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Diss Factsheets

Toxicological information

Direct observations: clinical cases, poisoning incidents and other

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Administrative data

Endpoint:
direct observations: clinical cases, poisoning incidents and other
Type of information:
experimental study
Adequacy of study:
weight of evidence
Reliability:
2 (reliable with restrictions)
Rationale for reliability incl. deficiencies:
other: Published peer reviewed clinical report by the New York City Poison Control Centre

Data source

Reference
Reference Type:
publication
Title:
Survival after intentional oral ingestion of an ammonium bifluoride containing commercial rust remover
Author:
Greller, H.A., Hoffman, R.S., Nelson, L.S.
Year:
2004
Bibliographic source:
Journal of Toxicology: Clinical Toxicology, 42(4): 485-486

Materials and methods

Study type:
poisoning incident
Endpoint addressed:
acute toxicity: oral
Test guideline
Qualifier:
no guideline available
Principles of method if other than guideline:
The paper describes a poisoning incident
GLP compliance:
not specified
Remarks:
: not relevant for this study type

Test material

Constituent 1
Chemical structure
Reference substance name:
Ammonium hydrogendifluoride
EC Number:
215-676-4
EC Name:
Ammonium hydrogendifluoride
Cas Number:
1341-49-7
Molecular formula:
F2H5N
IUPAC Name:
ammonium fluoride hydrofluoride
Details on test material:
Commercial rust remover containing ammonium bifluoride (reported concentration 2.5 mg/ml, pH 1.5

Method

Type of population:
general
Subjects:
One healthy 36 year old male
Ethical approval:
not applicable
Route of exposure:
oral
Reason of exposure:
intentional
Exposure assessment:
estimated
Details on exposure:
The man ingested approximately 180 ml of the rust remover at a reported concentration of 2.5 mg/ml and pH 1.5
Examinations:
ECG, serum chemistry, nasopharyngeal laryngoscopy, esophagogastroduodenoscopy.
Medical treatment:
Intraveneous CaCl2 and MgSO4 (2 g each). Endotracheal intubation. Boluses of 1 g of Ca gluconate and 2 g of MgSO4. Continuous infusion of NaHCO3 (27 mEq/h).

Results and discussion

Clinical signs:
Within minutes of ingestion, the subject was prostrate and vomiting profusely, complaining of severe abdominal pain.
Results of examinations:
An initial ECG showed a prolonged QTc of 0.516 s. Resuscitation measures included IV CaCl2 and MgSO4 (2gms each). The QTc narrowed to 0.400 s. Initial serum K+ was 5.8 mmol/L, ionized Ca2+ was 0.935 mmol/L, and lactate was 4.8 mmol/L. During direct nasopharyngeal laryngoscopy, he had hematemesis, and was endotracheally intubated. After intubation, his QTc widened again to 0.500 s. Boluses of 1 g of Ca gluconate and 2 g of MgSO4 were given, and he was started on a continuous infusion of NaHCO3 (27 mEq/h). Central venous access was obtained, and he received an additional 2 g of CaCl2, as well as 2 g of MgSO4 followed by the initiation of a continuous infusion of MgSO4 at 2 g/hr. His QTc narrowed to 0.413 s. Esophagogastroduodenoscopy performed at the bedside revealed mild edema throughout the length of the esophagus, moderate hemorrhagic gastritis, and a pale appearance to the fundus and greater curvature of the stomach consistent with ischemia. Although a nasogastric tube was placed under direct visualization, nothing was administered. The patient continued to receive intermittent boluses of CaCl2 when his QTc prolonged. By 4 hours after admission, he was admitted to the ICU. Once in the ICU, he required no additional boluses of calcium or magnesium although his infusions of bicarbonate and magnesium were continued for 24 hours. His serum calcium peaked at 5.4 mmol/L two hours post presentation, with ionized calcium of 2.85 mmol/L. His serum magnesium peaked at 3.8 mmol/L at three hours post presentation. Both values declined to normal reference range by his discharge.
Effectivity of medical treatment:
See above.
Outcome of incidence:
36 hours post admission he was extubated, stable, and was transferred to psychiatry on hospital day four.

Any other information on results incl. tables

No further information.

Applicant's summary and conclusion

Conclusions:
The paper reports a case of an adult male who ingested a massive dose of ammoium bifluoride, but survived due to early aggressive therapy. This route of exposure is previously reported to be uniformly fatal. Using the ECG as a guide, therapy was initiated to prevent significant electrolyte abnormalities. The patient was stable approximately 36 hours after the incident.
Executive summary:

The paper reports a case of an adult male who ingested a massive dose of ammoium bifluoride, but survived due to early aggressive therapy. This route of exposure is previously reported to be uniformly fatal. Using the ECG as a guide, therapy was initiated to prevent significant electrolyte abnormalities. The patient was stable approximately 36 hours after the incident.