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Brief Summary

GUIDELINE TITLE

Elemental mercury exposure: an evidence-based consensus guideline for out-of-hospital management.

BIBLIOGRAPHIC SOURCE(S)

GUIDELINE STATUS

This is the current release of the guideline.

BRIEF SUMMARY CONTENT

 
RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Grades of recommendation (A-D, Z) and levels of evidence (1a-6) are defined at the end of the "Major Recommendations" field.

  1. Patients with exposure due to suspected self-harm, abuse, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the exposure reported (Grade D).
  2. Patients with symptoms of acute elemental mercury poisoning (e.g., cough, dyspnea, chest pain) should be referred immediately to an emergency department for evaluation regardless of the reported dose. Patients with symptoms of chronic toxicity (rash, tremor, weight loss, etc.) should be referred for healthcare evaluation, the timing and location of which is guided by the severity of illness and circumstances of the exposure (Grade C).
  3. If the elemental mercury was recently heated (e.g., from stove top, oven, furnace) in an enclosed area, all people within the exposure area should be evaluated at a healthcare facility due to the high risk of toxicity (Grade C).
  4. If the elemental mercury was vacuumed or swept with a broom, the health department should be contacted to perform an environmental assessment for mercury contamination. Consider healthcare referral for those exposed to documented high air mercury concentrations (Grade C).
  5. Patients ingesting more mercury than in a household fever thermometer or those with abdominal pain after ingestion should be referred to an emergency department for evaluation (Grade C). Do not induce emesis or administer activated charcoal.
  6. Asymptomatic patients with brief, unintentional, low-dose vapor exposures can be observed at home. Asymptomatic patients can be evaluated as non-urgent outpatients if there is concern for exposures to high doses (e.g., more than contained in a thermometer) or for chronic duration (Grade D).
  7. Pregnant patients unintentionally exposed to elemental mercury and who are asymptomatic should be evaluated by their obstetrician or primary care provider as an outpatient. Immediate referral to an emergency department is not required (Grade D).
  8. Patients with elemental mercury deposited or injected into soft tissue should be referred for evaluation of surgical removal (Grade C).
  9. All elemental mercury spills should be properly cleaned up, including the small amount of mercury from a broken thermometer. Brooms and vacuum cleaners should not be used to clean up elemental mercury. The clean-up of any spill larger than a broken thermometer should be performed by a professional company, state health department, or the U.S. Environmental protection Agency (EPA). Detailed instructions are provided on the EPA website: http://www.epa.gov/mercury/spills/index.htm (Grade D).
  10. Patients with dermal exposures should remove all jewelry and wash the affected area with mild soap and water. Remove all contaminated clothing and place these items in a sealed plastic double-bag for proper disposal (Grade D).
  11. Do not discard elemental mercury in household trash, plumbing drains, or sewer systems. Consult local authorities for the proper disposal of low-level elemental mercury-contaminated household items and thermometers (Grade D).

Definitions:

Grades of Recommendation and Levels of Evidence

Grade of Recommendation Level of
Evidence
Description of Study Design
A 1a Systematic review (with homogeneity) of randomized clinical trials
1b Individual randomized clinical trials (with narrow confidence interval)
1c All or none (all patients died before the drug became available, but some now survive on it; or when some patients died before the drug became available, but none now die on it.)
B 2a Systematic review (with homogeneity) of cohort studies
2b Individual cohort study (including low quality randomized clinical trial)
2c "Outcomes" research
3a Systemic review (with homogeneity) of case-control studies
3b Individual case-control study
C 4 Case series, single case reports (and poor quality cohort and case control studies)
D 5 Expert opinion without explicit critical appraisal or based on physiology or bench research
Z 6 Abstracts

CLINICAL ALGORITHM(S)

An algorithm is provided in Appendix 4 of the original guideline document for triage for elemental mercury exposure.

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2007 Apr 9

GUIDELINE DEVELOPER(S)

American Association of Poison Control Centers - Professional Association

SOURCE(S) OF FUNDING

Health Resources and Services Administration, U.S. Department of Health and Human Services

GUIDELINE COMMITTEE

Not stated

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Primary Authors: E. Martin Caravati, MD, MPH; Andrew R. Erdman, MD; Gwenn Christianson, MSN; Lewis S. Nelson, MD; Alan D. Woolf, MD, MPH; Lisa L. Booze, PharmD; Daniel J. Cobaugh, PharmD; Peter A. Chyka, PharmD; Elizabeth J. Scharman, PharmD; Anthony S. Manoguerra, PharmD; William G. Troutman, PharmD

Expert Consensus Panel Members: Lisa L. Booze, PharmD, Certified Specialist in Poison Information, Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, Maryland; E. Martin Caravati, MD, MPH, FACMT, FACEP, Professor of Surgery (Emergency Medicine) University of Utah, Medical Director, Utah Poison Control Center, Salt Lake City, Utah; Gwenn Christianson, RN, MSN, Certified Specialist in Poison Information, Indiana Poison Center, Indianapolis, Indiana; Peter A. Chyka, PharmD, DABAT, FAACT, Professor, Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, Knoxville, Tennessee; Daniel J. Cobaugh, PharmD, FAACT, DABAT, Director of Research, ASHP Research and Education Foundation, Bethesda, Maryland, Former Associate Director, American Association of Poison Control Centers; Daniel C. Keyes, MD, MPH, Medical Director, Pine Bluff Chemical Demilitarization Facility, Associate Professor, Southwestern Toxicology Training Program, Dallas, Texas; Anthony S. Manoguerra, PharmD, DABAT, FAACT, Professor of Clinical Pharmacy and Associate Dean, School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, Former Director, California Poison Control System, San Diego Division, San Diego, California; Lewis S. Nelson, MD, FACEP, FACMT, FACCT, Associate Professor of Emergency Medicine, New York University School of Medicine, Associate Medical Director, New York City Poison Control Center, New York, New York; Elizabeth J. Scharman, PharmD, DABAT, BCPS, FAACT, Director, West Virginia Poison Center, Professor, West Virginia University School of Pharmacy, Dept. Clinical Pharmacy, Charleston, West Virginia; Paul M. Wax, MD, FACMT, Attending Toxicologist, University of Texas Southwestern Medical Center, Dallas, Texas; Alan D. Woolf, MD, MPH, FACMT, Director, Program in Environmental Medicine, Children's Hospital, Boston, Associate Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

There are no potential conflicts of interest reported by the expert consensus panel or project staff regarding this guideline.

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the American Association of Poison Control Centers.

Print copies: Available from the American Association of Poison Control Centers, 3201 New Mexico Avenue NW, Suite 330, Washington, DC 20016

AVAILABILITY OF COMPANION DOCUMENTS

None available

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on December 17, 2007. The information was verified by the guideline developer on January 14, 2008.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

DISCLAIMER

NGC DISCLAIMER

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