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Toxicity, Rodenticide: Treatment & Medication

Author: Steven Marcus, MD, Professor, Department of Preventive Medicine and Community Health, Associate Professor, Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey; Executive and Medical Director, New Jersey Poison Information and Education System; Consulting Staff, Departments of Pediatrics and Internal Medicine, University Hospital, University of Medicine and Dentistry of New Jersey; Consulting Staff, Department of Pediatrics, Newark Beth Israel Medical Center
Contributor Information and Disclosures

Updated: Oct 29, 2009

Treatment

Prehospital Care

  • As in most poisoning situations, it is best to "scoop and run;" very little can be done in the field.
  • Always look for a container so that the specific product can be determined.
  • Decontamination may be necessary for situations in which patients and their garments may be contaminated with the pesticide.
  • Administer benzodiazepines in patients with seizurelike activity.
  • Secure airway and place IV lines in hemodynamically unstable patients.
  • Evidence-based guidelines on the management of long-acting anticoagulant rodenticide poisoning are available from the AAPCC.7

Emergency Department Care

  • Patients who present or develop renal failure may require hemodialysis.
  • Patients with severe respiratory compromise from zinc phosphide, arsenic, or barium may require endotracheal intubation for ventilatory support.
  • Severe hemolysis from phosphine gas (released from zinc phosphide) may require exchange transfusion of RBCs.
  • GI evacuation is rarely useful; however, consider it for exceptional cases in which a huge overdose is suspected and in which the patient presents early to an emergency facility.
  • Give all patients with rodenticide overdose activated charcoal as soon as possible to prevent further absorption of ingested toxins. With anticoagulant overdoses, perform a careful physical examination to look for any sign of bleeding.
  • Other medical therapy depends on identification of specific substances involved.
    • If a heavy metal is suspected, institute chelation therapy (see Toxicity, Arsenic; Toxicity, Thallium).
    • If an organophosphate is suspected, administer atropine for initial management and consider oxime use (see Toxicity, Organic Phosphorous Compounds and Carbamates).
    • Monosodium fluoroacetate and zinc phosphide have no specific antidotal therapy that has been of any consistent advantage. Only supportive care is available.
    • Vacor (PNU) induces an alloxan like destruction of pancreatic beta cells, which may be prevented with nicotinamide.
    • If a coagulopathy is documented, institution of vitamin K therapy is suggested. If frank bleeding occurs, the administration of fresh frozen plasma and concentrated clotting factors may be warranted. Since all of the vitamin K – dependent clotting factors may be affected, the hemolytic factors C and S may be affected early and might cause the presentation to be one of acute thrombosis rather than anticoagulation.8,9

Consultations

Consult with the regional poison control center or a medical toxicologist (certified through the American Board of Medical Toxicology or the American Board of Emergency Medicine) for additional information and patient care recommendations.

  • Obtain a psychiatric evaluation if the ingestion was intentional.
  • Consult a hematologist or a medical toxicologist for long-term follow-up if a long-acting anticoagulant (eg, brodifacoum) was ingested.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

GI decontaminant

Empirically used to minimize systemic absorption of the toxin. May only be of benefit if administered within 1-2 h of ingestion.


Activated charcoal (Liqui-Char)

Emergency treatment in poisoning caused by drugs and chemicals. Network of pores present in activated charcoal adsorbs 100-1000 mg of drug per gram of charcoal. Does not dissolve in water.
May be administered with a cathartic (eg, 70% sorbitol), except in young pediatric patients in whom electrolyte disturbances may be of concern.
For maximum effect, administer within 30 min of ingesting poison.

Adult

1 g/kg (50-100 g) PO

Pediatric

1-2 g/kg (15-30 g) PO

May inactivate ipecac syrup if used concomitantly; effectiveness of other medications decreases with coadministration; do not mix with sherbet, milk, or ice cream (decreases adsorptive properties)

Documented hypersensitivity; poisoning or overdose of mineral acids and alkalies; unprotected airway with absent gag reflex

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor for presence of bowel sounds to minimize risk of charcoal ileus; not very effective in poisonings of ethanol, methanol, and iron salts; induce emesis before administration; after emesis with ipecac syrup, patient may not tolerate activated charcoal for 1-2 h; can administer in early stages of gastric lavage; without sorbitol, gastric lavage returns are black

Antidote

Treat anticoagulant rodenticide-induced hemorrhages with vitamin K.


Phytonadione (AquaMEPHYTON)

No need to begin therapy unless INR >2. No data exist to prove that such therapy prevents anticoagulation, although vitamin K therapy is shown to reverse anticoagulation once it develops. With long-acting anticoagulants, treatment may need to be at much higher doses and for a protracted period of time.

Adult

1-25 mg PO/SC q8h
With long-acting anticoagulants, doses exceeding 100 mg/d (50 to 250 mg/d) for weeks may be indicated
10 mg IV (Only for life-threatening bleeding due to elevated INR) at slow rate, not exceeding 1 mg/min to avoid anaphylactoid reaction

Pediatric

1-5 mg PO/IM q8h

Antagonizes effects of warfarin sodium and dicumarol; sucralfate may decrease PO absorption

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

If bleeding continues despite the administration of vitamin K, consider use of FFP and clotting factor concentrates; caution if considering IV administration because of possibility of allergic reactions; caution in anticoagulated patients for existing clotting concerns (eg, AFib, myocardial valvulopathy)

More on Toxicity, Rodenticide

Overview: Toxicity, Rodenticide
Differential Diagnoses & Workup: Toxicity, Rodenticide
Treatment & Medication: Toxicity, Rodenticide
Follow-up: Toxicity, Rodenticide
References
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References

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  7. [Guideline] Caravati EM, Erdman AR, Scharman EJ, Woolf AD, Chyka PA, Cobaugh DJ, et al. Long-acting anticoagulant rodenticide poisoning: an evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila). 2007;45(1):1-22. [Medline]. [Full Text].

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Further Reading

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Keywords

rodenticide ingestion, rat poison, rat poison ingestion, rodenticide toxicity, rodenticide poisoning, red squill, strychnine, thallium, arsenic, yellow phosphorus, warfarin-type anticoagulants, brodifacoum, Vacor, zinc phosphide, bromethalin, norbormide, cyanide

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Contributor Information and Disclosures

Author

Steven Marcus, MD, Professor, Department of Preventive Medicine and Community Health, Associate Professor, Department of Pediatrics, New Jersey Medical School, University of Medicine and Dentistry of New Jersey; Executive and Medical Director, New Jersey Poison Information and Education System; Consulting Staff, Departments of Pediatrics and Internal Medicine, University Hospital, University of Medicine and Dentistry of New Jersey; Consulting Staff, Department of Pediatrics, Newark Beth Israel Medical Center
Steven Marcus, MD is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Clinical Toxicology, American Academy of Pediatrics, American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Medical Society of New Jersey
Disclosure: Nothing to disclose.

Medical Editor

Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance
Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, Regional Director of Pharmacy, Sacred Heart & 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.

Managing Editor

Fred Harchelroad, MD, FACMT, FAAEM, FACEP, Chair, Department of Emergency Medicine, Director of Medical Toxicology - Allegheny General Hospital, Associate Professor, Department of Emergency Medicine, Drexel University College of Medicine
Disclosure: Nothing to disclose.

CME Editor

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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