Coumarin Plant Poisoning Treatment & Management

  • Author: Arasi Thangavelu, MD; Chief Editor: Asim Tarabar, MD   more...
 
Updated: Apr 30, 2012
 

Prehospital Care

  • Begin supportive care.
  • Establish intravenous lines if the patient has evidence of bleeding.
  • Infuse crystalloid if any signs of shock are present.
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Emergency Department Care

Implement supportive measures for severe or continuous bleeding.

The evaluation of patient with hydroxycoumarin ingestion varies, depending on clinical situation.

Single, small, acute ingestions of warfarin in children are unlikely to result in significant toxicity. Treatment may include only PTs at 24 and 48 hours. Utility of baseline coagulation studies soon after ingestion is probably small. Likewise, single small ingestions of rodenticide anticoagulants are unlikely to result in toxicity.

Patients requiring chronic anticoagulation may be merely observed if their coagulation studies are only moderately elevated and no evidence exists of bleeding or risk of significant trauma that may precipitate bleeding (eg, frequent falls in the nursing home).

Massive ingestions, particularly if intentional and repeated, require more aggressive interventions on initial visit.

  • GI decontamination
    • Consider activated charcoal in all large acute ingestions.
    • Consider gastric lavage in massive acute ingestion presenting within 1 hour of ingestion. Carefully consider risks of bleeding from this procedure.
  • Bleeding
    • Reverse life-threatening hemorrhage with fresh-frozen plasma (FFP) followed by vitamin K-1.
    • Use packed red blood cells for life-threatening hemorrhage.
  • Enhanced elimination
    • Warfarin undergoes enterohepatic recirculation. Multiple dose activated charcoal or cholestyramine may accelerate elimination.
    • Oral phenobarbital (30-60 mg/d) or rifampin (60 mg q12h) enhance hepatic P-450 metabolism of warfarin, decreasing its half-life. Consider only in cases of chronic brodifacoum ingestion refractory to vitamin K replacement.
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Consultations

  • Regional poison center can assist in management of hydroxycoumarin ingestion.
  • A toxicologist, if available, may be of assistance with significant ingestions.
  • Discuss cases of iatrogenic overanticoagulation with patient's primary care provider.
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Contributor Information and Disclosures
Author

Arasi Thangavelu, MD  Consulting Staff, Department of Emergency Medicine, Phoebe Putney Memorial Hospital

Arasi Thangavelu, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Coauthor(s)

Lisandro Irizarry, MD, MPH, FAAEM  Chair, Department of Emergency Medicine, Brooklyn Hospital Center; Assistant Professor, Department of Emergency Medicine, Weill Cornell School of Medicine

Lisandro Irizarry, MD, MPH, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

B Zane Horowitz, MD, FACMT  Professor, Department of Emergency Medicine, Oregon Health and Sciences University; Medical Director, Oregon Poison Center; Medical Director, Alaska Poison Control System

B Zane Horowitz, MD, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology and American College of Medical Toxicology

Disclosure: Nothing to disclose.

John T VanDeVoort, PharmD  Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Michael Hodgman, MD  Assistant Clinical Professor of Medicine, Department of Emergency Medicine, Bassett Healthcare

Michael Hodgman, MD is a member of the following medical societies: American College of Medical Toxicology, American College of Physicians, Medical Society of the State of New York, and Wilderness Medical Society

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Asim Tarabar, MD  Assistant Professor, Director, Medical Toxicology, Department of Emergency Medicine, Yale University School of Medicine; Consulting Staff, Department of Emergency Medicine, Yale-New Haven Hospital

Disclosure: Nothing to disclose.

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