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A patient with rodenticide overdose

A patient with rodenticide overdose. Dr WL Yip, AED, QMH. Case report. F/44, housewife Found lying on the floor with decrease in responsiveness Found an empty pack of ‘stilnox’ and an empty can of beer lying around Argued with her husband one day ago Brought to AED ~0730. Examination.

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A patient with rodenticide overdose

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  1. A patient with rodenticide overdose Dr WL Yip, AED, QMH

  2. Case report • F/44, housewife • Found lying on the floor with decrease in responsiveness • Found an empty pack of ‘stilnox’ and an empty can of beer lying around • Argued with her husband one day ago • Brought to AED ~0730

  3. Examination • BP 120/60 P 100 • Temp 35.70C • SaO2 98 with RR 22 • Drowsy, with GCS E4 V5 M5 • H’stix 4.7 • ECG NSR 85/min

  4. Further management • Bld / Urine samples taken, with result pending • Admit medical due to full ‘O’ ward • Patient woke up after 2 hours • Admitted taken 20 tabs of stilnox and 1 can of beer, and denied other drugs taken • Pending seeing psychiatrist

  5. Investigation… • At 1400, found INR 7.7, PT 86.8, PTT 57.1 • Repeated… INR 7.6 • Further questioning… taken 1 pack of rat poison bought over the counter few days ago • Contacted her husband… • found a pack of rat poison ~5 days ago in dust-bin at home

  6. Other investigation results • Hb 14.5 • Urine toxicology: BDZs, zolpidem metabolites • Otherwise unremarkable

  7. Management • Clinically stable • No bleeding clinically • Transfusion of 4 units of FFP • Daily vitamin K1 10mg • INR 1.4 the next day • Seen by psychiatrist – depression

  8. Psychiatric ward • Form 123, transferred to PYNEH psychiatric ward • Continued daily oral vitamin K (10mg QD) • INR finally back to 1.0 after 9 days • Vitamin K was continued for 1 more week afterwards

  9. INR FFP vit K1 (iv) vit K (po)

  10. Rodenticides • Warfarin / Superwarfarin • Arsenic • Cholecalciferol • Sodium monofluoroacetate • Strychine • Thallium

  11. Warfarin / Superwarfarin

  12. Warfarin / Superwarfarin • Commonest in Hong Kong • Anticoagulants • prevent vitamin K from reducing to its active form • inhibit hepatic synthesis of coagulation factors II, VII, IX, and X and the anticoagulant proteins C and S

  13. Vitamin K metabolism

  14. Coagulation pathway

  15. Initiation of coagulation

  16. Superwarfarin • Brodifacoum, bromadiolone • Warfarin-resistance rats • Clinical effects occur after depletion of the mentioned factors (~3-4 days) • Longer acting (weeks to months) • Longer half-life (156 vs. 17 hrs) • 100-folds more potent

  17. Clinical features • Rarely symptomatic, unless delayed presentation • Signs of bleeding • Reported complications: Spontaneous intra-abdominal hemorrhage, hematuria, hematemesis, spontaneous hemoperitoneum, intracerebral hemorrhage, death

  18. Investigation • Clotting profile, repeated in 24-48 hours • Drug level if available • Pregnancy test for females of childbearing age

  19. Management • GI decontamination • Activated charcoal • Specific treatment • Vitamin K • FFP

  20. Vitamin K • 15-120mg/d in divided doses • T1/2 = 6 hours • Antagonizes effects of warfarin • Indicated in INR>2 • ‘reverse’ anticoagulation, but not ‘prevent’ its effect • Anaphylactoid reaction if given iv • Caution if already anticoagulated for other reasons

  21. Superwarfarin poisoning • Required higher daily dose and longer duration (in months) of vitamin K

  22. FFP • Indicated if evidence of bleeding despite use of vitamin K

  23. 比山埃毒百倍 警檢鼠藥器皿毒鼠強奪命案枉死增至243人 16/09/2002【中國組報道】南京驚天毒殺案後第二日，部分留醫者家屬昨夜收到醫院發出病危通知，死亡人數可能進一步攀升。而摻在受害者早餐中的毒藥，證實是毒性比山埃還要強烈一百倍的老鼠藥「毒鼠強」；警方在案發地點和盛園的水井旁發現殘留毒鼠強的器皿，一名案發後失蹤的和盛園員工成重大疑犯。有消息稱，毒殺案死者人數高達二百四十三名，而非官方公布的四十一人…

  24. Tetramethylene Disulfotetramine • C4H8N4O4S2 • GABA-antagonist, with CNS excitation • Onset of symptoms several to 30 min (max. 13 hours) • 6-12 mg is sufficient to cause death • Proven to be toxic thru oral, inhalation and dermal routes • Rapid absorption with slow elimination

  25. Mild toxicity • Headache • Dizziness • Fatigue • Anorexia • Nausea and vomiting • Numbness of lips • Listlessness

  26. Severe toxicity • Loss of consciousness • Seizures • Foaming at the mouth • Urinary incontinence • Coma • Death from respiratory failure

  27. Management • Confirm its presence in vomitus, blood or urine • Symptomatic / supportive treatment • Gastric lavage and activated charcoal • Charcoal hemoperfusion • Hemodialysis

  28. ?Antidote • No specific antidote • Vitamin B6 and DMPS (2,3-dimercapto-1-sulphonate) • Inhibit convulsion and reduce mortality in animal studies • No data a/v in human cases

  29. Thank you

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