Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2011-5329

2. Registrant Information.

Registrant Reference Number: 32012178

Registrant Name (Full Legal Name no abbreviations): Monsanto Canada Inc.

Address: 180 Kent Street, Suite 810

City: Ottawa

Prov / State: ON

Country: Canada

Postal Code: K1P 0B6

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

11-OCT-11

5. Location of incident.

Country: UNITED STATES

Prov / State: ARIZONA

6. Date incident was first observed.

24-SEP-11

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 524-445

Product Name: Roundup Herbicide

• Active Ingredient(s)
  • GLYPHOSATE
    • Guarantee/concentration 41 %

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7. b) Type of formulation.

Liquid

Application Information

8. Product was applied?

No

9. Application Rate.

10. Site pesticide was applied to (select all that apply).

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Other

2. Demographic information of data subject

Sex: Male

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• Cardiovascular System
  • Symptom - Hypotension

• Blood
  • Symptom - Acidosis
  • Specify - metabolic acidosis
  • Symptom -
  • Specify - increased lactate

• Renal System
  • Symptom - Other
  • Specify - renal impairment

• Blood
  • Symptom -
  • Specify - anion gap
  • Symptom -
  • Specify - osmolar gap

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

Yes

6. b) For how long?

Unknown

7. Exposure scenario

Non-occupational

8. How did exposure occur? (Select all that apply)

Poisoning from ingestion of the pesticide

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

10. Route(s) of exposure.

Oral

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

Call received 5 days post exposure, from a resident MD from another Poison Center concerning a man that stated he drank diluted weed killer that was from a concentrate and vodka last Saturday. The man arrived to the ER by ambulance after being found down in a shed in his backyard. No container was available. EMS saw a spray cannister that the man had filled with product for home use. Both the man and his wife say it was a diluted weed killer from concentrate but no name or ingredients given. Reports of drinking 150-350 ml. The MD contacted MRPC with report of the man having hypotension requiring use of vasopressors, metabolic acidosis, increased lactate, renal impairment requiring continuous renal replacement therapy (CRRT) for 2 days. The man was intubated, sedated and placed on a ventilator for 5-6 days before being extubated. Supportive care with IV fluids, vasopressors, CRRT, sodium bicarbonate done. The man also had lab evidence of an anion gap, osmolar gap and was treated with fomepizole. One time dose of intralipids given. By day 4, the man was showing gradual signs of improvement as evidenced by decreased need for vasopressors, CRRT, and improved neuro status. No evidence of GI injury. MRPC was contacted on day 6 for information concerning Roundup product. MRPC discussed the product toxicity. Difficult to determine the certainty of the exact cause for the man's course of effects. If it is assumed that he ingested a large amount of a concentrated Roundup product, the symptoms of hypotension requiring vasopressors resulting in increased lactate leading to metabolic acidosis with evidence of renal impairment is consistent with ingestion of concentrated surfactant. If it was a product that contained diquat dibromide , renal impairment is the end point of toxicity. No further follow up obtained.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

This incident appears to be an attempted suicide but it is not clear from the information provided, therefore it is being reported.