Coumarin Plant Poisoning Treatment & Management

Updated: Mar 31, 2014
  • Author: Arasi Thangavelu, MD, FACEP, FAAEM; Chief Editor: Asim Tarabar, MD  more...
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Treatment

Prehospital Care

See the list below:

  • 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

See the list below:

  • 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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