ingestions (Yamashita et al, 1987a).
    B) CASE SERIES - In a series of 25 patients with blasticidin-S ingestion, 2 (8%) developed mild fever (Yang & Deng, 1996).

Heent

    3.4.1) SUMMARY
    A) Conjunctivitis, keratitis, and corneal ulcers have been reported in workers exposed to this fungicide.
    B) Pharyngitis and pain were seen in workers exposed to blasticidin-S.
    1) Pharyngitis is a common complaint following ingestions.
    3.4.3) EYES
    A) As little as 1 mcg may cause CONJUNCTIVITIS in rabbits. The dust has proved irritating to eyes of applicators (Ohoka & Shiozaki, 1965; Ojima, 1964). Symptoms generally appear 4 to 10 hours post exposure (Yamashita et al, 1987a). Conjunctival hyperemia has also been seen after ingestion (Yamashita et al, 1987a).
    B) CASE SERIES - In a series of 25 patients with blasticidin-S ingestion, 4 (16%) developed conjunctivitis (Yang & Deng, 1996).
    C) Twenty mcg in rabbit eyes caused KERATITIS. Emulsion forms were more toxic than solution or powder (Grant, 1986). When sufficient blasticidin-S comes in contact with the eye, a pseudo-membranous conjunctivitis, superficial keratitis, and hyperemia of the iris and conjunctiva may be seen (Hayes, Jr, 1982; (Grant, 1986). Exposed eyes recovered in 10 days (Grant, 1986).
    D) CORNEAL ULCERS have been noted in humans following occupational exposures (Imaizumi et al, 1972).
    3.4.6) THROAT
    A) CASE SERIES - PHARYNGITIS and pain were seen in 15 of 17 workers exposed to the dusting powder of 0.2% concentration for under 120 minutes (Hirono, 1974a).
    B) Pharyngitis is a presenting symptom in most cases of suicidal ingestions (Yang & Deng, 1995).
    1) CASE REPORT - Pharyngitis was seen in a woman who intentionally ingested 50 mL of undiluted emulsion (Yamashita et al, 1987a).

Cardiovascular

    3.5.1) SUMMARY
    A) Hypotension is a common clinical effect following profuse intestinal fluid losses.
    B) Tachyarrhythmias have been reported following suicidal ingestions.
    3.5.2) CLINICAL EFFECTS
    A) HYPOTENSIVE EPISODE
    1) Hypotension, leading to circulatory shock, and sometimes associated with tachycardia, has been reported in suicide cases with ingestion of 100 to 250 mL of emulsion. Most likely, the hypotension is due to fluid loss due to intense vomiting and diarrhea. It is unclear if Blasticidin-s has a direct contributing effect (Yamashita et al, 1987a).
    2) CASE SERIES - In a study including 25 cases of suicidal ingestions of blasticidin-S, five cases were reported as fatalities due to pronounced hypotension from profuse intestinal fluid losses and aspiration pneumonia. Hypotension was reported in all severe cases in association with arrhythmias (Yang & Deng, 1995). Three additional patients developed transient hypotension (Yang & Deng, 1996).
    B) TACHYARRHYTHMIA
    1) CASE REPORT - Tachycardia, with pulse rate of 120 beats/min, hypotension, and frequent PVC's were reported in a 46-year-old male following a suicidal ingestion of Blasticidin-S (Yamashita et al, 1987a).
    2) CASE SERIES - In a series of 25 patients with blasticidin-S ingestion, 2 (8%) developed tachycardia without hypotension or hypoxia and 2 (8%) developed tachycardia and hypotension (Yang & Deng, 1996).
    C) BRADYCARDIA
    1) CASE SERIES - In a series of 25 patients with blasticidin-S ingestion, 3 (12%) developed bradycardia, two of whom died (Yang & Deng, 1996).

Respiratory

    3.6.1) SUMMARY
    A) Dyspnea, coughing, and pulmonary edema were seen in workers exposed to the dusting powder of blasticidin-S.
    B) Aspiration pneumonitis has been reported following suicidal ingestions.
    3.6.2) CLINICAL EFFECTS
    A) DYSPNEA
    1) CASE SERIES - Dyspnea was seen in 5 of 17 workers exposed to the dusting powder (0.2% Blasticidin-s) for under 120 minutes (Hirono, 1974a). Wheezing, stridor, and dyspnea were reported in suicide patients (Yamashita et al, 1987a).
    B) COUGH
    1) CASE SERIES - Coughing was seen in 13 of 17 workers exposed to the dusting powder (0.2% Blasticidin-s) for under 120 minutes. Abnormal shadows and markings were seen on chest x-ray in 8 of 12 (Hirono, 1974a).
    C) ACUTE LUNG INJURY
    1) CASE SERIES - Pulmonary edema was seen in 1 of 4 patients exposed to blasticidin-S. The cause of the edema is unclear because the patient was given massive fluid therapy in order to compensate for dehydration due to severe vomiting and diarrhea (Suh et al, 1970) Mizutani, 1988).
    D) PNEUMONITIS
    1) ASPIRATION pneumonitis has been reported in cases of suicidal ingestions of Blasticidin-S (Yang & Deng, 1995).
    2) CASE SERIES - In a series of 25 patients with blasticidin-S ingestion, 6 (24%) developed aspiration pneumonitis, two of whom died subsequent to massive aspiration (Yang & Deng, 1996).
    E) APNEA
    1) CASE SERIES - In a series of 25 patients with blasticidin-S ingestion, 7 (16%) developed respiratory failure requiring intubation and ventilation, 5 of whom died (Yang & Deng, 1996).

Neurologic

    3.7.1) SUMMARY
    A) Headache was noted in one case series where workers were exposed for less than 120 minutes.
    B) A poisoning case associated with hyponatremia and CNS damage has been reported.
    C) Coma has been reported following suicidal ingestions.
    3.7.2) CLINICAL EFFECTS
    A) HEADACHE
    1) CASE SERIES - Headache was noted in 9 of 17 workers exposed to the dusting powder (0.2% Blasticidin-s) for under 120 minutes (Hirono, 1974a).
    B) NEUROPATHY
    1) CASE REPORT - A female case of blasticidin-S poisoning associated with CNS damage and mild hyponatremia was reported. When she presented with mild hyponatremia (serum Na+ = 125 mEq/L), she developed neurological deterioration with circulatory shock. The cause of CNS damage and hyponatremia are unclear (Mizutani, 1987).
    C) CENTRAL NERVOUS SYSTEM DEFICIT
    1) Coma has been reported in severe cases of suicidal ingestions of Blasticidin- S (Yang & Deng, 1995; Yamashita et al, 1987a).
    2) CASE SERIES - In a series of 25 patients with blasticidin-S ingestion, 10 (40%) developed abnormal mental status at some point during hospitalization (Yang & Deng, 1996).
    D) TREMOR
    1) CASE REPORT - A 51-year-old woman developed tremors of all limbs with associated hypocalcemia 10 hours after ingesting Blasticidin-S (Yang & Deng, 1996). Tremors resolved with calcium therapy.

Gastrointestinal

    3.8.1) SUMMARY
    A) Abdominal pain with nausea, vomiting and diarrhea have been reported. Profuse intestinal fluid losses may occur resulting in electrolyte imbalances and hypotension.
    3.8.2) CLINICAL EFFECTS
    A) ABDOMINAL PAIN
    1) CASE SERIES - Abdominal pain and/or nausea was seen in 15 of 17 workers exposed to dusting powder (0.2% blasticidin-S) for under 120 minutes (Hirono, 1974a).
    2) Intense abdominal pain is common following ingestions of Blasticidin-S (Yang & Deng, 1995).
    B) VOMITING
    1) Prolonged, persistent, occasionally bloody vomiting has been seen in suicide cases with ingestions of 50 to 250 mL of undiluted emulsions (Yamashita et al, 1987a) and ingestions up to estimated doses of 10 grams (Yang & Deng, 1995).
    2) CASE SERIES - In a series of 25 patients with blasticidin-S ingestion, 18 (72%) developed vomiting (Yang & Deng, 1996).
    C) DIARRHEA
    1) CASE SERIES - Diarrhea was seen in 10 of 17 workers exposed to the dusting powder (0.2% Blasticidin-s) for under 120 minutes (Hirono, 1974a).
    2) Severe, watery diarrhea was seen in suicide patients who ingested 50 to 250 mL of the undiluted emulsions (Yamashita et al, 1987a) and up to an estimated dose of 10 grams (Yang & Deng, 1995).
    3) CASE SERIES - In a series of 25 patients with blasticidin-S ingestion, 7 (28%) developed profuse diarrhea and abdominal pain (Yang & Deng, 1996).

Hepatic

    3.9.1) SUMMARY
    A) Mild elevations of liver function tests have been reported following ingestions.
    3.9.2) CLINICAL EFFECTS
    A) LIVER ENZYMES ABNORMAL
    1) CASE SERIES - Mild elevations of liver function tests were reported in 2 patients following ingestions of Blasticidin-S emulsions (Yamashita et al, 1987a).

Acid-Base

    3.11.2) CLINICAL EFFECTS
    A) ACIDOSIS
    1) METABOLIC acidosis develops with severe poisoning (Yang & Deng, 1996).

Hematologic

    3.13.1) SUMMARY
    A) Hemoconcentration has been reported in severe cases of suicidal ingestions following a course of profuse intestinal fluid losses.
    3.13.2) CLINICAL EFFECTS
    A) HEMATOCRIT - PCV - HIGH
    1) HEMOCONCENTRATION with elevated hematocrit and hemoglobin concentrations is a consistent finding following loss of extracellular fluid after ingestions of Blasticidin-S (Yamashita et al, 1987a).
    B) LEUKOCYTOSIS
    1) CASE SERIES - Leukocytosis was reported in 5 of 9 patients with blasticidin-S ingestion in whom a white blood cell count was obtained (Yang & Deng, 1996).

Dermatologic

    3.14.1) SUMMARY
    A) Dermatitis has developed in workers exposed to blasticidin-S.
    B) Acrocyanosis has been reported following ingestions of Blasticidin- S.
    3.14.2) CLINICAL EFFECTS
    A) DERMATITIS
    1) CASE SERIES - Seven of 17 patients exposed to the dusting powder (0.2% blasticidin--S) for under 120 minutes developed dermatitis (Hirono, 1974a).
    B) CYANOSIS
    1) Acrocyanosis has been reported in patients following suicidal ingestions (Yang & Deng, 1995). The acrocyanosis resembles Raynauds phenomena, with cold, painful and sweaty extremities which are cyanotic.
    a) CASE REPORT - Cyanosis, especially of the extremities, was seen in a patient who ingested 250 mL of the emulsion (Yamashita et al, 1987a).
    C) ERUPTION
    1) CASE SERIES - Generalized ERYTHEMA was seen in 2 patients after ingestion (Yamashita et al, 1987a).
    D) FLUSHING
    1) CASE SERIES - In a series of 25 patients with blasticidin-S ingestion, 2 (8%) developed facial flushing (Yang & Deng, 1996).

Endocrine

    3.16.2) CLINICAL EFFECTS
    A) HYPOGLYCEMIA
    1) Hypoglycemia has been reported in one case (Yang & Deng, 1996).

Carcinogenicity

    3.21.1) IARC CATEGORY
    A) IARC Carcinogenicity Ratings for CAS2079-00-7 (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) Laboratory methods are generally not available for determination of blasticidin-S. No toxic levels have been established.
    B) Monitor fluid and electrolyte status.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Laboratory methods are generally not available for determination of blasticidin-S. No toxic levels have been established.
    2) Fluid and serum electrolyte levels should be monitored, as extensive fluid losses have led to hypotension and circulatory shock.
    3) Monitor renal and hepatic function tests.

Radiographic Studies

    A) CHEST RADIOGRAPH
    1) Obtain a chest x-ray in patients with signs and symptoms of aspiration pneumonitis or respiratory failure.

Methods

    A) OTHER
    1) Laboratory methods are generally not available.

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Monitoring

    A) Laboratory methods are generally not available for determination of blasticidin-S. No toxic levels have been established.
    B) Monitor fluid and electrolyte status.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) DILUTION -
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    B) EMESIS/NOT RECOMMENDED -
    1) Emesis is not recommended as blasticidin-S may cause persistent vomiting, shock and coma after ingestion.
    C) ACTIVATED CHARCOAL -
    1) PREHOSPITAL ACTIVATED CHARCOAL ADMINISTRATION
    a) Consider prehospital administration of activated charcoal as an aqueous slurry in patients with a potentially toxic ingestion who are awake and able to protect their airway. Activated charcoal is most effective when administered within one hour of ingestion. Administration in the prehospital setting has the potential to significantly decrease the time from toxin ingestion to activated charcoal administration, although it has not been shown to affect outcome (Alaspaa et al, 2005; Thakore & Murphy, 2002; Spiller & Rogers, 2002).
    1) In patients who are at risk for the abrupt onset of seizures or mental status depression, activated charcoal should not be administered in the prehospital setting, due to the risk of aspiration in the event of spontaneous emesis.
    2) The addition of flavoring agents (cola drinks, chocolate milk, cherry syrup) to activated charcoal improves the palatability for children and may facilitate successful administration (Guenther Skokan et al, 2001; Dagnone et al, 2002).
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    6.5.2) PREVENTION OF ABSORPTION
    A) DILUTION
    1) DILUTION: If no respiratory compromise is present, administer milk or water as soon as possible after ingestion. Dilution may only be helpful if performed in the first seconds to minutes after ingestion. The ideal amount is unknown; no more than 8 ounces (240 mL) in adults and 4 ounces (120 mL) in children is recommended to minimize the risk of vomiting (Caravati, 2004).
    B) GASTRIC LAVAGE
    1) INDICATIONS: Consider gastric lavage with a large-bore orogastric tube (ADULT: 36 to 40 French or 30 English gauge tube {external diameter 12 to 13.3 mm}; CHILD: 24 to 28 French {diameter 7.8 to 9.3 mm}) after a potentially life threatening ingestion if it can be performed soon after ingestion (generally within 60 minutes).
    a) Consider lavage more than 60 minutes after ingestion of sustained-release formulations and substances known to form bezoars or concretions.
    2) PRECAUTIONS:
    a) SEIZURE CONTROL: Is mandatory prior to gastric lavage.
    b) AIRWAY PROTECTION: Place patients in the head down left lateral decubitus position, with suction available. Patients with depressed mental status should be intubated with a cuffed endotracheal tube prior to lavage.
    3) LAVAGE FLUID:
    a) Use small aliquots of liquid. Lavage with 200 to 300 milliliters warm tap water (preferably 38 degrees Celsius) or saline per wash (in older children or adults) and 10 milliliters/kilogram body weight of normal saline in young children(Vale et al, 2004) and repeat until lavage return is clear.
    b) The volume of lavage return should approximate amount of fluid given to avoid fluid-electrolyte imbalance.
    c) CAUTION: Water should be avoided in young children because of the risk of electrolyte imbalance and water intoxication. Warm fluids avoid the risk of hypothermia in very young children and the elderly.
    4) COMPLICATIONS:
    a) Complications of gastric lavage have included: aspiration pneumonia, hypoxia, hypercapnia, mechanical injury to the throat, esophagus, or stomach, fluid and electrolyte imbalance (Vale, 1997). Combative patients may be at greater risk for complications (Caravati et al, 2001).
    b) Gastric lavage can cause significant morbidity; it should NOT be performed routinely in all poisoned patients (Vale, 1997).
    5) CONTRAINDICATIONS:
    a) Loss of airway protective reflexes or decreased level of consciousness if patient is not intubated, following ingestion of corrosive substances, hydrocarbons (high aspiration potential), patients at risk of hemorrhage or gastrointestinal perforation, or trivial or non-toxic ingestion.
    C) ACTIVATED CHARCOAL
    1) CHARCOAL ADMINISTRATION
    a) Consider administration of activated charcoal after a potentially toxic ingestion (Chyka et al, 2005). Administer charcoal as an aqueous slurry; most effective when administered within one hour of ingestion.
    2) CHARCOAL DOSE
    a) Use a minimum of 240 milliliters of water per 30 grams charcoal (FDA, 1985). Optimum dose not established; usual dose is 25 to 100 grams in adults and adolescents; 25 to 50 grams in children aged 1 to 12 years (or 0.5 to 1 gram/kilogram body weight) ; and 0.5 to 1 gram/kilogram in infants up to 1 year old (Chyka et al, 2005).
    1) Routine use of a cathartic with activated charcoal is NOT recommended as there is no evidence that cathartics reduce drug absorption and cathartics are known to cause adverse effects such as nausea, vomiting, abdominal cramps, electrolyte imbalances and occasionally hypotension (None Listed, 2004).
    b) ADVERSE EFFECTS/CONTRAINDICATIONS
    1) Complications: emesis, aspiration (Chyka et al, 2005). Aspiration may be complicated by acute respiratory failure, ARDS, bronchiolitis obliterans or chronic lung disease (Golej et al, 2001; Graff et al, 2002; Pollack et al, 1981; Harris & Filandrinos, 1993; Elliot et al, 1989; Rau et al, 1988; Golej et al, 2001; Graff et al, 2002). Refer to the ACTIVATED CHARCOAL/TREATMENT management for further information.
    2) Contraindications: unprotected airway (increases risk/severity of aspiration) , nonfunctioning gastrointestinal tract, uncontrolled vomiting, and ingestion of most hydrocarbons (Chyka et al, 2005).
    D) SODIUM POLYSTYRENE SULFONATE
    1) Administer polystyrenesulfonate (cation exchange resin), because of high absorption capacity (Yamashita et al, 1987b).
    2) SUMMARY
    a) Sodium polystyrene sulfonate, a cationic exchange resin, has been used to treat severe hyperkalemia.
    3) ADULT DOSE
    a) ORAL: Average daily adult dose is 15 g to 60 g. The dose is usually administered as a 15 g resin 1 to 4 times per day as needed in a small (20 mL to 100 mL) slurry of water or syrup (to increase palatability) (Prod Info KAYEXALATE(R) oral powder for suspension rectal powder for suspension, 2010).
    b) RECTAL: It may be given as a retention enema, although this method is less effective than oral administration. DOSE: 30 g to 50 g resin as a retention enema every 6 hours. Dilute each dose as a warm emulsion (body temperature) in 100 mL of an aqueous vehicle (eg 20% Dextrose in Water). Gently, agitate the solution during administration. The enema should be retained as long as possible; followed by a cleansing enema (Prod Info KAYEXALATE(R) oral powder for suspension rectal powder for suspension, 2010).
    4) PEDIATRIC DOSE
    a) SUMMARY: The effectiveness of sodium polystyrene sulfonate has not been established in pediatric patients (Prod Info KAYEXALATE(R) oral powder for suspension rectal powder for suspension, 2010).
    b) ORAL: INFANTS and SMALLER CHILDREN: Use lower doses than adults; consider utilizing the exchange rate of 1 milliequivalent of excess potassium per gram of resin as the basis for the calculation. NEONATES: Sodium polystyrene sulfonate should NOT be given by the oral route to neonates (Prod Info KAYEXALATE(R) oral suspension, rectal suspension, 2003).
    c) RECTAL: INFANTS and SMALLER CHILDREN: Use lower doses than adults; consider utilizing the exchange rate of 1 milliequivalent of potassium per gram of resin as the basis for the calculation. NEONATES and CHILDREN: Rectal administration should be performed with caution, as excessive dosage or inadequate dilution could result in impaction of the resin (Prod Info KAYEXALATE(R) oral suspension, rectal suspension, 2003).
    5) MONITORING PARAMETERS
    a) Monitor serum electrolytes, particularly potassium and sodium concentrations.
    b) Monitor ECG for conduction disturbances, dysrhythmias.
    6) ADVERSE EFFECTS
    a) Nausea, vomiting, gastric irritation, anorexia and constipation can develop. Diarrhea may occur infrequently. Electrolyte abnormalities such as hypocalcemia, hypokalemia, hypomagnesemia and sodium overload are also possible (Prod Info KAYEXALATE(R) oral powder for suspension rectal powder for suspension, 2010). Large doses in the elderly may cause fecal impaction, and rarely colonic necrosis (Lillemoe et al, 1987).
    b) The combined use of sorbitol and sodium polystyrene sulfonate have produced intestinal necrosis, which can be fatal. Concomitant use is not recommended (Prod Info KAYEXALATE(R) oral powder for suspension rectal powder for suspension, 2010).
    c) Intestinal obstruction from aluminum hydroxide concretions has occurred when administered in combination with sodium polystyrene sulfonate (Townsend et al, 1973).
    6.5.3) TREATMENT
    A) SUPPORT
    1) No specific antidote is available for oral exposure. The material is irritating but not known to be caustic. Dilution followed by activated charcoal or polystyrenesulfonate, and supportive care with fluid and electrolyte monitoring is indicated.
    B) AIRWAY MANAGEMENT
    1) Endotracheal intubation and ventilatory assistance with supplemental oxygen may be required if CNS and respiratory depression are present.
    C) FLUID/ELECTROLYTE BALANCE REGULATION
    1) Adequate administration of intravenous fluids with monitoring and replacement of electrolytes is the mainstay in treatment of oral exposures. If the patient has good renal function, maintain at least a normal urine flow and sodium excretion by administering sodium chloride (0.45 percent or 0.9 percent) intravenously. Replace sodium and other electrolytes depleted through profuse intestinal fluid losses.
    D) HYPOTENSIVE EPISODE
    1) SUMMARY
    a) Infuse 10 to 20 milliliters/kilogram of isotonic fluid and keep the patient supine. If hypotension persists, administer dopamine or norepinephrine. Consider central venous pressure monitoring to guide further fluid therapy.
    2) DOPAMINE
    a) DOSE: Begin at 5 micrograms per kilogram per minute progressing in 5 micrograms per kilogram per minute increments as needed (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). If hypotension persists, dopamine may need to be discontinued and a more potent vasoconstrictor (eg, norepinephrine) should be considered (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
    b) CAUTION: If ventricular dysrhythmias occur, decrease rate of administration (Prod Info dopamine hcl, 5% dextrose IV injection, 2004). Extravasation may cause local tissue necrosis, administration through a central venous catheter is preferred (Prod Info dopamine hcl, 5% dextrose IV injection, 2004).
    3) NOREPINEPHRINE
    a) PREPARATION: 4 milligrams (1 amp) added to 1000 milliliters of diluent provides a concentration of 4 micrograms/milliliter of norepinephrine base. Norepinephrine bitartrate should be mixed in dextrose solutions (dextrose 5% in water, dextrose 5% in saline) since dextrose-containing solutions protect against excessive oxidation and subsequent potency loss. Administration in saline alone is not recommended (Prod Info norepinephrine bitartrate injection, 2005).
    b) DOSE
    1) ADULT: Dose range: 0.1 to 0.5 microgram/kilogram/minute (eg, 70 kg adult 7 to 35 mcg/min); titrate to maintain adequate blood pressure (Peberdy et al, 2010).
    2) CHILD: Dose range: 0.1 to 2 micrograms/kilogram/minute; titrate to maintain adequate blood pressure (Kleinman et al, 2010).
    3) CAUTION: Extravasation may cause local tissue ischemia, administration by central venous catheter is advised (Peberdy et al, 2010).

Inhalation Exposure

    6.7.1) DECONTAMINATION
    A) Move patient from the toxic environment to fresh air. Monitor for respiratory distress. If cough or difficulty in breathing develops, evaluate for hypoxia, respiratory tract irritation, bronchitis, or pneumonitis.
    B) OBSERVATION: Carefully observe patients with inhalation exposure for the development of any systemic signs or symptoms and administer symptomatic treatment as necessary.
    C) INITIAL TREATMENT: Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta-2 adrenergic agonists, if bronchospasm develops. Consider systemic corticosteroids in patients with significant bronchospasm (National Heart,Lung,and Blood Institute, 2007). Exposed skin and eyes should be flushed with copious amounts of water.
    6.7.2) TREATMENT
    A) ACUTE LUNG INJURY
    1) ONSET: Onset of acute lung injury after toxic exposure may be delayed up to 24 to 72 hours after exposure in some cases.
    2) NON-PHARMACOLOGIC TREATMENT: The treatment of acute lung injury is primarily supportive (Cataletto, 2012). Maintain adequate ventilation and oxygenation with frequent monitoring of arterial blood gases and/or pulse oximetry. If a high FIO2 is required to maintain adequate oxygenation, mechanical ventilation and positive-end-expiratory pressure (PEEP) may be required; ventilation with small tidal volumes (6 mL/kg) is preferred if ARDS develops (Haas, 2011; Stolbach & Hoffman, 2011).
    a) To minimize barotrauma and other complications, use the lowest amount of PEEP possible while maintaining adequate oxygenation. Use of smaller tidal volumes (6 mL/kg) and lower plateau pressures (30 cm water or less) has been associated with decreased mortality and more rapid weaning from mechanical ventilation in patients with ARDS (Brower et al, 2000). More treatment information may be obtained from ARDS Clinical Network website, NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary, http://www.ardsnet.org/node/77791 (NHLBI ARDS Network, 2008)
    3) FLUIDS: Crystalloid solutions must be administered judiciously. Pulmonary artery monitoring may help. In general the pulmonary artery wedge pressure should be kept relatively low while still maintaining adequate cardiac output, blood pressure and urine output (Stolbach & Hoffman, 2011).
    4) ANTIBIOTICS: Indicated only when there is evidence of infection (Artigas et al, 1998).
    5) EXPERIMENTAL THERAPY: Partial liquid ventilation has shown promise in preliminary studies (Kollef & Schuster, 1995).
    6) CALFACTANT: In a multicenter, randomized, blinded trial, endotracheal instillation of 2 doses of 80 mL/m(2) calfactant (35 mg/mL of phospholipid suspension in saline) in infants, children, and adolescents with acute lung injury resulted in acute improvement in oxygenation and lower mortality; however, no significant decrease in the course of respiratory failure measured by duration of ventilator therapy, intensive care unit, or hospital stay was noted. Adverse effects (transient hypoxia and hypotension) were more frequent in calfactant patients, but these effects were mild and did not require withdrawal from the study (Wilson et al, 2005).
    7) However, in a multicenter, randomized, controlled, and masked trial, endotracheal instillation of up to 3 doses of calfactant (30 mg) in adults only with acute lung injury/ARDS due to direct lung injury was not associated with improved oxygenation and longer term benefits compared to the placebo group. It was also associated with significant increases in hypoxia and hypotension (Willson et al, 2015).
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Eye Exposure

    6.8.1) DECONTAMINATION
    A) EYE IRRIGATION, ROUTINE: Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persist after 15 minutes of irrigation, an ophthalmologic examination should be performed (Peate, 2007; Naradzay & Barish, 2006).
    6.8.2) TREATMENT
    A) IRRITATION SYMPTOM
    1) Eye irritation appears to be reduced by the addition of calcium salts. When exposed rabbits had their eyes irritated with water or saline 1 minute after exposure, keratitis was not prevented (Shiozaki, 1967). The addition of calcium salts to the irrigant reduced the irritation in the rabbits and guinea pigs tested, and also human workers (Suh et al, 1970; Sugimoto, 1978). Addition of 5% calcium acetate to formulations for application appears to reduce eye irritation in field workers (Sugimoto, 1972).
    2) One source recommended glutathion ophthalmic solution, vitamin B2 ophthalmic lotion and ointment, as well as antibiotic ointment for corneal symptoms (Anon, 1986; Shiozaki, 1967).
    B) Treatment should include recommendations listed in the ORAL EXPOSURE section when appropriate.

Dermal Exposure

    6.9.1) DECONTAMINATION
    A) DERMAL DECONTAMINATION
    1) DECONTAMINATION: Remove contaminated clothing and wash exposed area thoroughly with soap and water for 10 to 15 minutes. A physician may need to examine the area if irritation or pain persists (Burgess et al, 1999).

Abstracts

Case Reports

    A) ADULT
    1) A 66-year-old male who ingested 100 mL of undiluted emulsion immediately developed nausea, vomiting, severe diarrhea, and intense abdominal pain. Nine hours post ingestion systolic blood pressure fell to 50 mmHg. Fever, tachycardia, dyspnea, and generalized erythema were seen. Treatment included IV fluids, vasopressors, adrenocortical steroids, and oxygen. The patient died 20 hours post ingestion (Yamashita et al, 1987a).
    2) A 46-year-old male ingested 250 mL of undiluted emulsion. Within 2 hours he had severe bloody vomiting and diarrhea. Four hours post ingestion stridor, conjunctival hyperemia, acrocyanosis, and erythema of the anterior chest and thigh were seen. Within 6 hours the patient developed wheezing, a systolic blood pressure of 80 mmHg, and tachycardia. By eight hours the pulse had increased and the blood pressure decreased further, and PVCs were seen. The patient died 26 hours post ingestion. Initial treatment included gastric lavage, antibiotics, IV lactated Ringer's solution, and adrenocortical steroids. Later treatment used was oxygen and vasopressors (Yamashita et al, 1987a).
    3) A 31-year-old female ingested an unknown amount of blasticidin-S emulsion in a suicide attempt. Her early manifestations were chiefly gastrointestinal symptoms, and no neurological disturbances were noticed. On the fifth day when she presented with mild hyponatremia (serum Na+ = 125 mEq/L), she developed neurological deterioration with circulatory shock. On the sixth day, she had a grand mal seizure, and then became comatose and quadriplegic. Gradually over the next two months, she regained consciousness to some extent, but remained hemiparetic and aphasic. The cause of brain damage in this case may be attributed to the CNS effect of blasticidin-S although it remains to be evaluated (Mizutani, 1987).

Range Of Toxicity

Summary

    A) Toxic levels have not been established.
    B) 4.3 to 34.2% of blasticidin-S applicators developed ocular problems when it was used between 1962 and 1968.

Minimum Lethal Exposure

    A) CASE REPORTS
    1) Doses of 250 mL in a 46 year old, 100 mL in a 66 year old and less than 200 mL in a 30 year old proved fatal. Doses of 33 and 83 mg/kg proved fatal; 17 mg/kg did not. All had conservative treatment (Yamashita et al, 1987).

Maximum Tolerated Exposure

    A) ROUTE OF EXPOSURE
    1) Ophthalmic problems due to blasticidin-S occurred in 4.3 to 34.2% of the applicators of this pesticide between 1962 and 1968 (Imaizumi et al, 1972).

Serum Plasma Blood Concentrations

    7.5.2) TOXIC CONCENTRATIONS
    A) TOXIC CONCENTRATION LEVELS
    1) GENERAL
    a) Has not been determined.

Workplace Standards

    A) ACGIH TLV Values for CAS2079-00-7 (American Conference of Governmental Industrial Hygienists, 2010):
    1) Not Listed

    B) NIOSH REL and IDLH Values for CAS2079-00-7 (National Institute for Occupational Safety and Health, 2007):
    1) Not Listed

    C) Carcinogenicity Ratings for CAS2079-00-7 :
    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 CAS2079-00-7 (U.S. Occupational Safety, and Health Administration (OSHA), 2010):
    1) Not Listed

Toxicity Information

    7.7.1) TOXICITY VALUES
    A) Benzylaminobenzenesulfonate salt
    1) LD50- (ORAL)MOUSE:
    a) 33 mg/kg
    b) 51.9 mg/kg
    2) LD50- (ORAL)RAT:
    a) 53.3 mg/kg
    B) Lauryl Sulfate
    1) LD50- (ORAL)MOUSE:
    a) 13.5 mg/kg
    2) LD50- (ORAL)RAT:
    a) 39.5 mg/kg
    3) LD50- (SKIN)RAT:
    a) 220 mg/kg
    b) 3100 mg/kg
    C) References: Martin & Worthing, 1977 Takagi, 1966
    1) LD50- (ORAL)MOUSE:
    a) 10.1 mg/kg -- free base
    2) LD50- (SKIN)MOUSE:
    a) 220 mg/kg
    3) LD50- (SUBCUTANEOUS)MOUSE:
    a) 16.3 mg/kg
    4) LD50- (ORAL)RAT:
    a) 39.5 mg/kg
    b) 16.3 mg/kg -- free base
    5) LD50- (SKIN)RAT:
    a) 3,100 mg/kg
    b) 75.5 mg/kg
    6) LD50- (SUBCUTANEOUS)RAT:
    a) 3.1 mg/kg

Pharmacology Toxicology

Pharmacologic Mechanism

    A) Is effective against rice blast by inhibiting spore protein polymerization (Yamaguchi et al, 1965).

Toxicologic Mechanism

    A) Rabbits injected intratracheally developed first pneumonitis and focal destruction of tissue. Within 3 days nonciliated, undifferentiated epithelial cells were seen in the respiratory bronchioles. By the 6th day these cells formed glandular structures extending from the bronchioles. Within another 4 days blood capillaries had surrounded these structures which had begun to differentiate to form alveoli. Two weeks post injection 2 types of alveolar cells could be distinguished (Ebe, 1969). Hirono (1974b) in a follow-up study showed that greater than 0.1 mg of blasticidin-S was required for the effect, but both the degree of injury and time to recovery increased as the dose administered increased from 0.1 to 10 mg/mL.

Physicochemical

Physical Characteristics

    A) BLASTICIDIN-S: needles
    B) BLASTICIDIN-S HYDROCHLORIDE: crystals

Molecular Weight

    A) 422.4 daltons

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) Alaspaa AO, Kuisma MJ, Hoppu K, et al: Out-of-hospital administration of activated charcoal by emergency medical services. Ann Emerg Med 2005; 45:207-12.
    14) 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.
    15) Anon: Management of Pesticide Poisonings Symptoms and Treatments, Ministry of Agriculture, Forestry and Fisheries, Japan, 1986.
    16) Artigas A, Bernard GR, Carlet J, et al: The American-European consensus conference on ARDS, part 2: ventilatory, pharmacologic, supportive therapy, study design strategies, and issues related to recovery and remodeling.. Am J Respir Crit Care Med 1998; 157:1332-1347.
    17) Brower RG, Matthay AM, & Morris A: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Eng J Med 2000; 342:1301-1308.
    18) Burgess JL, Kirk M, Borron SW, et al: Emergency department hazardous materials protocol for contaminated patients. Ann Emerg Med 1999; 34(2):205-212.
    19) Caravati EM, Knight HH, & Linscott MS: Esophageal laceration and charcoal mediastinum complicating gastric lavage. J Emerg Med 2001; 20:273-276.
    20) Caravati EM: Alkali. In: Dart RC, ed. Medical Toxicology, Lippincott Williams & Wilkins, Philadelphia, PA, 2004.
    21) Cataletto M: Respiratory Distress Syndrome, Acute(ARDS). In: Domino FJ, ed. The 5-Minute Clinical Consult 2012, 20th ed. Lippincott Williams & Wilkins, Philadelphia, PA, 2012.
    22) Chyka PA, Seger D, Krenzelok EP, et al: Position paper: Single-dose activated charcoal. Clin Toxicol (Phila) 2005; 43(2):61-87.
    23) 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.
    24) Dagnone D, Matsui D, & Rieder MJ: Assessment of the palatability of vehicles for activated charcoal in pediatric volunteers. Pediatr Emerg Care 2002; 18:19-21.
    25) 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/.
    26) Ebe T: Light and electron microscope studies on experimental pneumonitis induced by blasticidin-S, with special reference to alveolar regeneration. Arch Histol Jpn 1969; 30:149-182.
    27) Elliot CG, Colby TV, & Kelly TM: Charcoal lung. Bronchiolitis obliterans after aspiration of activated charcoal. Chest 1989; 96:672-674.
    28) FDA: Poison treatment drug product for over-the-counter human use; tentative final monograph. FDA: Fed Register 1985; 50:2244-2262.
    29) Golej J, Boigner H, Burda G, et al: Severe respiratory failure following charcoal application in a toddler. Resuscitation 2001; 49:315-318.
    30) Graff GR, Stark J, & Berkenbosch JW: Chronic lung disease after activated charcoal aspiration. Pediatrics 2002; 109:959-961.
    31) Grant WM: Toxicology of The Eye, Charles C. Thomas, Springfield, IL, 1986.
    32) Guenther Skokan E, Junkins EP, & Corneli HM: Taste test: children rate flavoring agents used with activated charcoal. Arch Pediatr Adolesc Med 2001; 155:683-686.
    33) Haas CF: Mechanical ventilation with lung protective strategies: what works?. Crit Care Clin 2011; 27(3):469-486.
    34) Harris CR & Filandrinos D: Accidental administration of activated charcoal into the lung: aspiration by proxy. Ann Emerg Med 1993; 22:1470-1473.
    35) Hayes WJ: Pesticides Studied in Man, William & Wilkins, Baltimore, MD, 1982.
    36) Hirono K: Clinical and experimental studies on pneumonitis caused by pesticides. Part I. Clinical Study. Niigata Med J 1974a; 88:64-69.
    37) 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.
    38) 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.
    39) 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.
    40) 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.
    41) 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.
    42) 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.
    43) Imaizumi K, Atsumi K, & Tanifuji Y: Clinical observations of ophthalmic disturbances due to agricultural chemicals. Folia Ophthalmol Jpn 1972; 22:154-156.
    44) 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.
    45) 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.
    46) 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.
    47) Kollef MH & Schuster DP: The acute respiratory distress syndrome. N Engl J Med 1995; 332:27-37.
    48) Lillemoe KD, Romolo JL, & Hamilton SR: Intestinal necrosis due to sodium polystyrene (Kayexalate) in sorbitol enemas: clinical and experimental support of the hypothesis. Surgery 1987; 101:267-272.
    49) Mizutani T: Blasticidin S poisoning associated with hyponatremia and CNS damage. The Pharmaceutical Monthly 1987; 29:1987-1989.
    50) NFPA: Fire Protection Guide to Hazardous Materials, 13th ed., National Fire Protection Association, Quincy, MA, 2002.
    51) NHLBI ARDS Network: Mechanical ventilation protocol summary. Massachusetts General Hospital. Boston, MA. 2008. Available from URL: http://www.ardsnet.org/system/files/6mlcardsmall_2008update_final_JULY2008.pdf. As accessed 2013-08-07.
    52) 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.
    53) 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.
    54) 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.
    55) 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.
    56) Naradzay J & Barish RA: Approach to ophthalmologic emergencies. Med Clin North Am 2006; 90(2):305-328.
    57) 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.
    58) 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.
    59) 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.
    60) 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.
    61) 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.
    62) 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.
    63) 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.
    64) 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.
    65) 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.
    66) 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.
    67) 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.
    68) 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.
    69) 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.
    70) 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.
    71) 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.
    72) 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.
    73) 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.
    74) 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.
    75) 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.
    76) 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.
    77) 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.
    78) 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.
    79) 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.
    80) 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.
    81) 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.
    82) 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.
    83) 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.
    84) 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.
    85) 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.
    86) 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.
    87) 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.
    88) 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.
    89) 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.
    90) 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.
    91) 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.
    92) 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.
    93) 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.
    94) 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.
    95) 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.
    96) 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.
    97) 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.
    98) 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.
    99) 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.
    100) 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.
    101) 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.
    102) 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.
    103) 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.
    104) 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.
    105) 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.
    106) 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.
    107) 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.
    108) 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.
    109) 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.
    110) 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.
    111) 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.
    112) 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.
    113) 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.
    114) 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.
    115) 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.
    116) 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.
    117) 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.
    118) 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.
    119) 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.
    120) 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.
    121) 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.
    122) 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.
    123) 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.
    124) 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.
    125) 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.
    126) 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.
    127) 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.
    128) 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.
    129) 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.
    130) 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.
    131) 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.
    132) 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.
    133) National Research Council : Acute exposure guideline levels for selected airborne chemicals, 5, National Academies Press, Washington, DC, 2007.
    134) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 6, National Academies Press, Washington, DC, 2008.
    135) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 7, National Academies Press, Washington, DC, 2009.
    136) National Research Council: Acute exposure guideline levels for selected airborne chemicals, 8, National Academies Press, Washington, DC, 2010.
    137) None Listed: Position paper: cathartics. J Toxicol Clin Toxicol 2004; 42(3):243-253.
    138) Ohoka R & Shiozaki H: Ocular lesion due to agricultural medicine. Jpn J Clin Ophthalmol 1965; 19:937-944.
    139) Ojima M: Ocular lesions by blasticidin (agricultural medicine) (Rinsho Ganka). Jpn Ophthalmol 1964; 18:813-823.
    140) Peate WF: Work-related eye injuries and illnesses. Am Fam Physician 2007; 75(7):1017-1022.
    141) 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.
    142) Pollack MM, Dunbar BS, & Holbrook PR: Aspiration of activated charcoal and gastric contents. Ann Emerg Med 1981; 10:528-529.
    143) Product Information: KAYEXALATE(R) oral powder for suspension rectal powder for suspension, sodium polystyrene sulfonate oral powder for suspension rectal powder for suspension. Sanofi-Aventis, US, LLC, Bridgewater, NJ, 2010.
    144) Product Information: KAYEXALATE(R) oral suspension, rectal suspension, sodium polystyrene sulfonate oral suspension, rectal suspension. Sanofi-Synthelabo Inc, New York, NY, 2003.
    145) Product Information: dopamine hcl, 5% dextrose IV injection, dopamine hcl, 5% dextrose IV injection. Hospira,Inc, Lake Forest, IL, 2004.
    146) Product Information: norepinephrine bitartrate injection, norepinephrine bitartrate injection. Sicor Pharmaceuticals,Inc, Irvine, CA, 2005.
    147) Rau NR, Nagaraj MV, Prakash PS, et al: Fatal pulmonary aspiration of oral activated charcoal. Br Med J 1988; 297:918-919.
    148) Sax NI: Dangerous Properties of Industrial Materials, 6th ed, Van Nostrand Reinhold Co, New York, NY, 1984.
    149) Shiozaki H: Studies on the ocular toxicity of blasticidin-S. Jpn J Clin Ophthalmol 1967; 21:111-122.
    150) Spiller HA & Rogers GC: Evaluation of administration of activated charcoal in the home. Pediatrics 2002; 108:E100.
    151) Stolbach A & Hoffman RS: Respiratory Principles. In: Nelson LS, Hoffman RS, Lewin NA, et al, eds. Goldfrank's Toxicologic Emergencies, 9th ed. McGraw Hill Medical, New York, NY, 2011.
    152) Sugimoto T: Reduction of eye irritation caused by blasticidin-S. Kurume Igakkai Zasshi 1978; 41:103-113.
    153) Sugimoto T: Studies on ocular disturbances by improved blasticidin-S dust formulation. J Jpn Assoc Rural Med 1972; 21:316-317.
    154) Suh D, Kim D, & Hong D: Acute intoxication due to agricultural chemicals. Taehan Naekwa Hakkoe Chapci 1970; 13:197-206.
    155) Thakore S & Murphy N: The potential role of prehospital administration of activated charcoal. Emerg Med J 2002; 19:63-65.
    156) Townsend CM, Remmers AR Jr, & Sarles HE: Intestinal obstruction from medication bezoar in patients with renal failure. N Engl J Med 1973; 288:1058.
    157) 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.
    158) 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.
    159) 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-.
    160) 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.
    161) 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.
    162) 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.
    163) 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.
    164) 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-.
    165) U.S. Occupational Safety, and Health Administration (OSHA): Process safety management of highly hazardous chemicals. 29 CFR 2010 2010; 29(1910.119):348-.
    166) 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.
    167) Vale JA, Kulig K, American Academy of Clinical Toxicology, et al: Position paper: Gastric lavage. J Toxicol Clin Toxicol 2004; 42:933-943.
    168) Vale JA: Position Statement: gastric lavage. American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. J Toxicol Clin Toxicol 1997; 35:711-719.
    169) Willson DF, Truwit JD, Conaway MR, et al: The adult calfactant in acute respiratory distress syndrome (CARDS) trial. Chest 2015; 148(2):356-364.
    170) Wilson DF, Thomas NJ, Markovitz BP, et al: Effect of exogenous surfactant (calfactant) in pediatric acute lung injury. A randomized controlled trial. JAMA 2005; 293:470-476.
    171) Yamaguchi H, Yamamoto C, & Tanaka N: Inhibition of protein synthesis by blasticidin S: studies with cell-free systems from bacterial and mammalian cells. J Biochem 1965; 57:642-667.
    172) Yamashita M, Nakamura K, & Naito H: Acute blasticidin S poisoning. Vet Hum Toxicol 1987a; 29:8-11.
    173) Yamashita M, Takeda M, & Yoshino K: The effectiveness of cation exchange resin as an absorbent of blasticidin S. The Pharmaceutical Monthly 1987b; 29:418-420.
    174) Yang CC & Deng JF: CLinical experience in poisonings following exposure to blasticidin S, a curiously strong fungicide. Vet Human Toxicol 1996; 38:107-112.
    175) Yang CC & Deng JF: Clinical experience in poisoning following exposure to Blasticidin S - A curiously strong fungicide (abstract), EAPCCT Scientific Meeting, Krakow, Poland, 1995, pp 210.