Toxicological Information Centre Research Articles

Exogenous intoxication in patients treated at the Toxicological Information and Assistance Center during the COVID-19 pandemic

Poisoning is defined as an adverse event resulting from the action of chemical substances that induces a pathology in an individual. The World Health Organization (WHO) has reported three million hospital admissions occurring annually due to toxic exposure worldwide. The growth of SARS-CoV-2 infection cases in 2020 also significantly increased calls to Poison Centers due to exposure to cleaning products, hand sanitizers, and disinfectants in early March 2020 in the United States. Based on this scenario, it was hypothesized that the pattern of exogenous intoxication has changed. Therefore, the aim of this study was to analyze the epidemiological profile of exogenous intoxications recorded by CIATOX-DF from March 2020 to February 2021, during the COVID-19 pandemic. At that time, there was an increase in accidental, environmental, venomous, and non-venomous animal cases, especially in babies, pre-adolescents, adolescents (11 to 15 years old), and women, due to the greater exposure of this age group and gender who have spent more time in rural environments. Most poisonings were accidental. It was observed that there was a decrease in suicide cases, but within these cases, there was a trend increase in poisoning in pre-adolescents and adolescents (11 to 15 years old) compared to other ages, which can be related to an increase in anxiety within this age group. The main toxic agents were venomous and non-venomous animals. The pattern of high frequency in cases involving medicines, pesticides, and household cleaning products was maintained, with a significant increase in cases involving 70% alcohol. It was found that patients living in towns further away from the Pilot Plan in Brasilia suffer accidents involving venomous animals. Accidental and attempted suicide cases occurred more frequently in cities closer to the Pilot Plan region. We concluded that these changes were explained by the new pattern of social behavior during the pandemic.

Self-medication cases reported to a poison information center in Brazil from 2014 to 2020

Introduction Self-medication is the use of drugs to treat self-diagnosed illnesses or symptoms, on one’s own initiative, without the guidance of a healthcare professional. Poison centers play an important role in understanding the relationship between self-medication and poisoning. The objective of this study is to evaluate the clinical and epidemiological profile of patients exposed to and/or poisoned by different drugs through self-medication. Methods This retrospective, cross-sectional, and descriptive study analyzed data from 2014 to 2020, provided by the Toxicological Information and Assistance Center of Santa Catarina, Brazil. Data were selected, tabulated, and analyzed by using descriptive statistics and group comparison with the chi-square test or Fisher’s exact test. A P value <0.05 was considered statistically significant. Results There were 683 cases of self-medication identified. Most patients were female (62.8 percent) and between 20 and 29 years old (26.1 percent). A toxic dose of a substance was administered in only 22.8 percent of the cases, and five deaths were recorded. The most commonly used medications were anxiolytics (18 percent), followed by analgesics and antipyretics (15.4 percent). Paracetamol was the drug used in three of the five cases that resulted in deaths. Discussion This study demonstrates the prevalence of self-medication among women aged between 20 and 29 years old. Statistical analysis failed to show a relationship between a toxic dose and clinical manifestations. Anxiolytics, analgesics, and antipyretics are the most reported medications probably because healthcare professionals are mostly the ones who contact the center. Analgesics and antipyretics account for more than fifty percent of the deaths caused by self-medication in the present report. Some limitations such as secondary sources are related. Conclusion We highlight the importance of health professionals in promoting the rational use of medicines, as well as poison centers in assisting the population and raising their awareness regarding the issue.

Root cause qualitative analysis of acute childhood poisonings as a study of sentinel surveillance

Objective: To analyze the root cause of occurrences of severe intoxication in children and adolescents from the perspective of sentinel events. Methods: Observational, retrospective, and qualitative study of a series of cases of seven children and young people with a confirmed clinical picture of intoxication by various agents, treated in a stabilization room of emergency care units or intensive care, and notified to toxicological information and assistance center from January to June 2019. The epidemiological surveillance of sentinel events was used based on a review of hospital documents and in-depth interviews with family members. The Root Cause Analysis (RCA) matrix was used to evaluate the cases and the systematic reconstruction of the cases' antecedents.Results: The age profile of the study population, the pattern of agents and substances involved - poisoning by intentional ingestion in five (71%) cases, indicated critical points and missed opportunities for prevention. The individual and family history analysis indicated as direct causal factors the deviations from norms for preventing poisoning at home or in the family context for all cases.The prevention and health promotion activities in the health services constituted the underlying causes of the occurrences.Conclusion: The root cause analysis identified a deficiency in public policies, but the interface between education, public security, social assistance, economy, and health policies would be preponderant for preventing childhood and youth poisoning.

Poisoning in Children and adolescents assisted during the COVID-19 pandemic at the Toxicological Information and Assistance Center in Federal District, Brazil (CIATOX -DF): Descriptive, Cross-sectional, and Analytical study with 1.037 patients

Exogenous poisonings are one of the principal accidents involving children and adolescents. The social isolation promoted by the COVID-19 pandemic raises concerns about the possibility of an increase in poisoning among children since most cases of poisoning occur in home environments. Therefore, the present study evaluated exogenous poisonings in children under ten years of age and adolescents aged 11 to 20 years old through data recorded at the Toxicological Information and Assistance Center in the Federal District (CIATOX-DF) from January to September 2020. The results showed a change in the number of notifications, with 1.037 poisonings registered in patients under 20 years of age. Registrations of poisoning by venomous animals, medications, and household cleaning products in children tend to be higher in months of vacation. This study demonstrated poisoning notifications by non-venomous animals in March and April and household cleaning products as the second leading cause of exogenous poisoning, demonstrating a clear temporal association among social isolation, increased use of household cleaning products, and exposure to these products. The multivariate analysis methodology managed to show the significant characteristics of the studied sample, contributing to creating local actions that aim to reduce the number of preventable cases of poisonings.

Drug-related female autointoxication registered at a toxicology care center

Objective: To analyze the data on epidemiological records of autointoxication reports registered at a toxicological assistance center. Methods: Exploratory, descriptive, and retrospective study with the analysis of secondary data, conducted from the audit on Toxicological Occurrence Notification and Attendance forms, referring to the period from 2014 to 2018, filed in a toxicological information and assistance center, located in a municipality in southern Brazil. The data obtained were compiled in spreadsheets and analyzed using simple descriptive statistics. Results: 2,942 epidemiological records on women's autointoxication were audited, 72.0% of the total cases in the period studied. The predominant age group was 18 to 29 years old, with 1697 (57.7%) cases. The main toxic agent was medication, and the only agent of intoxication in 2,358 cases (80.1%). Psychotropic drugs accounted for 55.2% (1,593) of the cases, mainly antiepileptic and psychoanalytic drugs. Clonazepam was present in 567 (35.6%) suicide attempts and as the sole agent in 275 (17.3%) of them. In 873 cases (54.8%), mental illness was reported, in 546 (34.3%) previous suicide attempts, and 1,082 (67.9%) continued use of psychotropic medication. The main outcome was hospital discharge in 1,239 cases (77.8%). Conclusion: The study showed an increase in cases of female autointoxication over the period studied. The high percentage of autointoxication with psychotropic medications may be related to the ease of access at home and society's medicalization.

Medical toxicology experience: Poisoning consultations cases registry in Saudi Ministry of Health -2020 annual report.

Saudi poison control centers provide surveillance data that should be used to determine the magnitude of poisoning exposures and the level of public awareness that is to evaluate control measures. This work aimed to review and assess the characteristics of toxic events received by toxicological information center's hotline all over Saudi Arabia during 2020. Data were collected from the poison control centers in Saudi Arabia. Cases of poisonings were studied during the period from 1st January to 31st December 2020. The poison control center received 20,513 calls in the year 2020. Most of calls were from Riyadh city (40.9 %) and from public places (92.9 %). Regarding the patients, most of the cases were less than 6 years old and more than half of them were males. The majority of toxic exposures were accidental oral poisoning. About 84 % of patients (84.3 %) called for help within one hour from poisons exposure. Household substances toxic exposure represented about one third of toxic cases. Chemicals and alcohol sanitizers' poisoning were the highest among house hold substances toxicities (39.3 % and 17.7 % respectively of all household substances toxicity). In addition, the most frequently ingested drugs were vitamins poisoning. Household chemicals represented the highest risk in exposures among children below 6 years. Finally, we recommended widespread awareness of the poisons risk and the importance of poison control that play a great role in time management and saving lives.

Poisoning by agricultural pesticides in the state of Goiás, Brazil, 2005-2015: analysis of records in official information systems.

The effect of pesticide use on human health is a problem that has received attention from the scientific community worldwide, especially in central countries, where the highest number of deaths due to human exposure to these agents is observed. Production and productivity increased through the progress of agro-industrialization, but risks to the environment and health were not taken into account. Over time, several cases of environmental contamination and public health problems, poisoning of rural workers, and food residues were observed. These factors triggered the recognition of risks arising from pesticide abuse. This study aimed to characterize pesticide poisonings reported to a toxicological information center of the state of Goiás through a retrospective analysis from 2005 to 2015. Data were mapped and tabulated by the purpose of pesticides, the circumstance of poisoning, and case development. The poisoning profile pointed to a higher occurrence of work- and suicide-related poisonings, with a predominance of poisoned patients, although chronic effects were not recorded, suggesting a false diagnosis of cure.

Uso indiscriminado do paracetamol no Rio Grande do Sul: perfil de uma década

O paracetamol é um fármaco de venda livre e um dos analgésicos mais utilizados na atualidade. A falta de conhecimento da população sobre seus efeitos tóxicos tem provocado aumento nos casos de intoxicações. Objetivou-se descrever os sinais clínicos e bioquímicos das intoxicações por paracetamol, ferramentas utilizadas para avaliar a necessidade do antídoto e reversão do quadro tóxico. Além disso, descrever dados estatísticos de intoxicações por medicamentos em especial por paracetamol no Rio Grande do Sul, registrados pelo Centro de Informação Toxicológica do estado (2008 a 2017). O paracetamol mostrou-se seguro em doses corretas, mas as intoxicações podem gerar lesão hepática grave. Quanto ao diagnóstico e tratamento, o Nomograma de Rumack-Matthew e o antídoto se mostraram ótimas ferramentas para evitar casos mais graves. Sobre dados estatísticos, os medicamentos somaram 30,85% das intoxicações totais no período, havendo um aumento das intoxicações associadas ao paracetamol (5.901 casos), o principal responsável por intoxicações na sua classe (analgésicos/antipiréticos), com 67,2% dos casos. O perfil mais prevalente de intoxicações foi em adultos por causa intencional. Conclui-se que o uso indiscriminado do paracetamol e consequente intoxicação representam uma grande preocupação para saúde pública.

Panorama das intoxicações associadas ao uso de medicamentos registradas no Brasil

A intoxicação exógena caracteriza-se pela interação de substâncias químicas com o organismo vivo. Anualmente 1,5 a 3% da população é intoxicada tornando o agravo uma questão de saúde pública/coletiva. Quantificar e analisar os casos notificados de intoxicações por medicamentos no Brasil. Tratou-se de uma pesquisa documental, retrospectiva, descritiva com abordagem quantitativa. Os casos notificados de intoxicação por medicamentos foram coletados a partir do Departamento de Informática do Sistema Único de Saúde (DATASUS) tendo como variáveis estudadas: região, ano, sexo, circunstância, classificação final e evolução. Foram estudados 224.901 casos de intoxicações por medicamentos, no período supracitado e, através desses casos verificou-se que há um aumento gradativo do número de notificações ao longo dos anos estudados sendo 28% em 2017. Dos casos notificados 51% pertenciam a região sudeste. O sexo feminino foi predominante, contabilizando 70% dos casos. A circunstância da intoxicação mais notificada foi a tentativa de suicídio (59%) e a classificação final predominante foi a intoxicação confirmada (68%). Considerando a evolução dos casos notificados a maioria deles evoluiu para a cura sem sequela (83%). A investigação possibilitou conhecer o perfil epidemiológico dos casos notificados de intoxicações por medicamentos no Brasil. A partir desses achados, conclui-se que há necessidade de implementar políticas para minimizar os riscos à saúde humana devido ao uso de medicamentos. Além disso, também, é importante incorporar o padrão como instrumento básico de trabalho para gerar dados precisos e atualizados nas bases de dados nacional. Tais fatores demonstram a importância da implantação de um Centro de Informação e Assistência Toxicológica (CIAT) em todo Brasil, bem como de Núcleos de Epidemiologia Hospitalar (NEH) para melhor acompanhamento do perfil das intoxicações por medicamentos.

A green and low-cost method employing switchable hydrophilicity solvent for the simultaneous determination of antidepressants in human urine by gas chromatography - mass spectrometry detection

In this study, the use of switchable hydrophilicity solvent with a simple and low-cost lab-made device for the extraction procedure in homogeneous liquid-liquid microextraction is proposed for the first time in the determination of antidepressants in human urine. The antidepressants studied consisted of fluoxetine, amitriptyline, nortriptyline, imipramine, desipramine and sertraline. The optimization of the main parameters that can influence on the extraction efficiency was performed through multivariate approaches. The analytes were separated and identified by gas chromatography coupled to mass spectrometry (GC-MS). The optimal extraction conditions consisted of using N,N-dimethylcyclohexylamine (DMCHA) as the switchable hydrophilicity solvent (SHS), 500 µL of urine sample previously diluted with ultrapure water at 1:1 ratio (v/v), 200 μL of a mixture of SHS:HCl 6 mol L−1 (1:1 v/v), 600 μL of NaOH 10 mol L−1 and 3 min of extraction time. A volume of 40 µL of diphenylamine at concentration of 500 µg L−1 (20 ng) was used as internal standard. The method developed was in-house validated, providing coefficients of determination higher than 0.995 for all analytes, limits of detection (LOD) from 0.02 to 0.88 µg L−1, limits of quantification (LOQ) from 0.05 to 2.92 µg L−1, relative recoveries of 68 to 102%, intra-day precision from 0.5 to 15.9%, inter-day precision from 4.2 to 19.3%, selectivity and robustness. The method proposed was successfully applied in five human urine samples from a Toxicological Information Center located in Porto Alegre (Brazil). The results demonstrated that the µP-SHS-HLLME approach is highly cost-effective, rapid, simple and environmentally-friendly with satisfactory analytical performance.

Acute exposures to e-cigarettes and heat-not-burn products reported to the Czech Toxicological Information Centre over a 7-year period (2012-2018).

E-cigarettes and heat-not-burn cigarettes (HNBC) present new health risks due to their rising popularity, high content of nicotine and serious adverse effects. The objective of the study was to analyse the cases of acute exposure to e-cigarettes, e-liquids and HNBC products containing nicotine that led to toxicological consultations at our poisons control centre during a 7-year period (2012-2018) and identify the categories of special concern that require further investigation and intervention. The demographic, toxicological and clinical data were analysed by descriptive statistics. Poisoning severity score (PSS) was estimated. From 119229 consultations, 148 cases concerned acute exposure to e-cigarettes. Children and adolescents were exposed in 91 (61%) cases, including exposure of neonates and infants in 54 (36%) cases. The main route of exposure was ingestion in 129 (87%), inhalation in nine (6%), ocular in six (4%) and intravenous administration in three (2%) cases. The source of exposure was the cartridge with e-liquid (107; 72%), refillable tank in 29 (20%) and HNBC refill in nine (6%) cases. The reason for exposure was accidental in 110 (74%), incorrect application of the device in 10 (7%), abuse in six (4%), suicide attempt in six (4%) and other/unknown in 16 (11%) cases. The dose estimation was severe/lethal in 6 (4%), toxic in 53 (36%), low-to-moderate in 35 (24%) and unknown in 54 (36%) cases. Vomiting was observed in 38 (26%) patients; 72% of patients were hospitalised. In symptomatic cases, 41 patient had PSS 1, 12 patients had PSS 2, and one patient had PSS 3. Activated charcoal was applied in 57 (39%) patients, and symptomatic treatment was recommended in 75 (51%) patients. Cases of unintentional exposure of children demonstrate the need for preventive risk reduction measures.

Child and adolescent violence: oral story of women who attempted suicide.

To unveil expressions of intrafamily violence experienced in childhood and/or adolescence by women who attempted suicide. This is a study with a qualitative approach based on Oral Story. Participants were ten women with a history of suicide attempt, who experienced intrafamily violence in childhood and/or adolescence. The research was carried out at the Center for the Study and Prevention of Suicide, linked to a Toxicological Information Center in the city of Salvador, Bahia, Brazil. From the orality of women, the study allowed the emergence of the following representative categories of intrafamily abuse experienced in childhood and/or adolescence: psychological violence, rejection, neglect, physical violence and sexual violence. The study alerts to intrafamily violence as an aggravation related to suicidal behavior, offering elements that help in the identification of their expressions, which will raise awareness to suicidal behavior and consequently suicide prevention.

Sinais de risco para o suicídio em mulheres com história de violência doméstica

Objetivo: Identificar sinais de risco para o suicídio em mulheres com história de violência doméstica. Método: Estudo exploratório-descritivo, com abordagem qualitativa. Participaram dez mulheres com história de violência doméstica e tentativa de suicídio por envenenamento. A pesquisa foi realizada no Núcleo de Estudo e Prevenção do Suicídio, vinculado a um Centro de Informação Toxicológica, em Salvador, Bahia, Brasil. Resultados: Sinaliza para a relação entre a vivência de violência doméstica e o comprometimento para a saúde mental, representado por: Comportamento depressivo e Comportamento suicida. Conclusão: O estudo revelou comportamentos que consistem em sinais de alerta para o risco de suicídio, ao tempo em que oferece subsídios para a promoção de estratégias de cuidado às mulheres com história de violência doméstica.

Epidemiological and clinical aspects of ophidian bothropic accidents in dogs

ABSTRACT: Snakebites are included in the group of emergencies for domestic animals, and these consultations demand technical knowledge as well as careful clinical evaluation of patients. Because of the importance of this theme and the higher prevalence of snakebites caused by snakes of the genus Bothrops in Rio Grande do Sul state, Brazil, this study aimed to address the epidemiological and clinical aspects of these accidents in dogs in the state, in addition to establishing their incidence. Clinical records of dogs, with a diagnosis of ophidian bothropic accident, assisted at the Toxicological Information Center of Rio Grande do Sul (CIT-RS) were revised from 2014 to 2016. These data were collected at the Toxicological Information Center, Statistics and Evaluation Center, State Secretary of Health. Data on the incidence of accidents and epidemiological and clinical information were obtained for each case. A total of 53 records were revised. In the records that included animal sex (n=49), 53% were female and 46.9% were male. As for animal age (n=47), the dogs ranged from one to 14 years, and most of them (46.9%) were in the 1-4-year age group. Over half of the cases occurred in the rural area (60.7%), and the head and neck were the main venom inoculation sites (76.3%). Diseases were characterized by clinical courses varying from hyperacute (&lt;30 min to 6h), acute (6-24h), to subacute (4-5 days). Severe accidents accounted for 40% of the cases, with edema as the most frequent clinical sign (88.7%) followed by hemorrhagic manifestations (41.5%). Associations of epidemiological and clinical aspects coupled with history of exposure are important characteristics to assist with suspicion and definitive diagnosis of bothropic accidents in dogs.

Profile of cases suspected of attempted suicide by exogenous intoxication

Objective: To characterize the profile of patients suspected of attempting suicide, based on cases reported by the Toxicological Information Center of the University hospital of Southern Brazil.Methods: This is a retrospective aggregate study, based on the analysis of medical records and files between January 2009 and December 2012, aiming to collect information that would create the profile of patients suspected of attempting suicide, from the cases notified by the Toxicological Information Center.Results: Regarding the physical consequences and the danger of the suicide attempt, 97% of the suicide attempts did not present life threatening (n = 1,605); 85.4% were not referred to any professional service (n = 1,412). The year 2012 was the year with the highest number of suicide attempts that the other years.Conclusions: It is considered important to improve the notification form for poisoning injuries, to better detect information about suicide attempts.

DERMATITIS CAUSED BY CENTIPEDE ENVENOMATION: A CASE REPORT

Accidents caused by centipedes in Brazil result in mild envenomation, where pain, erythema and edema are predominant. Cases rarely evolve to complication stages. This report presents a clinical case of dermatitis produced by an unidentified centipede, registered at the Toxicological Information Center of Belem-Para, which evolved to blisters and necrosis. The patient underwent treatment with antibiotics and oral anti-inflammatory drugs, topical bactericides and surgical cleaning; resulting in cicatrization of the wound. The purpose of this report is to inform health professionals of the possibility of complications, which should be considered and dealt with conventionally.

Validación de la escala Service Performance en un Centro Toxicológico de Chile

Objective: To assess construct validity and SERVPERF scale reliability in users requiring information by phone at the Toxicology Information Center of the Pontifical Catholic University of Chile (CITUC, Spanish acronym).Methodology: Instrument validation study for telephone service. The sample was made up of 180 users who required telephone information in a three-month period. Internal consistency of the instrument was determined using Cronbach´s alpha (?). Construct validity was assessed by exploratory factor analysis. Results: Factor analysis yield a 6-factor structure and showed that some items tend to blend among dimensions. When determining reliability for the dimensions we obtained: reliability, ?= 0.678; responsibility, ?=0.852; assurance, ?=0.878 and empathy, ?=0.887. Service provided by CITUC professionals was given the maximum score when assessed by users. Conclusions: SERVPERF scale gets adequate reliability levels; thus, the instrument has consistency and stability. Further analysis of construct validity would be interesting since empirical evidence is not consistent with theoretical evidence.

Caustic Ingestion in the Elderly: Influence of Age on Clinical Outcome.

Caustic poisonings are still associated with many fatalities. Studies focusing on the elderly are rare. The purpose of the present study was to compare the clinical outcomes of caustic ingestion injury in elderly and non-elderly adults with regard to gender, intent of exposure, substance ingested, severity of mucosal injury, complications, and mortality. Caustic substance exposures reported to the National Toxicological Information Centre in Slovakia during 1998–2015 were reviewed retrospectively. The patients were divided into two groups: the non-elderly (<60 years) and elderly adults (≥60 years). The mortality rate in the elderly was significantly higher (elderly 23.0% vs. non-elderly 11.3%; p = 0.041). The risk of fatal outcome in the elderly was increased by acid ingestion (OR = 7.822; p = 0.002), particularly hydrochloric acid (OR = 5.714, p = 0.006). The incidence of respiratory complications was almost two times higher in the elderly was 31.1% vs. 17.4% for the non-elderly (p = 0.037). Respiratory complications significantly correlated with an increased mortality rate (p = 0.001) in the elderly whereas there was no association between GI complications and mortality in the elderly (p = 0.480). Elderly patients with respiratory complications had the poorest clinical outcomes. The highest risk of complications and fatalities was observed in patients after hydrochloric acid ingestion.

Caustic effects of chemicals: risk factors for complications and mortality in acute poisoning

The aim of the study was to investigate the incidence of respiratory and gastrointestinal complications in relation to the type of caustic substance and to identify the risk factors for mortality in patients with acute caustic ingestion. We retrospectively reviewed all caustic substance exposures reported to the National Toxicological Information Centre in Slovakia during the 18-year period (1998–2015). Only patients who underwent an endoscopic evaluation within 24 h with positive findings were included in the study (n = 271). The median age was 37 years (1–87). Accidental exposures prevailed over suicidal intent (202/64). The median length of hospital stay was 6 days (1–45). Acid ingestion was associated with increased risk of respiratory (OR 6.5, p < 0.001) as well as gastrointestinal complications (OR 4.8, p < 0.001). The overall mortality was 8.2%. Twenty six of the patients died after ingestion of strong acids (n = 22), paraquat (n = 3), and glyphosate (n = 1). Grade IIIb of caustic injury (OR = 28.2, p < 0.001), ingestion of hydrochloric acid (OR = 7.3, p = 0.003), and suicidal intent (OR = 11.7, p < 0.001) were independent risk factors for fatal outcome after caustic ingestions. Mortality risk was significantly increased in patients ≥55 years (OR = 4.5, p < 0.001). The results of current analysis of the caustic exposures in Slovakia indicate that ingestion of strong acid, particularly hydrochloric acid, suicidal intent, grade IIIb of caustic injury, and age over 55 years are the most important risk factors for fatal outcome as well as predictors for systemic complications.

Suicide attempts by exposure to toxic agents registered in a Toxicological Information and Assistance Center in Fortaleza, Ceará, Brazil, 2013.

to describe cases of suicide attempts by exposure to toxic agents registered by the Toxicological Information and Assistance Center in Fortaleza, Ceará, Brazil. this is a descriptive study using secondary data of the cases registered in 2013. 410 cases were registered; 56.2% of the individuals were female and 79.7% were between 12 and 39 years old; most of them (86.4%) lived in urban areas and 67.2%, in Fortaleza; in 94.9% of the cases, the exposure took place in the individual's own home; the toxic agents most commonly used were pesticides (42.9%), especially for agricultural use (30.2%), medicines (39.5%) and house cleaning products (3.4%); of 16 suicide attempts that resulted in death, 15 were caused by agricultural pesticides. the study shows that the intake of toxic agents, especially of agricultural pesticides, is a common method used in suicide attempts; the integration between actions of promotion and prevention are essential.