A Case of Rat Poisoning

54 year old female presented with:

C/O:

Dizziness

Hemoptysis Of 5 Days Duration

Epistaxis

Vertigo

Facial Swelling

Patient later also gave history of consumption of medicine used for killing Rats

ON EXAMINATIONMultiple Ecchymoses over Chest both Lower Limbs

Hematoma noted around Tonsil region

Jaundice:Mild Anemic:MildLN:NilCyanosis:NilClubbing:NilOedema:NilDehydration:Nil

VITALS:P:80/minBP:100/70mmHgR/R:20/minT:36.6c

CHEST: B/l clear air entry

CVS:S1.S2.M0

P/A:Soft nontender,no organomegaly

MEDICAL h/o:HTN+,no DM,PTB,Hepatitis

SURGICAL h/o:non significant

ALLERGIC h/O:non significant

PERSONAL h/o:Alcoholic+

INVESTIGATIONS

COMPLETE BLOOD COUNT:

WBC:17.32X10*9/L(N=77.9%),L(14.1%),

RBC:2.44X10*12/L,HB:203g/L,HCT:60.2%,MCV:101.2fl

PLT:322X10*9/L

RENAL FUNCTION TEST:

Urea:6.8mmol/L,Cr:122umol/L

Na:140mmol/L,K:3.7mmol/L

Coagulation Profile

Prothrombin Time(PT): >120s

APTT:>180s

INR>10

Thromboplastin Time:16.2s

Fibrinogen:4.26g/L

D Dimer:Negative

Liver Function Test

Biochemistry Investigations

Urine R/E

Chest X-ray Report

Differential Diagnosis

Coagulation Abnormalities? Cause

Hemoptysis of unknown origin

WARFARIN Toxicity

Chronic Liver Disease

Moderate Anemia

Hemophilia

DIAGNOSIS

Rat Poisoning (Coagulation Disorder)

TREATMENT

Transfusion of FFP, Whole BLOOD

Inj Vitamin K

Antibiotics and other supportive measures

Coagulation Profile after Treatment

TREATMENT

LITERATURE

Composition of Rat Poisoning( Rodenticide)

CLASS(Anticoagulant) EXAMPLES

COUMARINS First Generation:Warfarin,CoumatetralylSecond Generation : Difenacoum,Bromadilolone

1,3 INDANDIONES Diphanicone,Pindone

INDIRECT Sometimes, anticoagulant rodenticides are potentiated by an antibiotic or bacteriostatic agent. The aim of this association is that the antibiotic suppresses intestinal symbiotic microflora, which are a source of vitamin K

These are generally Chronic(death usually occurs after few weeks after consumption of lethal dose,rarely sooner).

These acts by blocking Vitamin K cycle leading to inability to produce coagulation factor II,VII.IX,X.

Phosphide Used Rodentocide

Metal phosphides have been used as a means killing of rodents and are considered single-dose fast acting rodenticides (death occurs commonly within 1–3 days after single bait ingestion). A bait consisting of food and a phosphide (usually zinc phosphide) is left where the rodents can eat it.

AVAILABLE PHOSPHIDES:ALUMINIUM PHOSPHIDESMAGNESIUM PHOSPHIDESZINC PHOSPHIDES

Calciferols (vitamins D), cholecalciferol (vitamin D3) and ergocalciferol (vitamin D2)

They affect Calcium and Phosphate homeostasis.

On larger doses consumption causes Hypervitaminosis.

Hypercalcemia tends to affect Cardiac Muscle(affecting Contractility),Blood Vessels(leading to bleeding due to capillary damage) and Possibly ARF.

They are also synergetic with anticoagulants.

A suggested algorithm for the management of a warfarin- treated patient whose international

normalized ratio (INR) exceeds 4.

Garcia D A , and Crowther M A Circulation. 2012;125:2944-

2947

Copyright © American Heart Association, Inc. All rights reserved.

The prothrombin time (PT) and its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) are measures of the extrinsic pathway of coagulation. This test is also called "ProTime INR" and "PT/INR".

DISCUSSIONS

What is the role of Calcium Gluconate in the treatment, since the composition of Rodentocide also may consists of excessive Calcium?

Vitamin K dependent coagulation factor(II,VII,IX,X),can it be tranfused directly?

What Should be the target INR in management of this patient?

Random Blood Glucose Level is high is it not worthy sending Fasting & PP Blood Sugar?

Reference

http://circ.ahajournals.org/content/125/23/2944.full

www.aapf.org

Wikipedia

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