Pinky Poison

A child ingesting small pink rat poison tablets, austin hosting companies likely containing an anticoagulant like bromadiolone, requires immediate medical attention, including possible administration of vitamin K as an antidote.

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Pinky Poison Cont'

Thanks all for the comments ,

Thanks Sadaf for the extensive answer 😄

This is Brodifacoum a long active Anticoagulant ( Superwarfarin ), Vitamin K antagonist .

I will highlight the most important points

1. Patients with unintentional ingestions ( specially children) have a low likelihood of developing a coagulopathy and have rare morbidity or mortality.

2. Most patients (usually children) are entirely asymptomatic at presentation and have a normal coagulation profile , so no need for any initial lab investigation

3. A normal coagulation profile at 48 hours usually role out toxicity and we recommend bringing the child for a follow up coagulation profile at 48 hours. Although multiple retrospective studies suggest that children with unintentional acute exposures do not require any follow-up coagulation studies, but still the safest approach specially with unknown amount is to bring the child back after 48 hours for coagulation profile check.

Management

1.Administration of activated charcoal (AC) is recommended to prevent absorption in acute ingestion if no contraindication exists.

2. Gastric lavage is not recommenced unless massive intentional ingestion

3.NOT to give prophylactic vitamin K1 to asymptomatic patients with unintentional ingestions of long-acting warfarin like anticoagulants

for the following 3 reasons

(1) if the patient develops a coagulopathy, it will last for weeks, and the one or two doses of vitamin K1 given will not prevent complications;

(2) It takes few days for coagulation factors to decrease so an individual would not be expected to develop a life-threatening coagulopathy in 1 or 2 days;

(3) after vitamin K1 is administered, the onset of an INR abnormality will be delayed, which could impair the ability of the clinician to recognize a coagulation abnormality, possibly requiring the patient to undergo an unnecessarily prolonged observation period.

So for this child with unintentional ingestion

• AC should be given if presented within 2 hours and no contraindication

• No need for initial lab investigation

• No role for prophylactic vitamin K

• Child can be discharged with discharge instruction and repeat coagulation at 48 hours which if normal will r/o any toxicity.

* Brodifacoum is a 4-hydroxycoumarin anticoagulant that acts as a vitamin K antagonist. It was registered as a pesticide in 1979 in the United States although in 2008 it was made a restricted-use pesticide by EPA. This means it can only be used by certified pesticide applicators; however, the makers of D-Con which contains 0.005% brodifacoum by weight have challenged this and brodifacoum is currently available in D-Con and in various other pesticide products for the eradication of mice and rats. Brodifacoum currently remains available to the general public.

Commonly called “superwarfarins” they cause massive anticoagulation in patients that last from weeks to months. In contrast single ingestions can be benign, particularly in children when it would be extremely rare for them to ingest enough unintentionally as these agents contain a bittering agent.

Toxic Mechanism:

Vitamin K inhibition of clotting factors II, VII, IX and X. Due to higher affinity for vitamin K,2,3 epoxide reductase and higher hepatic accumulation they have increased potency and prolonged duration of action when compared to warfarin.

Toxicokinetics: 

• Completely absorbed following oral administration

• Highly lipid soluble

• High volume of distribution

• Hepatic metabolism and enterohepatic recirculation resulting in prolonged elimination phases (weeks to months)

Resuscitation:

• Rarely required

• Uncontrolled or life threatening haemorrhage:

  • Fresh frozen plasma (10 – 15 ml/kg)

  • Prothrombin complex concentrate (25 – 50 IU/kg)

  • Vitamin K 10 mg intravenous

Risk Assessment

• Single accidental ingestion does not cause significant anticoagulation

• Anticoagulation will result from >0.1 mg/kg of brodifacoum which equates to:

  • 2 g/kg of 0.005% bait

  • 3 x 50 g pellet packs in a 75kg adult

• Other concentrations:

  • A typical concentration is 0.005% = 5 mg/100g

  • Pellet packs of 50 grams contain 2.5 mg of brodifacoum

  • 0.25% concentrates = 250 mg/100g

• INR usually takes 12 hours to rise post ingestion and frequently delayed to 24 – 48 hours. Peak effect occurs at 72 – 96 hours.

• Anticoagulation is usually associated with repeated ingestions and high doses of vitamin K should be anticipated.

• Clinical features:

  • Usually asymptomatic

  • Severe coagulopathy may present as bruising, petechial or puerperal rashes, gingival bleeding, epistaxis, gastrointestinal bleeding or haematuria.

• Children: They need to ingest >30 grams of a 0.005% preparation as a single dose to cause significant anticoagulation. This has never been reported.

Supportive Care

• General supportive measures

Investigations

• Screening: 12 lead ECG, BSL, Paracetamol level

• Specific:

  • INR: This will not change in the first 6 – 12 hours. Check INR every 12 hours for the first 48 hours. Do not start vitamin K until there is evidence of anticoagulation. A normal INR at 48 hours excludes a toxic ingestion.

  • Superwarfarin: Levels are useful to confirm the diagnosis when there maybe diagnostic uncertainty or suspicion of non-accidental injury. Also useful in determining when it is safe to withdraw vitamin K therapy.

Decontamination:

• Activated charcoal is not indicated following accidental ingestions

• Following massive single acute deliberate self-poisoning administer 50 g of activated charcoal within 12 hours of ingestion.

Enhanced Elimination

• Not clinically useful.

Antidote

• Vitamin K is contraindicated prophylactically – this prolongs the need for medical supervision. Only give with proven anticoagulation.

• Vitamin K should be given with proven anticoagulation.

• Titrate vitamin K to an INR <4, often large doses are required for weeks to months.

Disposition

• Minor unintentional ingestions do not require investigation, observation or hospitalisation

• An INR is indicated if there is suspicion of repeated ingestion, abnormal bleeding or a large single ingestion. A normal INR 48 hours post ingestion (or last ingestion) excludes toxicity

• To establish vitamin K dosing patients will require admission to titrate the dose and supervision to observe compliance along with consultation with mental health.

reference

https://litfl.com/anticoagulant-rodenticides/

The poison contain Bromadiolone, which is superwarfarin, is a second-generation long-acting dicoumarin rodenticide.

we will go for gastric lavage

send labs for aptt,PT,INR

i will give Vit K

The

image is not that clear for me but I assume what he ingest is most likely rodenticide containing Warfarin.

I need more hx about the ingested amount. detailed hx of PMH and current symptoms after ingestion, specially if any episode of bleeding noticed or altered sensorium ( as CNS bleed may happened) . hx should focus also is child abuse part as what happened consider neglect.

then detailed and focus examination from head to toe looking for any bleeding , bruises, signs of abuse , neurological symptoms . Although witnessed ingestion happened 30 min ago he may had a previous unwitnessed ingestion of same substance.

lab investigation should be sent , including : CBC , UE , Coagulation , drug level of any other medication the child has access to ( ex aspirin/ paracetamol)

CT head if altered mental status / sleepy

if the child showed any evidence of active bleeding then FFP replacement is needed

if asymptomatic , then wait for coagulation results , If PT prolonged then Vit K replacement to be given.

if labs normal , keep him for observation, consider repeating coagulation profile ( I am not sure how long it take to affect the PT and INR )