What is the appropriate emergency management for a patient who ingested Ratol (yellow‑phosphorus) rodenticide within one hour, with a protected airway?

Emergency Management of Ratol (Yellow Phosphorus) Poisoning

For a patient presenting within one hour of Ratol ingestion with a protected airway, immediately contact poison control, perform gastric decontamination with activated charcoal (1-2 g/kg), initiate aggressive supportive care, and admit for monitoring regardless of initial symptoms due to the characteristic delayed toxidrome that emerges 18-72 hours post-exposure. 1, 2

Immediate Actions (First Hour)

Poison Control Consultation

• Contact the national poison control center immediately (1-800-222-1222 in the United States) for real-time expert guidance on yellow phosphorus management. 3, 4
• Do not delay supportive care while awaiting poison control advice. 3

Gastrointestinal Decontamination

• Administer activated charcoal at 1-2 g/kg body weight since the patient presents within 1 hour and has a protected airway. 3, 1
• Gastric lavage is not recommended for yellow phosphorus poisoning due to lack of proven benefit and significant risks including aspiration, dysrhythmias, and esophageal perforation. 3, 4
• Do not induce emesis with ipecac—it increases aspiration risk and is no longer recommended. 3, 5

Supportive Care Foundation

• Maintain continuous hemodynamic monitoring (blood pressure, heart rate, oxygen saturation) throughout the observation period. 3, 6
• Establish intravenous access for fluid resuscitation and medication administration. 3, 6
• Ensure airway protection remains secure, as yellow phosphorus can cause delayed central nervous system depression. 6, 1

Critical Clinical Awareness: The Delayed Toxidrome

Yellow phosphorus poisoning characteristically presents with a conspicuous absence of symptoms during the first 24 hours, followed by a symptomless phase with stable vitals, then sudden deterioration 18-72 hours post-exposure. 2, 7

• 72.73% of patients manifest toxicity after a lag period of 24-36 hours (range 18-72 hours). 2
• Never discharge a patient based on initial clinical stability—the case fatality demonstrates patients can appear well on day 2, then develop fatal multi-organ failure by days 3-5. 8, 2
• The mean time to death is 4.22 days since exposure (range 2-8 days), with 77.78% dying from fulminant hepatic failure. 2

Hospital Admission Criteria

All patients with yellow phosphorus ingestion require hospital admission for a minimum 72-hour observation period, regardless of initial symptom status. 1, 2

• Survival rates are significantly higher (97.87% vs 84.62%) when gastric decontamination is instituted within 2 hours of exposure. 2
• Time to resuscitation shows significant correlation with mortality. 2

Monitoring Protocol (First 72 Hours)

Clinical Surveillance

• Monitor for dominant clinical manifestations including: 2, 7
  • Abdominal pain (52.53% of cases)
  • Jaundice (22.21%)
  • Coagulopathy (15.15%)
  • Hepatic encephalopathy (10.10%)
  • Shock (10.10%)
  • Acute kidney injury (7.08%)
  • Multi-organ failure (17.17%)

Laboratory Monitoring

• Obtain baseline and serial measurements every 12-24 hours: 1, 2
  • Liver function tests (AST, ALT, bilirubin)
  • Coagulation studies (PT/INR, aPTT)
  • Renal function (creatinine, BUN)
  • Arterial blood gas (for metabolic acidosis)
  • Complete blood count

Poor Prognostic Indicators

The following predict bad outcomes and potential need for liver transplantation: 1, 2, 7

• Delayed resuscitation (>2 hours)
• Jaundice development
• Hepatic encephalopathy
• AST and ALT elevation >1000 IU/L
• Metabolic acidosis
• Refractory shock
• Coagulopathy (PT/INR prolongation)

Intensive Care Management

Hepatic Failure Management

• Prepare for potential fulminant hepatic failure—the most common cause of death (77.78% of fatalities). 2, 7
• Consider early consultation with liver transplant center if AST/ALT >1000 IU/L or coagulopathy develops. 1, 2
• Therapeutic plasma exchange may be considered in severe cases per expert consultation. 1

Supportive Interventions

• Treat hyperthermia aggressively with external cooling if present. 6
• Manage seizures with benzodiazepines if they occur. 6
• Provide vasopressor support (preferably norepinephrine) for refractory hypotension after adequate fluid resuscitation. 6
• Initiate renal replacement therapy if acute kidney injury develops. 1

Critical Pitfalls to Avoid

• Do not discharge patients based on initial clinical stability or after a symptom-free period—the characteristic delayed toxidrome makes early discharge potentially fatal. 8, 2
• Do not delay airway management while attempting decontamination procedures. 3, 6
• Do not assume single-agent ingestion—mixed rodenticide formulations (yellow phosphorus + zinc phosphide) occur in 24% of cases. 2
• Do not administer any oral agents unless specifically directed by poison control specialists. 4
• Do not provide supplemental oxygen unnecessarily if the patient maintains adequate saturation. 3

Discharge Criteria

Discharge is only appropriate after 72 hours of observation with: 1, 2

• No clinical manifestations of toxicity
• Normal or stable liver function tests
• Normal coagulation studies
• No metabolic acidosis
• Stable renal function
• Clear plan for outpatient follow-up within 48 hours