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Consumer Product Safety

Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2019-3870

2. Registrant Information.

Registrant Reference Number: 2462591

Registrant Name (Full Legal Name no abbreviations): McLaughlin Gormley King Company

Address: 8810 Tenth Ave North

City: Minneapolis

Prov / State: MN

Country: USA

Postal Code: 55427-4319

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

Human

4. Date registrant was first informed of the incident.

16-JUN-19

5. Location of incident.

Country: UNITED STATES

Prov / State: OHIO

6. Date incident was first observed.

Unknown

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.       PMRA Submission No.       EPA Registration No. 1021-2569

Product Name: Bedlam Plus

  • Active Ingredient(s)
    • D-PHENOTHRIN
      • Guarantee/concentration .4 %
    • IMIDACLOPRID
      • Guarantee/concentration .05 %
    • N-OCTYL BICYCLOHEPTENE DICARBOXIMIDE
      • Guarantee/concentration 1 %

7. b) Type of formulation.

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

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

Site: Res. - In Home / Rés. - à l'int. maison

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

Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding application.

To be determined by Registrant

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

Yes

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

1. Source of Report.

Medical Professional

2. Demographic information of data subject

Sex: Male

Age: >12 <=19 yrs / >12 <=19 ans

3. List all symptoms, using the selections below.

System

  • Gastrointestinal System
    • Symptom - Vomiting
  • Nervous and Muscular Systems
    • Symptom - Coma
    • Symptom - Seizure
  • Respiratory System
    • Symptom - Respiratory failure
  • Nervous and Muscular Systems
    • Symptom - Headache
    • Symptom - Other
    • Specify - possible lymphatic encephalopathy
    • Symptom - Other
    • Specify - abnormal movements

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)

What was the activity? Please refer to field 13 on Subform II or field 17 of subform III for a detailed description regarding the activity

Other

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

None

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

>8 hrs <= 24 hrs / >8 h <= 24 h

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.)

6/16/2019 Caller is the medical toxicologist for the hospital treating a patient that was taken to the emergency room after his parents found him unresponsive on the couch at home. The family states they used the product behind the couch and on the floor on 6/15/2016. The son stated he was not feeling well and had a headache. He has a history of migraines. He stayed home to take a nap on the couch while the others went out. When they returned, they found the son on the couch unresponsive. He had vomited everywhere and had abnormal movements. Once he arrived at the emergency room he did have a unilateral seizure. He was intubated and is now in hypercapnic respiratory failure. Computer tomography and lumbar puncture have been done, which shows lymphatic encephalopathy is possible. Non-specific labs have been drawn. The product was not sprayed directly on the patient and was not sprayed directly on the couch. The family states the patient may have been having some abnormal behavior for one week of not feeling well. The patient does not have any psychiatric history and has never had an indication of drug use. 6/17/2019 Call back to the original caller for follow up information. When caller left the hospital yesterday, the patient was improving and starting to wake up. Caller is not working today. Caller does not think the patient overdosed on anything and also does not think the symptoms were related to the use of the product. 6/18/2019 Attempted call back to the original caller. A message was left requesting follow up information. 6/20/2019 Attempted call back to the original caller. A message was left requesting follow up information.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

The information contained in this report is based on self-reported statements provided to the registrant during telephone Interview(s). These self-reported descriptions of an incident have not been independently verified to be factually correct or complete descriptions of the incident. For that reason, information contained in this report does not and can not form the basis for a determination of whether the reported clinical effects are causally related to exposure to the product identified in the telephone interviews.