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## Complete Summary

#### GUIDELINE TITLE

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

#### BIBLIOGRAPHIC SOURCE(S)

Caravati EM, Erdman AR, Christianson G, Nelson LS, Woolf AD, Booze LL,
Cobaugh DJ, Chyka PA, Scharman EJ, Manoguerra AS, Troutman WG. Elemental
mercury exposure: an evidence-based consensus guideline for
out-of-hospital management. Clin Toxicol (Phila) 2008 Jan;46(1):1-21.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18167033)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Elemental mercury exposure

**Note**:

-   This guideline addresses small spills and human exposures to
    elemental mercury. Exposures to organic mercury compounds (e.g.,
    methylmercury) or inorganic mercuric salts (e.g., mercuric chloride)
    are not included.

-   In addition, this guideline does not address chronic occupational
    exposure or large industrial releases of elemental mercury. It
    focuses primarily on small spills (typically less than 5 mL) that
    occur in a home or public area. It does not address aspiration or
    intravenous exposure to elemental mercury.

#### GUIDELINE CATEGORY

Evaluation\
Management\
Risk Assessment

#### CLINICAL SPECIALTY

Emergency Medicine\
Family Practice\
Internal Medicine\
Obstetrics and Gynecology\
Pediatrics

#### INTENDED USERS

Advanced Practice Nurses\
Allied Health Personnel\
Emergency Medical Technicians/Paramedics\
Nurses\
Pharmacists\
Physicians

#### GUIDELINE OBJECTIVE(S)

To assist poison center personnel in the appropriate out-of-hospital
triage and initial out-of-hospital management of patients with suspected
exposures to small amounts of elemental mercury by:

-   Describing the process by which a specialist in poison information
    should evaluate an exposure to elemental mercury

-   Identifying the key decision elements in managing cases of elemental
    mercury exposure

-   Providing clear and practical recommendations that reflect the
    current state of knowledge

-   Identifying needs for research

#### TARGET POPULATION

Children and adults including pregnant women with suspected exposure to
elemental mercury

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Evaluation**

1.  Assessment of key decision elements for triage

    -   Patient intent

    -   Route of exposure

    -   Presence of symptoms

    -   Time of onset of toxicity

    -   Whether there was intentional heating of elemental mercury

**Management**

1.  Referral to an emergency department

2.  Home observation or non-urgent outpatient evaluation

3.  Referral for evaluation of surgical removal of mercury injected into
    soft tissue

4.  Decontamination including removing jewelry and washing the affected
    area with mild soap and water, removing contaminated clothing and
    placing it in a sealed plastic double-bag for proper disposal

5.  Evaluation by obstetrician or primary care provider for asymptomatic
    pregnant women

6.  Proper clean-up according to Environmental Protection Agency (EPA)
    guidelines

7.  Consulting local authorities for proper disposal of contaminated
    items

**Note**: Emesis induction and administration of activated charcoal were
considered but not recommended.

#### MAJOR OUTCOMES CONSIDERED

-   Mortality

-   Signs and symptoms of toxicity

-   Environmental risk factors for elemental mercury poisoning

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

**Search Strategy**

A single investigator performed literature searches for relevant
articles. The National Library of Medicine\'s PubMed database was
searched (through May 2006) using elemental mercury poisoning as a
Medical Subject Headings (MeSH) term, limited to humans. The PubMed
database was further searched using mercury as a textword (title,
abstract, MeSH term, CAS registry) plus either poison\* or overdos\* or
intox\*, or toxic\* limited to humans. This process was repeated in
International Pharmaceutical Abstracts (1970--May 2006, excluding
abstracts of meeting presentations), Science Citation Index (1977--May
2006), Database of Abstracts of Reviews of Effects (accessed May 2006),
Cochrane Database of Systematic Reviews (accessed May 2006), and
Cochrane Central Register of Controlled Trials (accessed May 2006).
Reactions (1980--May 2006), the elemental mercury poisoning management
in Poisindex, and the bibliographies of recovered articles were reviewed
to identify previously undiscovered articles. Furthermore, North
American Congress of Clinical Toxicology (NACCT) abstracts published in
the Journal of Toxicology Clinical Toxicology (1995--2004) and Clinical
Toxicology (2005) were reviewed for original human data.

Five major toxicology textbooks were reviewed for recommendations on the
management of elemental mercury poisoning and for citations of
additional articles with original human data in the chapter
bibliographies. The Toxic Exposure Surveillance System (TESS) maintained
by the American Association of Poison Control Centers was searched for
deaths resulting from unintentional elemental mercury poisoning. These
cases were abstracted for review by panel members. All US poison control
centers were surveyed in 2006 to ascertain their out-of-hospital
management and triage practices for elemental mercury poisonings.

**Criteria Used to Identify Applicable Studies**

The recovered citations were entered into an EndNote library and
duplicate entries were eliminated. The abstracts of these articles were
reviewed, searching specifically for those that dealt with estimations
of doses with or without subsequent signs or symptoms of toxicity and
management techniques that might be suitable for out-of-hospital use
(e.g., gastrointestinal decontamination). Articles that did not meet
either of the preceding criteria, did not add new data (e.g., some
reviews, editorials), or that exclusively described inpatient-only
procedures (e.g., dialysis) were excluded.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

 

  ------------------------------------------------------------------------
  **Level of   **Description of Study Design**
  Evidence**   
  ------------ -----------------------------------------------------------
  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.)

  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

  4            Case series, single case reports (and poor quality cohort
               and case control studies)

  5            Expert opinion without explicit critical appraisal or based
               on physiology or bench research

  6            Abstracts
  ------------------------------------------------------------------------

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

**Data Extraction Process**

A trained physician abstractor reviewed all articles that were retrieved
from the original search. The complete paper was reviewed for original
human data regarding the toxic effects of elemental mercury or original
human data directly relevant to the out-of-hospital management of
patients with elemental mercury exposure. Relevant data (e.g., dose,
effects, time of onset of effects, therapeutic interventions or
decontamination measures provided, efficacy or results of any
interventions, and overall patient outcome) were compiled into a table
and a brief description of each article was written. This evidence table
is available at
[http://www.aapcc.org/DiscGuidelines/mercury%20evidence%20table%202006-10-30.pdf](http://www.aapcc.org/DiscGuidelines/mercury evidence table 2006-10-30.pdf).

The table of all abstracted articles was then forwarded to the panel
members for review and consideration in developing the guideline.
Efforts were made to locate foreign language articles and have their
crucial information extracted, translated, and tabulated. The abstractor
created and distributed a written summary of the data. All of the
abstracted articles were made available on a secure American Association
of Poison Control Centers (AAPCC) website for reading by the panel
members.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus (Delphi)

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

An expert consensus panel was established to develop the guideline (see
Appendix 1 of the original guideline document). The American Association
of Poison Control Centers (AAPCC), the American Academy of Clinical
Toxicology (AACT), and the American College of Medical Toxicology (ACMT)
appointed members of their organizations to serve as panel members. To
serve on the expert consensus panel, an individual had to have an
exceptional record in clinical care and scientific research in
toxicology, board certification as a clinical or medical toxicologist,
significant US poison control center experience, and be an opinion
leader with broad esteem. Two specialists in poison information were
included as full panel members to provide the viewpoint of the end-users
of the guideline.

**Guideline Writing and Review**

The lead author prepared a draft guideline. The draft was submitted to
the expert consensus panel for comment. Using a modified Delphi process,
comments from the expert consensus panel members were collected, copied
into a table of comments, and submitted to the lead author for response.
The lead author responded to each comment in the table and, when
appropriate, the guideline draft was modified to incorporate changes
suggested by the panel. The panel again reviewed the revised guideline
draft and, if there was no strong objection by any panelist to any of
the changes made by the lead author, the draft was prepared for the
external review process.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

The rating scheme for the strength of the recommendation (A-D, Z) is
directly tied to the level of evidence supporting the recommendation.

  -----------------------------------------------------------------------
  **Grade of Recommendation**                          **Level of\
                                                       Evidence**
  ---------------------------------------------------- ------------------
  A                                                    1a

                                                       1b

                                                       1c

  B                                                    2a

                                                       2b

                                                       2c

                                                       3a

                                                       3b

  C                                                    4

  D                                                    5

  Z                                                    6
  -----------------------------------------------------------------------

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

External review of the second draft was conducted by distributing it
electronically to American Association of Poison Control Centers
(AAPCC), American Academy of Clinical Toxicology (AACT), and American
College of Medical Toxicology (ACMT) members and the secondary review
panel. The secondary review panel consisted of representatives from the
federal government, public health, emergency services, pediatrics,
pharmacy practice, and consumer organizations (see Appendix 3 of the
original guideline document). Comments were submitted via a discussion
thread on the AAPCC web site or privately through e-mail communication
to AAPCC staff. All submitted comments were rendered anonymous, copied
into a table of comments, and reviewed by the expert consensus panel and
the lead author. The lead author responded to each comment in the table
and his responses and subsequent changes in the guideline were reviewed
and accepted by the panel.

### 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]{.underline}**:

**Grades of Recommendation and Levels of Evidence**

  ----------------------------------------------------------------------------
  **Grade of         **Level of\  **Description of Study Design**
  Recommendation**   Evidence**   
  ------------------ ------------ --------------------------------------------
  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\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate out-of-hospital triage and initial management of patients
with suspected elemental mercury exposure

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   This guideline was developed for the conditions prevalent in the
    United States. While the toxicity of elemental mercury is not
    expected to vary in a clinically significant manner in other
    nations, the out-of-hospital conditions could be much different. Do
    not extrapolate this guideline to other settings unless it has been
    determined that the conditions assumed in this guideline are
    present.

-   This guideline is based on an assessment of current scientific and
    clinical information. The expert consensus panel recognizes that
    specific patient care decisions may be at variance with this
    guideline and are the prerogative of the patient and the health
    professionals providing care, considering all of the circumstances
    involved. This guideline does not substitute for clinical judgment.

**Limitations of the Literature**

The elemental mercury literature suffered from many potential
limitations that could affect the interpretation of the data for this
guideline. Most of the data were retrospective and estimates of spill or
exposure amount, exposure duration, and the nature or onset of symptoms
were usually based on patient or family recall, often several weeks or
months after the exposure originally occurred. Exposure might have
occurred by more than one route (e.g. dermal, ingestion, inhalational)
in a given individual, but the extent to which each occurred was
generally not reported or might not have been known. The local
environmental conditions (e.g., location, temperature, ventilation,
vacuuming, heating) were not often reported with inhalational exposures.
Many of these factors can have a critical impact on the amount of
mercury inhaled and resulting toxicity.

Air mercury measurements can help circumvent some of the limitations in
using quantitative assessments of exposure amounts. However, they have
their own limitations as potential estimates of cumulative or peak
exposure. Air measurements represent only one point in time and space
and can fluctuate depending on a number of factors (e.g., higher
concentrations generally associated with higher temperatures, poorer
ventilation, and vacuuming). Thus, their interpretation depends on
environmental context, which was often not reported. In many instances,
it was not clear when the airborne mercury measurements were made in
relation to the spill/exposure, where in spatial proximity to the
exposure the air samples were obtained, or whether samples were taken at
the breathing space or surface level. Breathing space concentrations are
typically much lower than corresponding measurements taken directly
above an elemental mercury spill or contaminated object. In addition,
abatement measurements were frequently performed after peak exposure and
might have underestimated the actual concentration at the time of
exposure. In some cases, air mercury concentrations were reported but
not exposure amounts or vice versa.

Individuals can differ in their responses to similar exposures because
of inter-individual differences in minute ventilation, toxicokinetics,
or toxicodynamics. Such potential differences make comparing the data
between patients, or extrapolating it to the broader population,
difficult. The symptoms of mild mercury poisoning are nonspecific and
its diagnosis might be under-reported in the literature. Urine and blood
mercury concentrations are limited in their ability to confirm or rule
out a significant exposure. Depending on the circumstances (e.g., the
acuity of exposure, timing of measurements, laboratory performance),
urine or blood concentrations might not reflect the actual exposure. In
some cases, background occupational exposure might have been present and
could have contributed to a patient\'s reported symptoms or biological
mercury measurements.

In cases describing mercury spills from broken thermometers, the
thermometer size or volume of mercury was generally not reported.
Different thermometers contain different amounts of mercury.

In the few large cases series included in the evidence table, elemental
mercury exposure amounts, air concentrations, and frequency or severity
of subsequent effects were often reported as a ranges, percentages or
mean values, so that individual doses resulting in specific effects
could not be distinguished.

In several instances, the quality of data might have been lower than
implied by the level of evidence score. For example, an article
classified as level 2b could have been a cohort analysis of the
relationship between urine mercury concentrations and symptom severity,
but the quality of data relating to the more pertinent relationship of
exposure amount or air level vs. symptom severity might have been only a
level 4. Most studies reviewed were not designed to specifically assess
a toxic exposure threshold (i.e., the relationship between air
concentration or spill amount and clinical effects), yet this was a
primary question that the guideline panel sought to answer from the
review of the literature.

The number of articles reporting gastrointestinal or subcutaneous
exposures was limited. This could be the result of the infrequency of
such exposures, an inherent lack of toxicity by these routes, poor
recognition of such cases, or simply a lack of reporting. It was
difficult to draw robust conclusions from this data.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Caravati EM, Erdman AR, Christianson G, Nelson LS, Woolf AD, Booze LL,
Cobaugh DJ, Chyka PA, Scharman EJ, Manoguerra AS, Troutman WG. Elemental
mercury exposure: an evidence-based consensus guideline for
out-of-hospital management. Clin Toxicol (Phila) 2008 Jan;46(1):1-21.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=18167033)

#### 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](http://www.aapcc.org/FinalizedPMGdlns/mercury guideline for AAPCC 2007-4-9.doc.pdf).

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

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008