Incident Report
Subform I: General Information
1. Report Type.
New incident report
Incident Report Number: 2012-0112
2. Registrant Information.
Registrant Reference Number: x
Registrant Name (Full Legal Name no abbreviations): x
Address: x
City: x
Prov / State: x
Country: x
Postal Code: X
3. Select the appropriate subform(s) for the incident.
Domestic Animal
4. Date registrant was first informed of the incident.
5. Location of incident.
Country: CANADA
Prov / State: ONTARIO
6. Date incident was first observed.
12-DEC-12
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)
PMRA Registration No. 26489
PMRA Submission No.
EPA Registration No.
Product Name: Hartz Ultraguard Plus Flea & Tick Drops for Dogs and Puppies
- Active Ingredient(s)
- (S)-METHOPRENE
- PERMETHRIN
7. b) Type of formulation.
Application Information
8. Product was applied?
Yes
9. Application Rate.
1
Units: mL
10. Site pesticide was applied to (select all that apply).
Site: Animal / Usage sur un animal domestique
11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).
Gave 1 tube - 1ml of spot-on treatment directly on skin all the way down the cat's back. The owner doesn't believe that she licked any of the contents off. Cat was treated with dog flea medication spot-on treatment. Used 1ml tube which stayed on skin and absorbed into skin until washed off. 24 hours after applied.
To be determined by Registrant
12. In your opinion, was the product used according to the label instructions?
Unknown
Subform III: Domestic Animal Incident Report
1. Source of Report
Medical Professional
2. Type of animal affected
Cat / Chat
3. Breed
Domestic Shorthair
4. Number of animals affected
1
5. Sex
Female
6. Age (provide a range if necessary )
Unknown
7. Weight (provide a range if necessary )
Unknown
8. Route(s) of exposure
Skin
9. What was the length of exposure?
Unknown / Inconnu
10. Time between exposure and onset of symptoms
>8 hrs <=24 hrs / > 8 h < = 24 h
11. List all symptoms
System
- Nervous and Muscular Systems
- Symptom - Shaking
- Specify - shaking violently
- Nervous and Muscular Systems
- General
- Symptom - Abnormal behaviour
- Specify - acting funny
- Nervous and Muscular Systems
12. How long did the symptoms last?
>3 days <=1 wk / >3 jours <=1 sem
13. Was medical treatment provided? Provide details in question 17.
Yes
14. a) Was the animal hospitalized?
Yes
14. b) How long was the animal hospitalized?
15. Outcome of the incident
Fully Recovered / Complètement rétabli
16. How was the animal exposed?
Treatment / Traitement
17. Provide any additional details about the incident
(eg. description of the frequency and severity of the symptoms
Pesticide applied Dec.12th. Dec 13th AM the cat was hiding and acting 'funny'. By 5:45pm Dec.13th she was shaking violently. Owner bathed her with dish soap and brought her to the vet clinic immediately. Upon giving 2.55CC methocarbomol intravenous tremors. stopped immediately. Began tremoring again 1 hour later gave 1CC methocarbamol IV and began IV fluids Plasmalyte. Blood drawn and electrolytes evaluated calcium low (1.93 - range 2.05 - 2.7) (PK High (2030 - range 56 -529), all likely to prolonged seizures. Tremors started again Dec.15th AM - gave 3.5CC methocarbamol IV again and tremors stopped and didn't begin again. Got 1.5 L of fluids before being discharged.
To be determined by Registrant
18. Severity classification (if there is more than 1 possible classification
Not Applicable
19. Provide supplemental information here