What is the treatment for rodenticide (rat poison) poisoning?

Treatment of Rodenticide Poisoning

Immediate Management

For rodenticide poisoning, prioritize immediate supportive care and airway management over toxin identification, contact poison control immediately, and do not delay treatment while awaiting specific rodenticide confirmation. 1

Initial Stabilization

• Secure airway, provide hemodynamic support, and correct critical vital signs before attempting to confirm the specific rodenticide type 1
• Contact poison control center immediately for expert guidance, particularly in late-presenting cases with established coagulopathy and bleeding 1
• Remove all contaminated clothing to prevent continued exposure 2

Critical Early Actions

• Do NOT delay supportive care while awaiting rodenticide identification—treatment must begin immediately based on clinical presentation 1
• Do NOT use activated charcoal, ipecac, or gastric lavage in late presentations, as these are ineffective once absorption has occurred and may delay definitive care 1, 3
• Transportation to an emergency department should not be delayed for administration of activated charcoal 3

Anticoagulant Rodenticide Poisoning (Most Common Type)

Triage and Referral Decisions

Immediate ED referral is required for:

• Any suspected self-harm, abuse, misuse, or malicious administration regardless of dose 3
• Any symptoms of bleeding or bruising regardless of dose 3
• Chronic ingestion of any amount 3
• Unintentional ingestion of ≥1 mg active ingredient 3

Safe home observation without laboratory monitoring:

• Unintentional ingestion of <1 mg active ingredient (includes practically all unintentional pediatric ingestions in children <6 years) 3

Vitamin K Therapy

For symptomatic bleeding or documented coagulopathy:

• Acute hemorrhagic symptoms often require intravenous vitamin K1 in excess of 50-100 mg 4
• Chronic maintenance typically requires 100 mg PO vitamin K1 daily 4
• Treatment courses average 168 days due to the extremely high affinity of long-acting anticoagulant rodenticides (LAARs) for vitamin K epoxide reductase 4
• Do NOT administer vitamin K prophylactically before coagulopathy is documented in asymptomatic patients without significant exposure 1, 3

Laboratory Monitoring

For patients requiring monitoring:

• Baseline prothrombin time (PT) should be measured, then repeated at 48-72 hours after ingestion 3
• Patients taking therapeutic anticoagulants who ingest any dose of LAAR should have baseline PT and repeat at 48-72 hours 3
• Outpatient facilities must obtain coagulation study results in <24 hours 3
• Most symptomatic patients present with coagulation assay values beyond measurable limits 4

Adjunctive Hemostatic Therapy

For life-threatening bleeding:

• Monitor for metabolic derangements requiring correction 1
• Recombinant factor VIIa and prothrombin complex concentrate have been reported as adjunctive therapy 4
• Phenobarbital has been used to expedite LAAR metabolism 4

Management of Specific Complications

Intracranial Hemorrhage

• EEG monitoring for non-convulsive seizures in patients with altered mental status 1
• Benzodiazepines for seizures or agitation 1
• Intracranial hemorrhage is the most common cause of death from LAAR poisoning 4

Bleeding Patterns

• Most frequent bleeding sites are mucocutaneous, with hematuria being the most common feature 4
• LAAR-induced paradoxical thrombosis and thrombotic complications accompanying hemostatic therapy have been observed 4

Rebound Coagulopathy

• LAARs are characterized by rebound coagulopathy and bleeding after initial treatment due to their extremely high affinity for vitamin K epoxide reductase compared to warfarin 4
• This necessitates high-dose, long-term vitamin K1 therapy 4

Special Populations

Pregnancy

• Pregnant patients with unintentional exposure to <1 mg LAAR active ingredient should be evaluated by their obstetrician or primary care provider as outpatient—immediate ED referral not required 3
• Brodifacoum ingestion in pregnancy can cause substantial maternal hemorrhage, but aggressive vitamin K therapy can control coagulopathy 5
• No fetal hemorrhage or teratogenic effects were observed in reported cases with appropriate treatment 5

Dermal Exposure

• Decontaminate by washing skin with mild soap and water 3

Complex Cases

Medical toxicology consultation is recommended for complex presentations 1

Common Pitfalls to Avoid

• Never delay supportive care for toxin identification 1
• Never give vitamin K before documenting coagulopathy in asymptomatic patients 1, 3
• Never use gastrointestinal decontamination (ipecac, gastric lavage) in these cases 3
• Never underestimate treatment duration—average 168 days of vitamin K1 therapy required 4
• Never assume single-dose vitamin K is sufficient—rebound coagulopathy is characteristic of LAARs 4