What is the treatment approach for a patient presenting with rat killer paste poisoning?

Emergency Management of Rat Killer Paste Poisoning

Immediate Actions

Contact the Poison Control Center (1-800-222-1222) immediately while initiating treatment, and activate EMS if the patient exhibits any signs of life-threatening conditions including altered mental status, seizures, difficulty breathing, or active bleeding. 1, 2, 3

• Remove all contaminated clothing and jewelry to prevent continued exposure, taking care to avoid self-contamination 2
• Do NOT administer anything by mouth (including water, milk, or attempts at dilution) unless specifically directed by poison control, as this may cause emesis and aspiration without proven clinical benefit 1, 3
• Do NOT induce vomiting or administer ipecac syrup under any circumstances 1, 4

Type-Specific Management

For Anticoagulant Rodenticides (Most Common: Brodifacoum, Warfarin-derivatives)

Administer high-dose intravenous vitamin K1 (phytonadione) 50-100 mg for acute hemorrhagic symptoms, followed by chronic oral maintenance of 100 mg daily, as these long-acting anticoagulant rodenticides have 200-fold greater potency than warfarin and half-lives up to 60 times longer. 5, 6

• Obtain baseline coagulation studies (PT/INR) immediately, as most symptomatic patients present with values beyond measurable limits 5
• Monitor for bleeding manifestations: hematuria (most common), mucocutaneous bleeding, epistaxis, hematochezia, and life-threatening intracranial hemorrhage 5, 6
• Anticipate prolonged treatment courses averaging 168 days due to extremely high affinity for vitamin K epoxide reductase (VKOR) 5
• Watch for rebound coagulopathy after initial treatment cessation—this is characteristic of superwarfarin poisoning 5
• Consider adjunctive hemostatic therapy with fresh frozen plasma, prothrombin complex concentrate, or recombinant factor VIIa for severe active bleeding 5, 6

For Non-Anticoagulant Rodenticides (Zinc Phosphide, Aldicarb)

Do NOT perform gastric lavage or administer water/milk, as these interventions may cause emesis with aspiration of toxic phosphine gas in zinc phosphide poisoning or worsen absorption in other formulations. 3, 7

• Activated charcoal (1 g/kg or 20-30 g mixed in minimum 8 ounces liquid) via small-bore nasogastric tube may be administered ONLY if specifically recommended by poison control 3, 8, 4
• For zinc phosphide: Monitor for rapid deterioration and potential phosphine gas toxicity causing cardiorespiratory collapse 3
• For carbamate pesticides (aldicarb, illegally sold as "Tres Pasitos"): Recognize cholinergic toxidrome (salivation, lacrimation, urination, defecation, miosis, bradycardia) and prepare atropine for severe bradycardia 7, 1

Life-Threatening Complications Management

Implement immediate life-support measures before definitive identification of the specific rodenticide type. 4

• Cardiorespiratory arrest: Begin CPR and activate EMS 1
• Seizures/Status epilepticus: Administer benzodiazepines (diazepam) 4
• Severe agitation: Use diazepam or clorazepate if no respiratory depression risk; otherwise haloperidol 4
• Severe bradycardia: Give atropine 1, 4
• Hypotension: Elevate legs; consider vasopressors if refractory 4
• Unconscious patient: Place in left lateral head-down position and check glucose 4

Hospital Admission Criteria

Admit all patients with potentially severe poisoning, including those who ingested unknown doses, exhibit any symptoms, have abnormal coagulation studies, or present after intentional self-harm. 5, 4

• Anticoagulant rodenticide exposures require prolonged monitoring (weeks to months) due to delayed hepatotoxicity and rebound coagulopathy 5, 6
• Some formulations have delayed effects requiring extended observation periods 4
• Evaluate suicide risk in intentional ingestions and maintain admission until acute risk subsides 4

Critical Pitfalls to Avoid

• Never delay EMS activation to attempt home interventions 3
• Never assume safety based on initial normal coagulation studies in anticoagulant rodenticide exposure—coagulopathy may develop days later 5
• Never discharge patients early from anticoagulant rodenticide poisoning—the average treatment course is 168 days with high risk of rebound 5
• Never use gastric lavage except in rare life-threatening situations with drugs not adsorbed by activated charcoal 4