Okay. Welcome back, everybody, for the pesticides. I want to say first, though, that the pesticides, there are tens of thousands of them approved for use in the U.S. and the world. It's no possible way I can cover all of them in this. So it's super important to get the safety data sheets from the employer for whatever the person's been spraying when they come in to see you. You can get it with the skin or potentially even in the eyes. Most important thing that you do is decontaminate, decontaminate, decontaminate. Removal of saturated clothing and skin decontamination with copious amounts of water should be done immediately and you should let your staff know if anybody comes into your facility smelling like any kind of fumes, whether it's pesticides, paint fumes, whatever it smells like, they need to get their clothes off immediately, preferably outside, and even if you give them a basin of water, they need to get that stuff off of their skin. Otherwise they present a risk to you and your staff and the other patients from off gassing. And in doubt, if you're not sure what to do, contact poison control. There's their number. They're very, very helpful. So pesticides implicated in occupational pesticide-related illness. This data is a little bit old, but it's hard to find newer stuff. You can see the sort of list there, but you're looking at potentially several thousand cases during that time frame and across a broad variety of spectrums. And the other thing you have to remember is a lot of these pesticides are mixtures. So it's hard to say in some cases which one is causing somebody's symptom, but it's just critical to know what they were exposed to, what specifically they were using. So insecticides come in a variety of versions. Main ones, again, it's not an exhaustive list, but the main ones are organophosphates, pyrethrins, pyrethroids, and methyl carbamates, organochlorines, arsenicals, some of which are also used as fungicides, and sulfur-containing compounds. Those are also used as fungicides and reventicides. They're almost the jack of all trades. They're almost the jack of all trades. Organophosphates can include things like parathion, malathion, dursban, which also goes by chlorpyrifos, fenthian, and others. You can get exposure, dermal ingestion, or inhalation. Ingestion is actually a common means of suicide or intentional poisoning in developed countries. Most of the information we have from the ingestion exposures are from deliberate poisonings like suicides. Onset can be from minutes to hours after exposure. These work by inhibiting acetylcholinesterase at the neuromuscular junction, effects that are also very similar to nerve gas poisoning. Organophosphates can have muscarinic effects, nicotinic effects, and CNS effects. Starting with the organophosphates, if you all remember back to medical school, we had a couple of acronyms for that. The first was SLUDGE, which was salivation, lacrimation, urination, diarrhea, GI upsets, and emesis, or dumbbells. Sometimes it's D-U-M-B-B-B-E-L-S, but it's diaphoresis, diarrhea, urination, meiosis, bradycardia, bronchospasm, bronchorrhea, emesis, lacrimation, salivation. Or as I like to think of it, they are secreting from every orifice. That's the easiest way to remember that. The nicotinic effects are usually covered by a little days of the week mnemonic. Monday, or medriasis, Tuesday's tachycardia, Wednesday's weakness, Thursday, the first part of it is twitching, and then we have to add the H on for Thursday for hypertension, and Friday for fasciculation. Organophosphates can also cause CNS effects like anxiety, ataxia, confusion, coma, seizures, tremors. It doesn't really have a mnemonic, and I don't really have one, but you can choose your favorite out of those if it helps you remember that. So you may or may not have seen this cholinergic toxidrome picture before, with this gentleman reading his bradycardia times and sitting on the toilet, but he's got pinpoint pupils like meiosis, sweating, lacrimation, frothing of the mouth, which is salivation bronchuria, urination, defecation, but basically they're secreting from every orifice. If you see that, it's organophosphate poisoning or nerve gas poisoning, one of the two. Even though the guy who's reading his bradycardia times in that image, you can have tachycardia, and you can also have respiratory depression. The meiosis is a really helpful diagnostic sign. They can come in complaining about blurry vision or darkened vision, but also from the nicotinic effects, they can have medriasis or dilated pupils. There are blood tests for red blood counts, serum and plasma, acetylcholinesterase and or butylcholinesterase, but they're difficult to interpret in the absence of a baseline test, unless there's a marked decrease in levels. Some employers have routine monitoring for exposed workers so that they can provide you that baseline level, but normal results don't exclude pesticide poisoning. If it's abnormal, testing can be repeated several weeks later to establish a baseline after the fact, such as if you are trying to prove that this was, in fact, an organophosphate exposure or a pesticide exposure. But don't wait on the blood test to initiate treatment. You don't have time to get those back. You administer atropine right away, IV, IM, or via the endotracheal tube until symptoms improve, and that may be a lot of doses of atropine. In one severely affected person, you could potentially go through every amp of atropine in your hospital, sometimes up to 300 milligrams. Once their symptoms improve, then you give pralidoxine, also known as 2-PAM. Auto-injectors of atropine and 2-PAM are found together in a Mark I kit, which if it's been in the military is probably familiar with those. And some civilian first responders on ambulances and stuff have those for use in case of a terrorist attack with nerve gas. If you've got somebody with organophosphate poisoning, you want to avoid morphine, succinylcholine, theophylline, phenothiazines, and resurfing. These people start out with like the acute phase, but then there's an intermediate syndrome, which occurs 24 to 96 hours after the poisoning, where they get acute weakness of muscles in the face, necks, proximal limbs, and respiratory muscles. So just because you get them through the first 24 hours, you're not out of the woods. At that point, atropine and 2-PAM don't help, so there's no point in giving more at that stage. And then assuming that you're not out of the woods, there's no point in giving more at that stage. And then assuming they recover, chronic effects, you can get a thing called organophosphate-induced delayed neuropathy, which is weakness, paralysis, and paresthesias in the legs. It can last for weeks to years. All right, moving on to pyrethrins. They're used in enraged ant and roach spray, various lice and flea foggers. It's an extract of chrysanthemum flowers. Overall, pretty safe, minimal dermal absorption, limited bioavailability when inhaled or ingested, but you can get contact dermatitis and allergic respiratory symptoms like rhinorrhea, wheezing, anaphylaxis, but you treat it just like you would any other acute allergic reaction, antihistamines and corticosteroids when needed. Pyrethroids, they are becoming more common. Some examples are things like elemite or nix, which are used for lice, ambush and dragnet. Poisoning effects are usually generally pretty mild. Fine tremor or hyperreflexia, although with severe toxicity, again, this is usually when people ingest it on purpose. You can get CNS and GI symptoms like marked salivation, hyper excitability, chorioathetosis and paresthesias. Again, for this one, whenever you see the bold items there, that's something to remember for later. Treatment is largely symptomatic, although vitamin E oil preparations appear to be effective at relieving some of the paresthesias. Moving on to N-methylcarbamates. These are kind of like organophosphate light. They have a very similar mechanism of action, similar toxicity, but less severe. You cannot use the blood cholinesterase levels in N-methylcarbamate poisoning. They are not helpful. Exposure can be dermal inhalation or ingestion. One difference between the N-methylcarbamates and the organophosphates is that you can get acute pancreatitis from the N-methylcarbamates. Atropine can help with symptoms. You do that acutely titrated to symptom improvement, but don't give too pam. It's not going to help with N-methylcarbamates. Organochlorines mostly have gone by the wayside in the United States, but they're still available overseas. The most common one that many of us have prescribed at some point or another is lindane. Other organochlorines are things like DDT, and those are banned in the U.S. You can get exposure through the skin, inhalation or ingestion, but CNS symptoms predominate. This is why we tell people we're not going to continue to prescribe them lindane for repeated courses, just because they keep getting lice back. Treatment is largely supportive, although cholesteramine resin and activated charcoal may help with the toxicity regardless of the route of exposure. If they've just used bottle after bottle of lindane for lice and they end up with a systemic symptom, you can still use those. Don't give epinephrine or atropine, as they can predispose to developing ventricular fibrillation. I think we're all clear on that being bad. Arsenicals. Most arsenic-containing pesticides have been banned in the U.S., but there are still some around. They're used in the U.S. They're still legal to be used on sod farms, highway rights of way and on golf courses. I have to say, I found an astounding number of pesticides and toxic chemicals that were okay for use on golf courses, so remember that the next time you go play around. Chromated copper arsenic was used to treat lumber in the United States until 2003, and it's still a risk of exposure today if that old lumber is burned, sanded, or sawed. The CCA-treated wood down on the bottom right, it kind of has that medium greenish hue. Today, they treat a lot of lumber with borate, and it's much more of a bluish color. It's maybe a little bluish green, but it's definitely a noticeable difference in color, and the borate-treated wood is fine, but you can see people that tear down old houses, renovate old houses, do things with old wood and lumber that can end up with arsenic poisoning from a CCA-treated wood. Dermal and ingestion risk is possible, and inhalation exposure risk with arsene gas only. Arsene is released in the manufacturer of this and some other industrial uses, but you don't really get an inhalational risk from CCA. Now, some people that saw and sand and burn the stuff end up inhaling particulates, and that becomes the biggest problem, and they end up ingesting it. Acute symptoms can begin within a few hours. It can affect just about every brain system, GI, neuro, liver, kidneys. You can get a garlic odor of the breath and feces, metallic taste in the mouth. They actually get mucosal sloughing of the mouth, pharynx, and esophagus. Subacute exposures, liver, kidney, bone marrow, and vascular. They get a sensory motor peripheral neuropathy that can be confused with Guillain-Barre syndrome. Also get Raynaud's and acrocyanosis. Chronic effects, skin, lung cancer, hyperkeratosis of the palms and the soles, which you see down there at the bottom right, and they can also get measlines in the fingernails. These are horizontal bands. They do grow out with the fingernail, so it can kind of give you some idea of when the exposure was, but treatment's largely supportive. If they're super symptomatic, get a consult, and they can chelate with dimercaprol, also known as BAL, or British anti-lewisite, if the poison is severe, but most people don't need that. So with all these pesticides, keep in mind it's not just the people who are involved in the manufacture, or the spraying, or use of these chemicals occupationally. We have, I'm sure, a lot of our patients travel for work, and they end up staying in hotels, or resorts, or Airbnbs, or rental houses, and you're pretty much at the mercy of whoever owns that domicile to treat for insects, and most of them are very conscious of the fact they don't want insects in the places they're renting out to tourists, especially bed bugs. They're a very common problem, and owners want an easy fix, but you got to keep pesticides in mind for your patients who travel, and present with unusual, or explained symptoms, or unexplained deaths. Pesticides could have been sprayed near, or in the traveler's rooms without their knowledge. They could also be illegal chemicals, or illegal applications, such as spraying a pesticide that's only approved for an outdoor application, indoors, or in much larger than normal quantities. Such as in the U.S. Virgin Islands in 2015, a family of four was poisoned with bromomethane, also known as methyl bromide, when it was sprayed in an adjacent condo, not even theirs, by Terminix. So you would think that Terminix being a professional company would not be spraying that, but apparently it happened, because it was illegal at the time to use that. They ended up with seizures, and three of them had long-term paralysis, one recovered. It was banned for residential use in 1984, and most commercial uses by 2005. It's still occasionally used in the in the U.S. It's used to fumigate logs, or wood packaging, like pallets, that especially that are going to be shipped internationally, and it's used to fumigate out shipping containers, and certain produce prior to export, has been linked to pancreatic cancer as well. More travel stories. Dominican Republic in 2018, there were a series of six unexplained deaths, and two additional illnesses, and tourists, many of them who stayed at the same resort. The two who survived reported like a chemical poisoning, the two who survived reported like a chemical smell in their rooms, almost like paint. They had observed an employee spraying chemicals on plants right next to their AC unit intake that day. They developed headache, dyspnea, watery eyes, blurred vision, increased tearing, hypersalivation, abdominal cramps, diarrhea. So they seem to be secreting from every orifice, so that was most likely culprit was organophosphate poisoning. A number of those at autopsy, the Dominican medical examiners tried to write most of these off as MIs, or respiratory failure, and called them natural causes on the death certificates, but the two that survived did report that they were told by a physician in the U.S. that they had organophosphate poisoning. So moving on to herbicides. You have chlorophenoxy compounds, pentachlorophenol, paraquat, diquat, and glyphosate, aka Roundup. Again, this is not an exhaustive list of every herbicide out there, but it's the bigger ones. So chlorophenoxy compounds absorption is more ingestional than inhalational than dermal. It includes 2,4-D, which is the not so bad part of Agent Orange, if there is such a thing. But 2,4-D is actually one of the top five or 10 pesticides used in the United States. Also includes cycloroprop, MCPA, and a variety of others. You can measure urine and blood levels at a few of the labs, but you never get the results back in time to make it meaningful, if you can track down the labs that do them. Manufacturing of these compounds can create dioxin. So you can have occupational exposure to dioxins. If anybody remembers the Times Beach Superfund, just down the road from me here in the St. Louis area. And that was where dioxins that were created in a plant manufacturing Agent Orange for the government. They hired a company to get rid of the dioxin. So they mixed it with waste oil and sprayed it on the streets, all over Times Beach to keep the dust levels down. That didn't go well. They can cause local cutaneous depigmentation. Also an inhibition of taste receptors just for sweets, not for the other types of taste. Muscle weakness, metabolic acidosis, peripheral neuropathy, and also chloroacne on the manufacturing exposure to dioxins. You don't get it specifically from the chlorophenoxy compounds, the herbicides as at the end product, but the manufacturing of it can cause chloroacne. And if you've never seen that, it kind of looks like the picture there to the right. That's Viktor Yushchenko. He's former president of the Ukraine. He was poisoned with, they think, dioxin in his soup by the Russians. And he developed chloroacne, which is kind of, it's usually a mixture of sort of blackheads, like open comedone looking things, and small cysts with kind of yellowish fluid in them. And they eventually figured out he had, I think, 50,000 times the normal level of dioxins in his body. Alkalization of the urine can help with excretion. And specifically 2,4-D, again, probably the most common of the chlorophenoxy compounds can cause abnormal shape of the sperm and decrease male fertility. Then there's pentachlorophenol. It's used only on wood utility poles, but it can volatilize from the treated wood and leach into the soil. You can get it from inhalational and intestinal, dermal exposure, got about a 20-day half-life. Plasma urine tests are available. Good luck tracking those down in any kind of timeframe that will help you. Can cause CNS, reproductive, bone marrow, kidney, dermatologic, cardiac, hepatic effects. Also can cause chloracne and strangely, hypothermia. And also a maternal or paternal exposure to pentachlorophenol can cause fetal defects, miscarriage, and low birth weight. Moving on to dinocap or dinitrophenolic. You can get inhalational, ingestional, or dermal exposure. It's got five, 14-day half-life. Again, hangs around for quite a while. Symptoms are initially nonspecific, but more serious exposures results in hyperthermia, again, pancreatitis, and hepato-renal failure. Chronic exposure causes cataracts and glaucoma. Dermal exposure may cause a bright yellow staining of the hair, skin, sclera, and urine. So if it looks like somebody put fluorescein there or a yellow highlighter, you got to be thinking about dinitrophenolic compounds. You want to avoid salicylates, aspirin, because it worsens the hyperthermia, and avoid atropine because it increases the risk of cardiac arrhythmias. All right, moving on to Paraquat. Also known as Gramoxone or methylbiologin. The EPA has a warning that one sip can kill, and apparently it can kill you even if you take a small mouthful of the concentrated product and then even spit it out. There've been 17 deaths from accidental ingestions in the U.S. since 2000 from storage of Paraquat in beverage containers, but it's actually still used fairly frequently in the U.S. because that stuff apparently kills weeds incredibly quickly like within minutes. Ingestion can cause like a burning pain, pulmonary edema, cardiac, liver, renal effects, and then seven to 14 days after exposure, they can get pulmonary fibrosis and death. So, you know, you want to, the dermal Paraquat exposure can cause the dry fissured hands, horizontal ridging or loss of the fingernails. It's also been linked to skin cancer, second degree burns, Parkinson's, especially Parkinson's, and developmental and reproductive effects. There's no confirmed antidote. It's possible cyclophosphamide may be beneficial, but that really hasn't been proven. With regard to that acute progressing onto the seven to 14 day pulmonary fibrosis and death, you may have an initial period of improvement, but that doesn't mean anything. They can still go on to develop that pulmonary fibrosis and death. And sometimes in some cases, it can take them up to 30 days to die from an exposure to Paraquat. The stuff that they spray on the actual plants is diluted from what they get when you buy just the chemical itself. So the concentrate is far more dangerous than the spray once it's diluted. So there has been efforts to ban Paraquat worldwide. There've been a variety of articles about that and calls for that over the years, but it just really works well. And so that's why it continues to hang around in the United States and in the world. You've got Diquat, which is kind of Paraquat light. It's symptoms of exposure are similar to the Paraquat, except there's less lung toxicity. And you do not get that pulmonary fibrosis seven to 14 days later, but the CNS effects are more prominent. And it is also like Paraquat is linked to risk of Parkinson's. There's a dithionate test of the urine and serum that can be done. Bentonite, Fuller's Earth, or activated charcoal may be used as absorbents in the case of ingestion. Do not give supplemental oxygen unless it's just severe hypoxemia with this because that can worsen other lung toxicity. Even though there's less lung toxicity than with Paraquat, it can increase it. All right, everybody's favorite, glyphosate or Roundup. It's the most commonly used herbicide in the United States. When used appropriately, human toxicity is pretty low. Most reports of acute toxic effects are from intentional ingestion like suicide attempts, but these effects are probably more due to the surfactant that they add into the Roundup than the glyphosate itself. You can get mild skin irritation with contact to the skin. Inhalation of the mist while spraying can cause some airway irritation. You get eye irritation. It's possible to get superficial corneal injury if you do not irrigate the eye when you get a bunch of the mist in the eye. And ingestion, you can have a really significant quantity, usually intentional, it's not an accidental sip, but it can be fatal. So everybody I'm sure has heard about the Monsanto legal cases and glyphosate being implicated in exposure, in risk of non-Hodgkin's lymphoma, especially B-cell lymphoma. The WHO considers glyphosate to be probably carcinogenic, not the EPA, even the CDC and the EPA disagree on the health effects. There's a lot of disagreement amongst various European governmental organizations about whether or not there is a risk of cancer with glyphosate. So it's been banned in some areas and it's not banned in other areas. Some places consider it a probable carcinogen, others don't. The studies are really contradictory. They're subject to confounding factors and or bias. One of the studies was funded by Monsanto, so there's your bias. But others have confounding factors like the people that spray glyphosate occupationally likely are also exposed to other pesticides or other chemicals. There really has never been a good risk established in any journal article with the use in the home. So you go buy a bottle of Roundup to use on your sidewalk at home, that has not been found to be a risk. There was only one study and it was a meta-analysis found some association with non-Hodgkin's lymphoma, specifically B-cell lymphoma. Other meta-analyses, though, have not found an association with any type of cancer. So juries have awarded millions of dollars in settlements, but it's still not entirely clear if there is a good evidence for risk there. Sulfur-containing compounds, those are used as pesticides, rodenticides, and fungicides. They're pretty much the jack-of-all-trades of pesticides. And they're approved for both residential and commercial use. You can go dust your roses with the sulfur-containing compound. Overall, they have low toxicity. You can get a little bit of ingested, you can get a burning sensation, diarrhea, it can be an airway irritant, skin irritant, eye irritant, sometimes up to blurry vision, but overall fairly safe. Whoops. That slide was supposed to go earlier. Just another example of being careful with your tourists, your people that travel for their work to a variety of places. There were like 20 deaths, most of them in one hotel in Thailand, related to probably chlorpyrifos, which is an organophosphate, possibly phosphine, to kill bedbugs. All right, moving on to fungicides. We've got thiram, copper compounds, and sulfur. We've already talked about sulfur, so I'm not going to talk about it again here. But most of the available fungicides have very low human toxicity. They can be skin and mucous membrane irritants. You can get sensitizations with allergic contact dermatitis, and can cause exacerbations of asthma. Thiram specifically can cause a disulfurin-like reaction in high doses, with or without exposure to alcohol. So they get like hyperactivity, ataxia, decreased muscle tone, dyspnea, convulsions, nausea, vomiting, confusion, rash, profuse sweating. It's pretty rare, but it can happen. So that's the most notable thing about the thiram compounds. Treatment's supportive. OH2ID fluids from Greenberg. Copper-containing compounds, again, primarily an ingestion risk. And again, most of that is intentional suicide attempts. It's not usually a concern with dermal or inhalational exposure, but ingestion can cause methemoglobinemia. Antimetallic taste in the mouth affects blood, liver, and renal. If you've never seen methemoglobinemia, it's that chocolate brown blood color that we all learned about in medical school. You can check serum copper levels, blood counts, methemoglobin. You can give eight ounces of water or milk, and also methylene blue if the methemoglobin is severe. So just remember methylene blue for methemoglobin. But it's got to be a pretty significant amount. You don't need to do it for smaller amounts. Moving on to rodenticides. Got an extra in there. You've got coumarins and indandiones, zinc and aluminum phosphide, strychnine and crimidine, and again, the sulfur compounds. Coumarins are the most common rodenticides in the U.S. They depress hepatic synthesis of vitamin K, dependent blood clotting factors like 2, 7, 9, and 10, just like warfarin. That's the coumarin, the brand name of warfarin. So they elevate PTI and R. Exposure, again, usually ingestion, less commonly dermal. You can get symptoms onset 12 to 48 hours post-exposure, and they can persist potentially for months. You've got to check the PTI and R levels frequently. As we all know, with coumarin excess, you can treat with vitamin K and FFP if they're deeply bleeding. For zinc and aluminum phosphides, these release phosphine gas on contact with water. If you ingest them, they can get GI, renal, CNS, tetany from low calcium levels and pulmonary edema. Inhalation, you can get pulmonary edema and myocardial injury. The patient can actually off-gas phosphine gas from emesis and feces. So if you think you've got somebody that's been affected by a significant amount of one of these, you better be using a respirator around them. Phosphine gas is said to have kind of an odor of decaying fish, but I wouldn't use that as the determining factor as to what they're exposed to. Treatment's supportive. Magnesium sulfide may decrease mortality, but it's hard to say. But these people can die from this stuff very, very quickly. In Amarillo, Texas in January 2017, a father applied some aluminum phosphide pellets under his mobile home and then for whatever reason tried to wash them away with some water. And then that caused the release of phosphine gas, which killed four of his children, severely sickened him, his spouse, and four other children that were in the mobile home at the time. Strychnine and chromidine, these are used only below ground to kill gophers. These can cause severe awake seizures. In other words, they look like they're seizing, but they are actually awake and cognizant of everything that's happening around them. They get respiratory arrest from diaphragm paralysis. They can get rhabdo from the intense seizure activity and muscle contraction, and the rhabdo can give them renal failure. It's kind of a classic painting down there at the bottom from Episthotonus, which is kind of the awake seizures due to spasms and seizures from strychnine. Treatment is GI decontamination. If there's no seizures, because you really shouldn't be trying to decontaminate somebody who's actively seizing, you treat for the seizures and give B6. So chronic pesticide exposure, chronic low levels, this kind of gets back to the Roundup issue and a variety of other pesticides. It's difficult to get solid data on this because, again, usually people that have exposure to one of these things have exposure to multiple pesticides and or other chemicals in the course of their job. But chronic low level may cause numbness in the hands and feet. Neuropsychological symptoms like depression, dizziness, headache, fatigue, irritability, but they're very nonspecific as far as that goes. Parkinson's, cancer, and potentially endocrine disorders. The APA publishes a great, huge document about management of pesticide poisonings. So if you have a question about anything specific, that's a great resource. You can also contact the National Pesticide Information Center. I checked today and I think they are open 8 a.m. to 12 noon. I think they're on the West Coast, so they're on West Coast time. But they can also help you out with any specific pesticide concerns and up to date. So like this lady, she wants a spray that kills everything but isn't dangerous. I'm sure everybody who grows crops or has any need for any of these chemicals thinks the same. But as of yet, we don't have it. Okay. So also I'm sure Jeffrey will get to you. You'll have access to a couple of little documents or cheat sheets of the clinical practice highlights. The most important things to remember from the pesticide and the plastics lecture. There's sort of one for each. And it just goes through the big bullet points. Because both those lectures, there's a lot of information to be had in there. And it's difficult to remember it just the first walk-through. But do look for the bolded or underlined items in each slide. That will give you an idea of the most important things to remember long-term. Because so many of them have a variety of nonspecific signs and symptoms. Or their skin and respiratory irritants. And it's hard to remember which ones are which. And you probably don't need to remember that part as much long-term as these sort of big hallmark things. So hopefully you'll find those documents somewhat helpful. So just a couple of pages each. And so take a look at that. And have that on hand for when you need it. And that's it. Thank you. Okay, and then here's the one about for plastics, just kind of a little cheat sheet things to remember. Because again, you'll, you'll never remember all the different things that are shared by so many of the different plastics. But it'll help you remember hopefully things like Teflon flu, polymer fume fever, Acroosteolysis from the vinyl chloride, Raynaud's that type of thing. So again, for a little, little document but have that on hand for the highlights of all of that.

pesticide exposure

organophosphates

pyrethrins

decontamination

toxicology

medical response

poison control