What is the management of rodenticide (rat poison) poisoning in India?

Management of Rodenticide Poisoning in India

The management of rodenticide poisoning in India should focus on rapid identification of the specific rodenticide type, immediate supportive care, and administration of appropriate antidotes based on the toxin involved, as early intervention significantly reduces mortality.

Types of Rodenticides Commonly Encountered in India

• Yellow phosphorus is the most common rodenticide poison in Southern India, accounting for approximately 67.2% of rodenticide poisonings, with yellow phosphorus + zinc phosphide combinations accounting for another 24% 1
• Long-acting anticoagulant rodenticides (LAARs) are another significant category causing coagulopathy and potential bleeding complications 2, 3
• Organophosphorus compounds, while primarily used as insecticides, represent a major portion (36%) of all poisoning cases in some regions of India 4

Initial Management

Immediate Actions (First 1-2 Hours)

• Remove all contaminated clothing and avoid self-contamination when handling the patient 5
• Establish and secure airway, breathing, and circulation according to standard protocols 6, 5
• Early endotracheal intubation is recommended for patients with respiratory distress or decreased level of consciousness 6, 5
• Gastric decontamination should be performed within 2 hours of exposure, as this significantly improves survival rates (97.87% vs 84.62%) 1
• Do not induce vomiting with ipecac syrup or perform gastric lavage without medical supervision 2
• For dermal exposures, decontaminate by washing skin with mild soap and water 2

Specific Management Based on Rodenticide Type

1. Anticoagulant Rodenticide Poisoning

• Obtain baseline prothrombin time (PT), activated partial thromboplastin time (aPTT), and INR 2, 3
• For confirmed or suspected anticoagulant rodenticide poisoning with abnormal coagulation parameters or active bleeding, administer Vitamin K1 as the primary antidote 2, 3, 7
• Initial dosing:
  • For active bleeding: 10-20 mg IV slow infusion, followed by maintenance therapy 7
  • For coagulopathy without bleeding: 5-10 mg IV or oral administration 7
• Maintenance therapy: 10-120 mg/day IV, gradually decreasing the dose over time 7
• For cerebral hemorrhage due to anticoagulant rodenticides, administer Vitamin K1 infusion along with dehydrating agents to reduce intracranial pressure 3
• Monitor coagulation parameters every 24-48 hours during treatment 2, 7
• Continue Vitamin K1 therapy until coagulation parameters normalize, which may require several weeks 7

2. Yellow Phosphorus Poisoning

• Yellow phosphorus poisoning often presents with a latent asymptomatic period (18-72 hours) followed by severe toxicity 1
• Monitor liver function tests (AST, ALT, bilirubin) every 12-24 hours for at least 72 hours 1
• Watch for development of jaundice, coagulopathy, encephalopathy, shock, and acute kidney injury 1
• There is no specific antidote for yellow phosphorus; management is primarily supportive 1
• Consider early transfer to a facility with liver transplantation capabilities if signs of fulminant hepatic failure develop 1
• Poor prognostic indicators include:
  • Jaundice
  • Hepatic encephalopathy
  • AST/ALT >1000 IU/L
  • Metabolic acidosis
  • Refractory shock 1

3. Organophosphorus Compound Poisoning

• For organophosphorus poisoning, follow standard management protocols for cholinergic crisis 6, 4
• Administer atropine for muscarinic symptoms and pralidoxime (2-PAM) for nicotinic symptoms 6
• Provide respiratory support as needed, as respiratory arrest occurs in approximately 23.2% of cases 4

Special Considerations

• Time to treatment is critical - mortality is significantly higher with delayed presentation 4, 1
• For pregnant patients with unintentional exposure to less than 1 mg of LAAR active ingredient, evaluation by an obstetrician or primary care provider is recommended 2
• Patients with suspected self-harm attempts should receive psychiatric evaluation once medically stable 2
• For patients with chronic ingestion of rodenticides, immediate referral to an emergency department is necessary to evaluate intent and potential coagulopathy 2

Monitoring and Follow-up

• For anticoagulant rodenticide poisoning, continue monitoring coagulation parameters for at least 1-2 weeks after discharge 2, 7
• For yellow phosphorus poisoning, liver function should be monitored for at least 1-2 weeks after discharge due to risk of delayed hepatotoxicity 1
• All patients should receive poison prevention education before discharge 2

Regional Considerations in India

• Contact regional poison control centers when available for guidance on management 6
• In rural settings with limited resources, early transfer to tertiary care centers should be prioritized, as early care in tertiary centers may help reduce mortality 4