Accidental or intentional exposure to potentially toxic medications, natural toxins and chemicals during pregnancy: analysis of data from Tox Info Suisse.

OBJECTIVE: Affected women and health professionals are still often unsure about how to react to exposures to potentially harmful agents during pregnancy. We wanted to find out which agents worry both pregnant women and professionals, under what circumstances the exposures take place, how they are currently dealt with and how serious they are. METHODS: Making use of the archives of Tox Info Suisse, the foundation that provides poisons information in Switzerland both for members of the general public and for healthcare professionals, we set up an analysis of exposures to possibly harmful agents during pregnancy. Queries during pregnancy between 1995 and 2015 were analysed. Demographic information, exposure and agent characteristics as well as - in a subgroup of cases - the corresponding treatments were considered in the present descriptive, retrospective analysis. RESULTS: Over the 21-year period, 2871 exposures during pregnancy were identified. The majority of the calls were made by members of the general public (2035, 70.9%; most often by the affected women themselves), followed by physicians (733, 25.5%). General public queries were mostly due to exposures connected with household chemicals (675/2035, 33.2%); those of physicians were most often due to medications (415/733, 56.6%). The majority of agent exposures occurred accidentally at home, at work, outdoors or at various other places (2297/2871, 80.0%). Less frequently, the exposures were intentional and had a suicidal, abusive, criminal or other character (471/2871, 16.4%). Of the 2871 calls, 905 cases with symptoms were recorded. Of the 1268 symptoms, 820 were mild (64.7%), 144 moderate (11.3%), 24 severe (1.9%, including 12 abortions) and 280 were not further specified (22.1%). In 1867 cases (65%), a total of 2331 measures were recommended by Tox Info Suisse, 1961 thereof to be carried out immediately. The two most common immediate measures were exposure interruption (412/1961, 21.0%) and forwarding to another institution (345/1961, 17.6%). In 70 cases, physicians' follow-up reports could be analysed; paracetamol was the agent most frequently involved (15 cases), followed by mefenamic acid (9) and the household product sodium hypochlorite (9). CONCLUSIONS: Tox Info Suisse recorded an average of 137 cases of agent exposure during pregnancy per year, mostly due to accidents with household products. Suicidal intentions played a role in a considerable number of exposures. Measures are needed to prevent accidental exposure of pregnant women to toxic substances and to support them in this exceptional life period.

Acute Toxicity Associated With the Recreational Use of the Novel Psychoactive Benzofuran N-methyl-5-(2 aminopropyl)benzofuran.

N-methyl-5-(2 aminopropyl)benzofuran (5-MAPB) is a novel psychoactive benzofuran, created by N-methylation of 5-(2-aminopropyl)benzofuran (5-APB), which shares structural features with methylenedioxymethamphetamine (MDMA). To our knowledge, no case of 5-MAPB-related toxicity has been published in the scientific literature. We report a case of oral 5-MAPB exposure confirmed by liquid chromatography-tandem mass spectrometry in a 24-year-old previously healthy white man. Observed symptoms and signs such as paleness, cold and clammy skin, hypertension, elevated high-sensitive troponin T level, tachycardia, ECG change, diaphoresis, mild hyperthermia, mydriasis, tremor, hyperreflexia, clonus, agitation, disorientation, hallucinations, convulsions, reduced level of consciousness, and creatine kinase level elevation (305 IU/L) were compatible with undesired effects related to 5-APB or MDMA exposure. Signs and symptoms resolved substantially within 14 hours with aggressive symptomatic treatment, including sedation with benzodiazepines, external cooling, analgesia and sedation with fentanyl-propofol, and treatment with urapidil, an α-receptor-blocking agent. 5-MAPB showed first-order elimination kinetics with a half-life of 6.5 hours, comparable to the half-life of MDMA. According to the chemical structure, this case report, and users' Web reports, 5-MAPB appears to have an acute toxicity profile similar to that of 5-APB and MDMA, with marked vasoconstrictor effect.

Acute toxicity profile of tolperisone in overdose: Observational poison centre-based study.

INTRODUCTION: Tolperisone is a centrally acting muscle relaxant that acts by blocking voltage-gated sodium and calcium channels. There is a lack of information on the clinical features of tolperisone poisoning in the literature. The aim of this study was to investigate the demographics, circumstances and clinical features of acute overdoses with tolperisone. METHODS: An observational study of acute overdoses of tolperisone, either alone or in combination with one non-steroidal anti-inflammatory drug in a dose range not expected to cause central nervous system effects, in adults and children (< 16 years), reported to our poison centre between 1995 and 2013. RESULTS: 75 cases were included: 51 females (68%) and 24 males (32%); 45 adults (60%) and 30 children (40%). Six adults (13%) and 17 children (57%) remained asymptomatic, and mild symptoms were seen in 25 adults (56%) and 10 children (33%). There were nine adults (20%) with moderate symptoms, and five adults (11%) and three children (10%) with severe symptoms. Signs and symptoms predominantly involved the central nervous system: somnolence, coma, seizures and agitation. Furthermore, some severe cardiovascular and respiratory signs and symptoms were reported. The minimal dose for seizures and severe symptoms in adults was 1500 mg. In 11 cases the latency between the ingestion and the onset of symptoms was known and was reported to be 0.5-1.5 h. CONCLUSIONS: The acute overdose of tolperisone may be life-threatening, with a rapid onset of severe neurological, respiratory and cardiovascular symptoms. With alternative muscle relaxants available, indications for tolperisone should be rigorously evaluated.

Acute toxicity associated with the recreational use of the novel dissociative psychoactive substance methoxphenidine.

INTRODUCTION: Methoxphenidine is a novel dissociative designer drug of the diarylethylamine class which shares structural features with phencyclidine (PCP), and is not at present subject to restrictive regulations. There is very limited information about the acute toxicity profile of methoxphenidine and the only sources are anonymous internet sites and a 1989 patent of the Searle Company. We report a case of analytically confirmed oral methoxphenidine toxicity. CASE DETAILS: A 53-year-old man was found on the street in a somnolent and confusional state. Observed signs and symptoms such as tachycardia (112 bpm), hypertension (220/125 mmHg), echolalia, confusion, agitation, opisthotonus, nystagmus and amnesia were consistent with phencyclidine-induced adverse effects. Temperature (99.1°F (37.3°C)) and peripheral oxygen saturation while breathing room air (99%) were normal. Laboratory analysis revealed an increase of creatine kinase (max 865 U/L), alanine aminotransferase (72 U/L) and gamma-glutamyl transpeptidase (123 U/L). Methoxphenidine was identified by a liquid chromatography tandem mass spectrometry toxicological screening method using turbulent flow online extraction in plasma and urine samples collected on admission. The clinical course was favourable and signs and symptoms resolved with symptomatic treatment. CONCLUSION: Based on this case report and users' web reports, and compatible with the chemical structure, methoxphenidine produces effects similar to those of the arylcyclohexylamines, as PCP.

Acute mycophenolate overdose: case series and systematic literature analysis.

BACKGROUND: Literature regarding acute human toxicity of mycophenolate mofetil (MMF) and enteric-coated mycophenolate sodium (EC-MPS) is limited. OBJECTIVES: Our objectives were to describe all cases of overdose with MMF or EC-MPS reported to the Swiss Toxicological Information Centre (STIC) or in the literature between 1995 and 2013. Therefore, we performed an observational case-series and systematic literature search to determine circumstances, magnitude, management and outcome of overdose with MMF or EC-MPS. RESULTS: Of 152,762 reports to STIC, 15 (7 pediatric) involved overdose with MMF (n = 13) or EC-MPS (n = 2). Three cases from other centers were identified from a systematic literature search. The magnitude of overdose ranged from 1.2 to 16.7 (median 2.9) times usual dose. Six (33%) MMF overdoses had attributable symptoms, which included abdominal pain, vomiting, headache and dizziness. The majority of findings were minor, although a 9-fold MMF overdose caused hypotension 8 h after ingestion and a 12.5-fold overdose caused leukopenia after 5 days. Symptoms did not occur in patients who took 2.5 times or less of their usual MMF dose. Gastrointestinal decontamination measures with activated charcoal were undertaken in one-third of cases. CONCLUSIONS: Acute MMF and EC-MPS overdoses had a favorable outcome in all cases reported to STIC and in the literature.

Acute thiopurine overdose: analysis of reports to a National Poison Centre 1995-2013.

Literature regarding acute human toxicity of thiopurines is limited to a handful of case reports. Our objectives were to describe all cases of overdose with thiopurines reported to the Swiss Toxicological Information Centre between 1995-2013. A retrospective analysis was performed to determine circumstances, magnitude, management and outcome of overdose with these substances. A total of 40 cases (14 paediatric) were reported (azathioprine, n = 35; 6-mercaptopurine, n = 5). Of these, 25 were with suicidal intent, 12 were accidental and 3 were iatrogenic errors. The magnitude of overdose ranged from 1.5 to 43 (median 8) times the usual dose in adults. Twelve cases (30%) had attributable symptoms. The majority of these were minor and included gastrointestinal complaints and liver function test and blood count abnormalities. Symptoms were experienced by patients who took at least 1.5-times their usual daily thiopurine dose. Overdoses over two or more consecutive days, even if of modest size, were less well tolerated. One case of azathioprine and allopurinol co-ingestion over consecutive days led to agranulocytosis. Decontamination measures were undertaken in 11 cases (10 activated charcoal, 1 gastric lavage) and these developed fewer symptoms than untreated patients. This study shows that acute overdoses with thiopurines have a favourable outcome in the majority of cases and provides preliminary evidence that gastrointestinal decontamination with activated charcoal may reduce symptom development after overdose of these substances if patients present to medical services soon after ingestion.

Factors that trigger emergency physicians to contact a poison centre: findings from a Swiss study.

OBJECTIVE: Poison centres offer rapid and comprehensive support for emergency physicians managing poisoned patients. This study investigates institutional, case-specific and poisoning-specific factors which influence the decision of emergency physicians to contact a poison centre. METHODS: Retrospective, consecutive review of all poisoning-related admissions to the emergency departments (EDs) of a primary care hospital and a university hospital-based tertiary referral centre during 2007. Corresponding poison centre consultations were extracted from the poison centre database. Data were matched and analysed by logistic regression and generalised linear mixed models. RESULTS: 545 poisonings were treated in the participating EDs (350 (64.2%) in the tertiary care centre, 195 (35.8%) in the primary care hospital). The poison centre was consulted in 62 (11.4%) cases (38 (61.3%) by the tertiary care centre and 24 (38.7%) by the primary care hospital). Factors significantly associated with poison centre consultation included gender (female vs male) (OR 2.99; 95% CI 1.69 to 5.29; p<0.001), number of ingested substances (>1 vs 1) (OR 2.84; 95% CI 1.65 to 4.9; p<0.001) and situation (accidental vs intentional) (OR 2.76; 95% CI 1.05 to 7.25; p=0.039). In contrast, age, medical history and hospital size did not influence poison centre consultation. Poison centre consultation was significantly higher during the week, and significantly less during night shifts. The poison centre was consulted significantly more when patients were admitted to intensive care units (OR 5.81; 95% CI 3.25 to 10.37; p<0.001). Asymptomatic and severe versus mild cases were associated with more frequent consultation (OR 4.48; 95% CI 1.78 to 11.26; p=0.001 and OR 2.76; 95% CI 1.42 to 5.38; p=0.003). CONCLUSIONS: We found low rates of poison centre consultation by emergency physicians. It appears that intensive care unit admission and other factors reflecting either complexity or uncertainty of the clinical situation are the strongest predictors for poison centre consultation. Hospital size did not influence referral behaviour.

Atypical antipsychotic poisoning in young children: a multicentre analysis of poisons centres data.

UNLABELLED: Although paediatric patients frequently suffer from intoxications with atypical antipsychotics, the number of studies in young children, which have assessed the effects of acute exposure to this class of drugs, is very limited. The aim of this study was to achieve a better characterization of the acute toxicity profile in young children of the atypical antipsychotics clozapine, olanzapine, quetiapine, and risperidone. We performed a multicentre retrospective analysis of cases with atypical antipsychotics intoxication in children younger than 6 years, reported by physicians to German, Austrian, and Swiss Poisons Centres for the 9-year period between January 1, 2001 and December 31, 2009. One hundred and six cases (31 clozapine, 29 olanzapine, 12 quetiapine, and 34 risperidone) were available for analysis. Forty-seven of the children showed minor, 28 moderate, and 2 severe symptoms. Twenty-nine cases were asymptomatic. No fatalities were recorded. Symptoms predominantly involved the central nervous and cardiovascular systems. Minor reduction in vigilance (Glasgow Coma Scale score >9) (62 %) was the most frequently reported symptom, followed by miosis (12 %) and mild tachycardia (10 %). Extrapyramidal motor symptoms were observed in one case (1 %) after ingestion of risperidone. In most cases, surveillance and supportive care were sufficient to achieve a good outcome, and all children made full recovery. CONCLUSIONS: Paediatric antipsychotic exposure can result in significant poisoning; however, in most cases only minor or moderate symptoms occurred and were followed by complete recovery. Symptomatic patients should be monitored for central nervous system depression and an electrocardiogram should be obtained.

Gastric pharmacobezoars in quetiapine extended-release overdose: a case series.

OBJECTIVE: Although extended-release (XR) formulations are recognized to bear some risk of pharmacobezoar formation in overdose, there are no previously documented reports of this phenomenon with quetiapine. We describe nine cases of pharmacobezoar formation in acute quetiapine XR overdose. METHODS: Observational case series of all patients who underwent gastroscopy after quetiapine XR overdose, which were reported by physicians to the Swiss Toxicological Information Centre between January 2010 and December 2012, with detailed analysis of cases with documented pharmacobezoar. RESULTS: Gastric pharmacobezoars were detected in 9 out of 19 gastroscopic evaluations performed during the study period. All these patients ingested a large dose of quetiapine XR (10-61 tablets; 6-24.4 g quetiapine). All patients but one also coingested at least one other substance, and in three cases another XR drug formulation. Gastroscopic pharmacobezoar removal was achieved without complications in all patients, but was difficult due to the particular "gelatinous-sticky-pasty" consistency of the concretion. The subsequent clinical course was favorable. CONCLUSIONS: The possibility of pharmacobezoar formation following a large quetiapine XR overdose should be considered, as this may influence acute patient management. Complete endoscopic pharmacobezoar removal may be a promising approach in selected cases, but further studies are needed to define its role.

Medication wrong route administration: a poisons center-based study.

OBJECTIVES: To describe clinical effects, circumstances of occurrence, management and outcomes of cases of inadvertent administration of medications by an incorrect parenteral route. METHODS: Retrospective single-center consecutive review of parenteral route errors of medications, reported to our center between January 2006 and June 2010. We collected demographic data and information on medications, route and time of administration, severity of symptoms/signs, treatment, and outcome. RESULTS: Seventy-eight cases (68 adults, 10 children) were available for analysis. The following wrong administration routes were recorded: paravenous (51%), intravenous (33%), subcutaneous (8%), and others (8%). Medications most frequently involved were iodinated x-ray contrast media (11%) and iron infusions (9%). Twenty-eight percent of the patients were asymptomatic and 54% showed mild symptoms; moderate and severe symptoms were observed in 9% and 7.7%, respectively, and were mostly due to intravenous administration errors. There was no fatal outcome. In most symptomatic cases local nonspecific treatment was performed. CONCLUSIONS: Enquiries concerning administration of medicines by an incorrect parenteral route were rare, and mainly involved iodinated x-ray contrast media and iron infusions. Most events occurred in adults and showed a benign clinical course. Although the majority of exposures concerned the paravenous route, the occasional severe cases were observed mainly after inadvertent intravenous administration.

Patterns of toxicity and factors influencing severity in acute adult trimipramine poisoning.

AIMS: To analyze the clinical features of trimipramine poisoning, identify a minimal toxic dose, and the dose bearing a 50% risk of developing a moderate, severe or fatal outcome. METHODS: All acute adult trimipramine monointoxications reported by physicians to the Swiss Toxicological Information Centre between January 1992 and December 2009 were identified. RESULTS: Two hundred and thirty cases (26 confirmed and 204 probable) were analyzed, the mean age was 35.7 years and 74% were females. One hundred and thirty-seven patients showed mild, 54 moderate and 21 severe symptoms. Three cases were fatal due to refractory cardiovascular collapse. Ninety-three per cent of the events were attempted or completed suicides. The most common symptoms were central nervous system depression (79.2%), tachycardia (19.1%) and QT(c) prolongation (13.9%). The severity of poisoning depended significantly on the ingested dose (P < 0.001). The minimal dose for moderate symptoms was 250 mg (median dose 1.2 g) and 850 mg for severe symptoms (median dose 2.7 g). The dose for a 50% risk of developing a moderate, severe or fatal outcome was 5.11 g. In 38 patients early gastrointestinal decontamination was performed. Overall, these patients ingested higher trimipramine doses than the late- or not-decontaminated patients (P = 0.113). The median doses were also higher in the decontaminated group within each severity category except in the fatal cases. CONCLUSIONS: We demonstrated that moderate trimipramine poisoning can already occur after ingestion of doses in the high therapeutic range. Poisoned patients have to be monitored for central nervous system depression, dysrhythmias and QT(c) prolongation. Early decontamination might be beneficial.

Mushroom poisoning: a study on circumstances of exposure and patterns of toxicity.

BACKGROUND: Picking wild mushrooms is a popular pastime in Switzerland. Correct identification of the species is difficult for laypersons. Ingestion of toxic mushrooms may result in serious toxicity, including death. The aim of the study is to analyze and describe the circumstances of exposure to mushrooms, and to define the clinical relevance of mushroom poisoning for humans in Central Europe. MATERIALS AND METHODS: We performed a retrospective case study and analyzed all inquiries concerning human exposures to mushrooms (n = 5638, 1.2% of all inquiries) which were reported to the Swiss Toxicological Information Centre between January 1995 and December 2009. RESULTS: The most frequent reason for contacting the poison center in cases of adult exposure was toxicity resulting from edible species. Pediatric exposure predominantly occurred from mushrooms found around the home. Severe symptoms have not only been observed after ingestion of non-amatoxin-containing toxic mushrooms, i.e. Boletus sp. and Cortinarius sp., but also after meals of edible species. The mortality of confirmed amatoxin poisonings was high (5/32) compared to other reports. CONCLUSIONS: Inquiries regarding mushroom poisoning were a relatively infrequent reason for contacting the poison center. Nevertheless, accidental ingestion of toxic mushrooms can be responsible for severe or fatal poisonings. Although pediatric exposure to mushrooms found around the home has not led to serious toxicity in this study, prevention of exposure is warranted. Inspection of wild mushrooms by a certified mushroom expert or a mycologist seems to be a safe procedure which should be recommended.

Ketamine-like effects after recreational use of methoxetamine.

Methoxetamine, the N-ethyl derivative of ketamine, is a novel recreational drug that is not at present subject to restrictive regulations in most countries. To our knowledge, no case of methoxetamine abuse has been published to date in the scientific literature, and the only sources of information are illegal drug users' Web discussion forums. We report the first case of analytically confirmed intravenous methoxetamine abuse in a 19-year-old man. Observed signs and symptoms such as tachycardia, hypertension, confusion, agitation, stupor, ataxia, mydriasis, and nystagmus were consistent with ketamine-induced adverse effects and resolved with symptomatic treatment. According to this case report, user Web reports, and the chemical structure, methoxetamine produces ketamine-like effects. Complete recovery can be expected with supportive care.

Acute plant poisoning: analysis of clinical features and circumstances of exposure.

INTRODUCTION: Human contact with potentially toxic plants, which may occur through abuse or by accident or attempted suicide, is frequent and sometimes results in clinically significant toxicity. OBJECTIVE: The aim of the present study was to identify which plants may lead to severe poisoning, and to define the clinical relevance of plant toxicity for humans in Switzerland. METHODS: We analyzed 42,193 cases of human plant exposure and 255 acute moderate, severe, and lethal poisonings, which were reported to the Swiss Toxicological Information Centre between January 1995 and December 2009. RESULTS: Plant contact was rarely responsible for serious poisonings. Lethal intoxications were extremely rare and were caused by plants with cardiotoxic (Taxus baccata) or mitosis-inhibiting (Colchicum autumnale) properties. CONCLUSIONS: Most often, plant contact was accidental and patients remained asymptomatic or developed mild symptoms, which fully resolved within a short time.

Moderate toxic effects following acute zonisamide overdose.

Zonisamide is an antiepileptic drug that acts on voltage-sensitive sodium and calcium channels, with a modulatory effect on GABA-mediated neuronal inhibition and an inhibitory effect on carbonic anhydrase. It is used mainly for the treatment of partial seizures, and is generally well tolerated at therapeutic doses. The most common reported adverse effects are somnolence, anorexia, dizziness, and headache. There are limited data on zonisamide overdose in the literature, and no case of zonisamide mono-intoxication has been published to date. We describe the first case of zonisamide mono-intoxication in a 25-year-old woman who ingested 12.6 g of this substance with suicidal intent. Despite a plasma zonisamide concentration of 182 mg/L on admission, the patient exhibited a benign clinical course with vomiting and central nervous system depression, requiring brief intubation. Somnolence persisted for 50 hours, and normal-anion-gap metabolic acidosis and polyuria for several days. Complete recovery may be expected with supportive care, even after ingestion of large zonisamide overdoses.

Paracetamol orodispersible tablets: a risk for severe poisoning in children?

PURPOSE: Childhood paracetamol (acetaminophen) ingestion with subsequent risk of hepatotoxicity is a major medical problem. The aim of this study was to investigate the risk of high-dose ingestion of orodispersible, fast-disintegrating paracetamol tablets in children. METHODS: A retrospective single-center case study of all accidental selfadministrations of solid or orodispersible 500-mg paracetamol tablets occurring in children ≤ 6 years, reported to the Swiss Toxicological Information Centre between June 2003 and August 2009. RESULTS: We found 187 cases with ingestion of solid 500-mg paracetamol tablets and 16 cases with ingestion of orodispersible 500-mg tablets. The mean ingested dose in the orodispersible-tablet group was 59% higher than in the solid-tablet group (p = 0.085). Administration of activated charcoal and/or N-acetylcysteine because of ingestion of a potentially hepatotoxic paracetamol dose ( ≥ 150 mg/kg body weight) was recommended in 32 patients (17.1%) in the solid-tablet group and in five (31%) in the orodispersible-tablet group. CONCLUSIONS: Orodispersible paracetamol formulations may represent an important risk factor for severe paracetamol poisoning in children. Over-the-counter availability may contribute to increasing the use of this galenic formulation and eventually the number of poisonings in children.

Minimal dose for severe poisoning and influencing factors in acute human clozapine intoxication: a 13-year retrospective study.

OBJECTIVES: Clozapine is an atypical antipsychotic drug used in the treatment of resistant schizophrenia. Intoxications with this drug are frequently observed. The aim of the present study was to identify a minimal dose and the dose bearing a 50% risk of developing moderate or severe intoxication symptoms. We also investigated the influence of age, sex, effect of decontamination measures, and pretreatment with clozapine on the severity of poisoning. METHODS: A retrospective case study of 73 acute clozapine monointoxications reported by physicians to the Swiss Toxicological Information Centre between 1995 and 2007. RESULTS: The most common symptoms were central nervous system depression (63.1%), tachycardia (39.7%), restlessness/agitation (16.4%), confusion/disorientation (15.1%), dysarthria (15.1%), arterial hypertension (10.9%), bradykinesia (9.6%), respiratory depression (9.6%), and QTc prolongation (8.2%). We found a significant correlation between ingested clozapine dose and severity of poisoning. The minimal dose for both moderate and severe intoxications was 0.1 g. The dose for a 50% risk of developing moderate or severe intoxications was 0.9 g in patients older than 50 years and 14.5 g in patients younger than 50 years. Patients older than 50 years had a significantly increased risk for a severe clinical course (odds ratio, 6.41; 95% confidence interval, 1.88-21.90). We found no significant correlation between pretreatment, sex or decontamination, and the severity of the intoxication. CONCLUSIONS: Moderate and severe clozapine intoxications can already occur after ingestion of doses in the low therapeutic range, especially in patients older than 50 years. Poisoned patients have to be monitored for central nervous system depression, tachycardia, blood pressure abnormalities, respiratory depression, and QTc prolongation.

Household chemicals: management of intoxication and antidotes.

Exposure to household products is very common, but in industrialized countries severe or fatal poisoning with household products is rare today, due to the legal restriction of sale of hazardous household products. The big challenge for physicians, pharmacologists and toxicologists is to identify the few exceptional life-threatening situations where immediate intervention is needed. Among thousands of innocuous products available for the household only very few are hazardous. Substances found in these products include detergents, corrosives, alcohols, hydrocarbons, and some of the essential oils. The ingestion of batteries and magnets and the exposure to cyanoacrylates (super glue) can cause complications in exceptional situations. Among the most dangerous substances still present in household products are ethylene glycol and methanol. These substances cause major toxicity only through their metabolites. Therefore, initial symptoms may be only mild or absent. Treatment even in asymptomatic patients has to be initiated as early as possible to inhibit production of toxic metabolites. For all substances not only the compound itself but also the route of exposure is relevant for toxicity. Oral ingestion and inhalation generally lead to most pronounced symptoms, while dermal exposure is often limited to mild irritation. However, certain circumstances need special attention. Exposure to hydrofluoric acid may lead to fatal hypocalcemia, depending on the concentration, duration of exposure, and area of the affected skin. Accidents with hydrocarbon pressure injectors and spray guns are very serious events, which may lead to amputation of affected limbs. Button batteries normally pass the gastrointestinal tract without problems even in toddlers; in rare cases, however, they get lodged in the esophagus with the risk of localized tissue damage and esophageal perforation.