ICU Management of Rodenticide Poisoning in India
The management of rodenticide poisoning in an ICU setting requires immediate supportive care, identification of the specific rodenticide, and targeted interventions based on the type of poison involved.
Initial Assessment and Stabilization
- Provide immediate supportive care including airway management, hemodynamic support, and correction of critical vital sign and metabolic derangements as the first priority 1
- Identify the specific rodenticide type if possible (common types in India include yellow phosphorus, zinc phosphide, and long-acting anticoagulant rodenticides) 2
- Contact poison control center for expert treatment guidance if available 1
Management Based on Rodenticide Type
Yellow Phosphorus (Most Common in India)
- Gastric decontamination should be performed within 2 hours of exposure for significantly improved survival rates (97.87% vs 84.62%) 2
- Monitor for delayed onset of symptoms (typically 24-36 hours after ingestion) including abdominal pain, jaundice, and coagulopathy 2
- Serial liver function tests are essential as fulminant hepatic failure is the most common cause of death (77.78% of mortality cases) 2
- Watch for predictors of poor outcomes: jaundice, hepatic encephalopathy, AST/ALT >1000 IU/L, metabolic acidosis, and refractory shock 2
Long-Acting Anticoagulant Rodenticides (LAARs)
- Administer vitamin K1 as the specific antidote along with fresh frozen plasma and cryoprecipitate for coagulopathy 3
- Initial high-dose vitamin K1 therapy followed by maintenance dosing (10-120 mg/day, intravenous) with gradual tapering 4
- Monitor coagulation parameters (PT/INR) regularly, but note that normalization of INR alone is not sufficient to discontinue vitamin K1 treatment 5
- Extended treatment with vitamin K1 may be necessary as serum LAAR concentrations can remain above safe levels (10 ng/mL) despite normalized INR 5
Management of Specific Complications
Neurological Complications
- For seizures or agitation, administer benzodiazepines as recommended by the American Heart Association 6
- Monitor for signs of increased intracranial pressure in patients with coagulopathy 1
- Consider EEG monitoring in patients with altered mental status to detect non-convulsive seizures 1
Cardiovascular Complications
- For hypotension, administer vasopressors as needed 6
- Monitor cardiac function and treat dysrhythmias according to standard protocols 1
Hepatic Complications
- Monitor liver function tests closely, especially with yellow phosphorus poisoning 2
- Consider N-acetylcysteine in cases of hepatotoxicity, though evidence is limited 2
Renal Complications
- Monitor renal function as acute kidney injury occurs in approximately 7% of rodenticide poisoning cases 2
- Consider renal replacement therapy in cases of severe renal impairment 2
Special Considerations
- Do not administer activated charcoal unless advised by poison control center or emergency medical personnel 1
- Do not induce emesis with syrup of ipecac as it has no clinical advantage and may delay advanced medical care 1, 7
- For patients with chronic ingestion or intentional self-harm, psychiatric evaluation is recommended 7
Follow-up Care
- Continue monitoring coagulation parameters for at least 48-72 hours after exposure to LAARs 7
- For yellow phosphorus poisoning, monitor liver function for at least 4-5 days (mean time to death is 4.22 days) 2
- Consider consultation with a medical toxicologist for complex cases 6
Pitfalls to Avoid
- Do not rely solely on normalized INR to discontinue vitamin K1 treatment in LAAR poisoning 5
- Do not delay supportive care while waiting for identification of the specific rodenticide 1
- Be aware that symptoms of yellow phosphorus poisoning may be absent in the first 24 hours, creating a false sense of security 2