What is the treatment for a patient, potentially a child or adult with liver or kidney disease, experiencing a rat poison emergency after ingesting anticoagulant, bromethalin, or cholecalciferol-containing poison?

Rat Poison Emergency Management

For anticoagulant rodenticide poisoning, immediately administer vitamin K1 (phytonadione) 2.5-25 mg orally in adults (up to 50 mg if needed), contact poison control, and provide aggressive supportive care while monitoring coagulation parameters; for bromethalin or cholecalciferol poisoning, no specific antidote exists—focus entirely on supportive care and poison control consultation. 1, 2

Immediate Priorities (All Rat Poison Types)

Contact poison control immediately (1-800-222-1222 in US) for expert toxicology guidance, as management varies dramatically by rodenticide type and specialized consultation is essential. 1, 3

Supportive care takes absolute priority over toxin identification or antidotal therapy—secure airway, establish hemodynamic monitoring, and correct critical vital sign derangements before anything else. 1

Type-Specific Management

Anticoagulant Rodenticides (Most Common)

Vitamin K1 (phytonadione) is the definitive antidote:

• Initial dose: 2.5-10 mg orally, up to 25 mg initially; some cases require 50 mg 2
• Avoid oral route if absorption is compromised; bile salts must be co-administered if biliary supply is deficient 2
• Coagulant effects are NOT immediate—INR improvement takes 1-8 hours 2
• Evaluate INR after 6-8 hours and repeat dosing if INR remains prolonged 2
• Sustained treatment time varies but typically requires days to weeks of maintenance therapy with gradually decreasing doses (10-120 mg/day IV) 4

Critical monitoring:

• Check prothrombin time/INR regularly as clinical conditions indicate 2
• If INR not shortened satisfactorily in 12-48 hours after oral administration, repeat the dose 2
• Interim use of whole blood or component therapy may be necessary if bleeding is severe 2

Important caveats:

• Repeated large doses are not warranted in liver disease if initial response is unsatisfactory 2
• Failure to respond may indicate congenital coagulation defect or vitamin K-unresponsive condition 2
• Overzealous therapy may restore prothrombotic conditions—keep dosage as low as possible 2

Bromethalin Rodenticides

No specific antidote exists—management is entirely supportive: 5, 6

• Most accidental exposures (89.7%) result in no effects, with only 7.9% showing minor self-limited gastrointestinal symptoms 5
• However, maintain high index of suspicion as bromethalin may cause more symptomatic patients than anticoagulant agents 5
• Administer benzodiazepines (diazepam or midazolam) if seizures or severe agitation occur 1, 3
• Monitor neurological status closely for delayed effects 5
• Prognosis for accidental ingestions is generally excellent, but intentional large ingestions may cause severe neurotoxicity 5

Cholecalciferol (Vitamin D3) Rodenticides

No specific antidote—focus on supportive care and monitoring: 6

• Monitor calcium and phosphorus levels closely 6
• Provide aggressive IV fluid therapy to promote calciuresis 6
• Treat hypercalcemia aggressively if present 6
• Consider hemodialysis for severe cases with refractory hypercalcemia 1

Decontamination Considerations

Do not induce vomiting unless specifically advised by poison control, as this may worsen condition and delay definitive care. 7

Activated charcoal should only be administered if specifically recommended by poison control, as benefits are uncertain and vary by toxin type. 7

Universal Supportive Care Measures

• Airway management: Intubate immediately for coma, respiratory depression, or inability to protect airway 3
• Hemodynamic support: Treat hypotension with fluid boluses (10-20 mL/kg normal saline); consider vasopressors (norepinephrine or epinephrine preferred) for refractory hypotension 8
• Seizure management: Benzodiazepines (diazepam or midazolam) are first-line for seizures from any rodenticide 1, 3
• Dysrhythmia management: Treat life-threatening dysrhythmias with standard ACLS protocols 1, 8

Critical Pitfalls to Avoid

Never delay treatment waiting for toxicology confirmation—treat based on clinical presentation and exposure history. 7, 3

Do not assume all rodenticides are anticoagulants—bromethalin and cholecalciferol require completely different management approaches without vitamin K1. 5, 6

For anticoagulant poisoning in patients with liver disease, do not continue escalating vitamin K1 doses if no initial response occurs—this indicates the condition is unresponsive to vitamin K. 2

Vitamin K1 does not counteract heparin—do not use for heparin-related coagulopathy. 2