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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 • • • • • • 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 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 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 Other investigation results • Hb 14.5 • Urine toxicology: BDZs, zolpidem metabolites • Otherwise unremarkable 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 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 INR Day 0 Day 1 Day 3 Day 6 Day 9 7.7 1.4 2.0 1.7 1.0 FFP vit K1 (iv) vit K (po) Rodenticides • • • • • • Warfarin / Superwarfarin Arsenic Cholecalciferol Sodium monofluoroacetate Strychine Thallium Warfarin / Superwarfarin 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 Vitamin K metabolism Coagulation pathway Initiation of coagulation 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 Clinical features • Rarely symptomatic, unless delayed presentation • Signs of bleeding • Reported complications: Spontaneous intraabdominal hemorrhage, hematuria, hematemesis, spontaneous hemoperitoneum, intracerebral hemorrhage, death Investigation • Clotting profile, repeated in 24-48 hours • Drug level if available • Pregnancy test for females of childbearing age Management • GI decontamination • Activated charcoal • Specific treatment – Vitamin K – FFP 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 Superwarfarin poisoning • Required higher daily dose and longer duration (in months) of vitamin K FFP • Indicated if evidence of bleeding despite use of vitamin K 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… 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 Mild toxicity • • • • • • • Headache Dizziness Fatigue Anorexia Nausea and vomiting Numbness of lips Listlessness Severe toxicity • • • • • • Loss of consciousness Seizures Foaming at the mouth Urinary incontinence Coma Death from respiratory failure Management • Confirm its presence in vomitus, blood or urine • Symptomatic / supportive treatment • Gastric lavage and activated charcoal • Charcoal hemoperfusion • Hemodialysis ?Antidote • No specific antidote • Vitamin B6 and DMPS (2,3-dimercapto-1sulphonate) • Inhibit convulsion and reduce mortality in animal studies • No data a/v in human cases Thank you