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Rodenticide Toxicity Treatment & Management

  • Author: Derrick Lung, MD, MPH; Chief Editor: Asim Tarabar, MD  more...
 
Updated: Dec 29, 2015
 

Approach Considerations

For small, unintentional ingestions of an anticoagulant rodenticide, repeat PT measurements 24 and 48 hours post ingestion to ensure that no effects on the coagulation pathway are present. This may be done on an outpatient basis if no other reason for inpatient hospitalization exists.

Intentional exposure to an anticoagulant rodenticide for suicidal or other reasons may require substantial treatment with vitamin K for a protracted period of time, particularly in the face of exposure to one of the superwarfarins (see Warfarin and Superwarfarin Toxicity). It may be wise to monitor brodifacoum levels to determine a treatment endpoint.[11] The source of exposure to a superwarfarin should be disclosed to avoid recidivism.

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Prehospital Care

Points to remember in prehospital patient care for rodenticide poisoning include the following:

  • 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 are contaminated with the pesticide
  • Administer benzodiazepines in patients with seizurelike activity
  • Secure airway and place intravenous (IV) lines in hemodynamically unstable patients

Evidence-based guidelines on the management of long-acting anticoagulant rodenticide poisoning are available from the AAPCC.[12]

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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.

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.

Severe hemolysis from phosphine gas (released from zinc phosphide) may require exchange transfusion of RBCs.

Other medical therapy depends on identification of specific substances involved. Examples are as follows:

  • If a heavy metal is suspected, institute chelation therapy (see Arsenic Toxicity in Emergency Medicine and Thallium Toxicity)
  • If an organophosphate is suspected, administer atropine for initial management and consider oxime use
  • Monosodium fluoroacetate and zinc phosphide have no specific antidotal therapy that has been of any consistent advantage; only supportive care is available
  • PNU induces an alloxan-like destruction of pancreatic beta cells, which may be prevented with nicotinamide

If no coagulopathy or active bleeding is found in the setting of an anticoagulant exposure, prophylactic treatment with vitamin K is absolutely contraindicated. This would potentially mask the onset and severity of an ingestion and would obfuscate the time required for clinical and/or laboratory monitoring.

If a coagulopathy is documented, but without active hemorrhage, institution of vitamin K therapy is suggested (see Warfarin and Superwarfarin Toxicity). Since all of the vitamin K–dependent clotting factors may be affected, the hemolytic factors C and S may be affected early and may cause the presentation to be one of acute thrombosis rather than anticoagulation.[13, 14]

In addition to vitamin K, prothrombin complex concentrates and/or fresh-frozen plasma may be needed to rapidly reverse anticoagulation from warfarin and superwarfarins when patients present with life-threatening hemorrhage (see Warfarin and Superwarfarin Toxicity for an extended discussion regarding treatment).

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Contributor Information and Disclosures
Author

Derrick Lung, MD, MPH Assistant Clinical Professor, Department of Emergency Medicine, San Francisco General Hospital; Assistant Medical Director, California Poison Control System, San Francisco Division

Derrick Lung, MD, MPH is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Steven Marcus, MD Professor, Department of Preventive Medicine and Community Health, Associate Professor, Department of Pediatrics, Rutgers New Jersey Medical School, Rutgers University School of Biomedical and Health Sciences; Executive and Medical Director, New Jersey Poison Information and Education System; Consulting Staff, Departments of Pediatrics and Internal Medicine, University Hospital; 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, Medical Society of New Jersey

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.

Acknowledgements

Fred Harchelroad, MD, FACMT, FAAEM, FACEP Director of Medical Toxicology, Allegheny General Hospital

Disclosure: Nothing to disclose.

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.

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.

References
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  2. Decker WJ, Baker HE, Tamulinas SH, Korndorffer WE. Two deaths resulting from apparent parenteral injection of strychnine. Vet Hum Toxicol. 1982 Jun. 24(3):161-2. [Medline].

  3. O'Callaghan WG, Joyce N, Counihan HE, Ward M, Lavelle P, O'Brien E. Unusual strychnine poisoning and its treatment: report of eight cases. Br Med J (Clin Res Ed). 1982 Aug 14. 285(6340):478. [Medline]. [Full Text].

  4. Rhyee SH, Heard K. Acute barium toxicity from ingestion of "snake" fireworks. J Med Toxicol. 2009 Dec. 5(4):209-13. [Medline]. [Full Text].

  5. Zolotarevski L, Jovic M, Popov Aleksandrov A, Milosavljevic P, Brajuskovic G, Demenesku J, et al. Skin response to epicutaneous application of anticoagulant rodenticide warfarin is characterized by differential time- and dose-dependent changes in cell activity. Cutan Ocul Toxicol. 2015 Feb 24. 1-8. [Medline].

  6. Spahr JE, Maul JS, Rodgers GM. Superwarfarin poisoning: a report of two cases and review of the literature. Am J Hematol. 2007 Jul. 82(7):656-60. [Medline].

  7. La Rosa FG, Clarke SH, Lefkowitz JB. Brodifacoum intoxication with marijuana smoking. Arch Pathol Lab Med. 1997 Jan. 121(1):67-9. [Medline].

  8. Bochner R. [National Poisoning Information System - SINITOX and human intoxication by pesticides in Brazil]. Cien Saude Colet. 2007 Jan-Mar. 12 (1):73-89. [Medline]. [Full Text].

  9. Dashti-Khavidaki S, Ghaffari S, Nassiri-Toossi M, Amini M, Edalatifard M. Possible unaware intoxication by anticoagulant rodenticide. J Res Pharm Pract. 2014 Oct. 3 (4):142-4. [Medline].

  10. Nelson LS, Perrone J, DeRoos F, Stork C, Hoffman RS. Aldicarb poisoning by an illicit rodenticide imported into the United States: Tres Pasitos. J Toxicol Clin Toxicol. 2001. 39(5):447-52. [Medline].

  11. Bruno GR, Howland MA, McMeeking A, Hoffman RS. Long-acting anticoagulant overdose: brodifacoum kinetics and optimal vitamin K dosing. Ann Emerg Med. 2000 Sep. 36(3):262-7. [Medline].

  12. Caravati EM, Erdman AR, Scharman EJ, 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].

  13. Papin F, Clarot F, Vicomte C, et al. Lethal paradoxical cerebral vein thrombosis due to suspicious anticoagulant rodenticide intoxication with chlorophacinone. Forensic Sci Int. 2007 Mar 2. 166(2-3):85-90. [Medline].

  14. Laposata M, Van Cott EM, Lev MH. Case records of the Massachusetts General Hospital. Case 1-2007. A 40-year-old woman with epistaxis, hematemesis, and altered mental status. N Engl J Med. 2007 Jan 11. 356(2):174-82. [Medline].

 
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