Diagnosis and therapy of anticoagulant rodenticide intoxications

A retrospective evaluation of confirmed and suspected poisonings in 166 cats between 2016 and 2020

Background and Aim

Poisonings commonly bring cats and dogs to veterinary emergency facilities. This retrospective study aimed to analyze clinical signs, confirmed or suspected toxicants, treatments, and outcomes of feline poisoning cases presented over 5 years to the emergency service of a small animal referral center.

Materials and Methods

Medical records of 166 cats were evaluated for a history of confirmed or presumed poisoning, suspected toxicant, clinical signs, treatment, and outcome. Poisoning probability was determined using patient history, clinical findings, observation, toxicologic examination, and, in some cases, gastric contents.

Results

Most cats were hospitalized (94.0%) due to poisoning with mostly unknown toxicants (48.2%), rodenticides (21.1%), and various toxic plants (12.0%), followed by antiparasitics (6.0%), chemicals (6.0%), drugs (4.2%), tetrahydrocannabinol (1.2%), or inhaled smoke (1.2%). Patients presented predominantly with neurologic deficits (68.7%), reduced general condition (60.2%), and hypothermia (43.4%). The survival rate was 88.6%. Most cats (93.2%) showed no apparent complications at the time of discharge from the hospital. Toxicant-related complications (48.2%) included thermodysregulation (22.9%), central nervous system signs (18.7%), respiratory issues (7.2%), nephrotoxicity (6.0%), gastrointestinal complications (4.8%), evidence of hepatic failure (4.8%), and hemorrhage (1.8%).

Conclusion

In this study, the causative toxicant remained unidentified in many cases. Known poisonings were mostly caused by rodenticides. Neurological signs were the most common clinical presentation. Survival rates were high and comparable with those reported by others.

An in vitro study of canine cryopoor plasma to correct vitamin K-dependent coagulopathy in dogs

OBJECTIVE

To compare the efficacy of fresh frozen plasma (FFP) with cryopoor plasma (CPP) to treat vitamin K-dependent factor deficiency in a canine in vitro setting.

DESIGN

In vitro laboratory study.

SETTING

University veterinary medical teaching hospital.

ANIMALS

Seven units of FFP and 6 units of CPP from unique canine donors from the university veterinary blood bank.

INTERVENTIONS

Canine FFP was adsorbed by oral barium sulfate suspension to mimic vitamin K-dependent coagulopathy. A sequential mixing study was completed by adding FPP or CPP to the adsorbed plasma. Measurements of prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, and factor activities of factors II, VII, and IX (FII, FVII, and FIX) were compared between the 2 treatment groups.

MEASUREMENTS AND MAIN RESULTS

When comparing the sequential addition of CPP or FPP to adsorbed plasma, the following had no statistical significance: PT (P = 0.94), aPTT (P = 0.66), FII (P = 0.05), and FIX (P = 0.90). There was a dose-dependent decrease with PT and aPTT and a dose-dependent increase with FII and FIX. In contrast, after the addition of either CPP or FFP, there was a significant difference between the treatment groups for the concentration of fibrinogen (P = 0.005) and activity of FVII (P = 0.044), with FFP resulting in a greater concentration of fibrinogen and CPP resulting in a greater concentration of FVII. Measurements of factor X (FX) were initially included in the study but were later excluded because FX appeared to be continually adsorbed even after the addition of CPP or FFP.

CONCLUSIONS

CPP partially corrected the coagulation times and concentration of vitamin K-dependent coagulation factors to the same degree as FFP. CPP, generally less expensive than FFP, may provide an alternative treatment option for vitamin K-dependent coagulopathies, although in vivo testing is needed.

Intravenous vitamin K1 normalises prothrombin time in 1 hour in dogs with anticoagulant rodenticide toxicosis

Four dogs with anticoagulant rodenticide toxicosis were treated with intravenous vitamin K₁ in lieu of plasma transfusion due to client cost constraints. Two dogs experienced a suspected anaphylactoid reaction, necessitating cessation of the treatment in one dog. Prothrombin time was rechecked 1 h after treatment in the remaining three dogs and all results were within the normal reference range. All four dogs were discharged from hospital within 48 h of presentation. Intravenous vitamin K₁ rapidly reverses the coagulopathic state in dogs with anticoagulant rodenticide toxicosis. It is a viable alternative therapy to plasma transfusion if circumstances preclude its use; however, patients must be monitored for anaphylactoid reactions.

Upper Airway Obstruction Secondary to Anticoagulant Rodenticide Toxicosis in Five Dogs

Five dogs were presented with clinical signs compatible with upper airway obstruction, including stridor, stertor, coughing, gagging, and varying degrees of respiratory distress. All dogs had radiographic findings of soft tissue opacity in the area of the pharynx, larynx, or trachea, and several had narrowing of the tracheal lumen. Coagulation abnormalities (prolonged prothrombin time, activated partial thromboplastin time) were present in the four dogs that underwent testing. Four of five dogs were treated for the coagulopathy, presumably due to anticoagulant rodenticide toxicosis, and survived to discharge.Upper airway obstruction is an unusual presentation for anticoagulant rodenticide toxicosis in dogs. Raising the index of suspicion for this treatable condition may help clinicians to identify this sooner.

Adverse outcome pathway and risks of anticoagulant rodenticides to predatory wildlife

Despite a long history of successful use, routine application of some anticoagulant rodenticides (ARs) may be at a crossroad due to new regulatory guidelines intended to mitigate risk. An adverse outcome pathway for ARs was developed to identify information gaps and end points to assess the effectiveness of regulations. This framework describes chemical properties of ARs, established macromolecular interactions by inhibition of vitamin K epoxide reductase, cellular responses including altered clotting factor processing and coagulopathy, organ level effects such as hemorrhage, organism responses with linkages to reduced fitness and mortality, and potential consequences to predator populations. Risk assessments have led to restrictions affecting use of some second-generation ARs (SGARs) in North America. While the European regulatory community highlighted significant or unacceptable risk of ARs to nontarget wildlife, use of SGARs in most EU member states remains authorized due to public health concerns and the absence of safe alternatives. For purposes of conservation and restoration of island habitats, SGARs remain a mainstay for eradication of invasive species. There are significant data gaps related to exposure pathways, comparative species sensitivity, consequences of sublethal effects, potential hazards of greater AR residues in genetically resistant prey, effects of low-level exposure to multiple rodenticides, and quantitative data on the magnitude of nontarget wildlife mortality.

Anticoagulant rodenticide screening in dogs: 123 cases (1996-2003)

OBJECTIVE

To identify dogs with anticoagulant rodenticide (AR) screens submitted, determine whether detected concentrations of the anticoagulants correlated with severity of clinical signs for dogs with positive results on AR screens, and identify the most common disease processes present and the prognosis for those with negative AR screens.

DESIGN

Retrospective case series.

ANIMALS

123 dogs.

PROCEDURES

History, signalment, clinical signs, physical examination findings, PCV, total solids concentration, prothrombin time, activated partial thromboplastin time, platelet count, AR concentrations, duration of hospitalization, blood products administered, final diagnosis, and outcome were recorded from medical records of dogs that underwent AR toxicology screenings.

RESULTS

75 of 123 (60.9%) dogs tested positive for AR. Dogs tested positive for brodifacoum, diphacinone (also called diphenadione), and chlorophacinone. Dogs with positive AR screenings weighed significantly less, received significantly more fresh frozen plasma, had significantly longer initial prothrombin time, and were significantly more likely to survive, compared with those with negative screens. Anticoagulant rodenticide concentrations ranged from trace amounts to 1,120 parts per billion and were not correlated with any recorded parameter. The most common conditions diagnosed in the 48 dogs with negative screens included neoplasia in 15 (31.3%), immune-mediated disease in 7 (14.6%), and gastrointestinal bleeding in 5 (10.4%) dogs.

CONCLUSIONS AND CLINICAL RELEVANCE

AR concentrations were not correlated with severity of clinical signs or the degree of prolongation of coagulation times in this series of patients. Patients with severe coagulopathies but negative results of AR screening had a poor prognosis, with neoplasia as the most common diagnosis. Anticoagulant rodenticide intoxication had the best prognosis, with a survival rate of 98.7% in this study.

Assessment of toxicity and potential risk of the anticoagulant rodenticide diphacinone using Eastern screech-owls (Megascops asio)

In the United States, new regulatory restrictions have been placed on the use of some second-generation anticoagulant rodenticides. This action may be offset by expanded use of first-generation compounds (e.g., diphacinone; DPN). Single-day acute oral exposure of adult Eastern screech-owls (Megascops asio) to DPN evoked overt signs of intoxication, coagulopathy, histopathological lesions (e.g., hemorrhage, hepatocellular vacuolation), and/or lethality at doses as low as 130 mg/kg body weight, although there was no dose-response relation. However, this single-day exposure protocol does not mimic the multiple-day field exposures required to cause mortality in rodent pest species and non-target birds and mammals. In 7-day feeding trials, similar toxic effects were observed in owls fed diets containing 2.15, 9.55 or 22.6 ppm DPN, but at a small fraction (<5%) of the acute oral dose. In the dietary trial, the average lowest-observed-adverse-effect-level for prolonged clotting time was 1.68 mg DPN/kg owl/week (0.24 mg/kg owl/day; 0.049 mg/owl/day) and the lowest lethal dose was 5.75 mg DPN/kg owl/week (0.82 mg/kg owl/day). In this feeding trial, DPN concentration in liver ranged from 0.473 to 2.21 μg/g wet weight, and was directly related to the daily and cumulative dose consumed by each owl. A probabilistic risk assessment indicated that daily exposure to as little as 3-5 g of liver from DPN-poisoned rodents for 7 days could result in prolonged clotting time in the endangered Hawaiian short-eared owl (Asio flammeus sandwichensis) and Hawaiian hawk (Buteo solitarius), and daily exposure to greater quantities (9-13 g of liver) could result in low-level mortality. These findings can assist natural resource managers in weighing the costs and benefits of anticoagulant rodenticide use in pest control and eradication programs.

Determination of bromadiolone residues in fox faeces by LC/ESI-MS in relationship with toxicological data and clinical signs after repeated exposure

In many countries, the fox (Vulpes vulpes), predator of small mammals, is particularly affected by anticoagulant rodenticides such as bromadiolone due to secondary poisoning. Nevertheless, to date, no method of exposure monitoring is applicable in the field over large areas, and no toxicological data are available concerning sensitivity of foxes to bromadiolone. The aim of this work was to compare excretion kinetics of bromadiolone in fox faeces with clinical and haemostatic effects after repeated exposure to intoxicated voles. A sensitive method for the quantification of bromadiolone excretion in fox faeces and plasma was developed, using liquid chromatography combined with electrospray ionisation mass spectrometry (LC/ESI-MS). The LoD was 0.9microg/kg and 0.15microg/L, and the LoQ was 3.0microg/kg and 0.5microg/L, in faeces and in plasma, respectively. Four captive foxes were fed for 2 or 5 days with water voles (Arvicola terrestris Sherman) spiked with bromadiolone at concentrations close to those measured in the field. Faeces and blood were collected for bromadiolone titration, and blood-clotting tests were performed to monitor fox health daily during 10 days and then every 3-4 days until the end of the experiment (D28). Then, after euthanasia, a complete necropsy was performed, and levels of bromadiolone residues in the liver were determined. Bromadiolone residues were detected in faeces 15h after the first exposure. They increased dramatically during the exposure period and then gradually decreased, but they remained detectable at the end of the experiment, i.e., 26 days after the last exposure. Bromadiolone residues in plasma showed a similar pattern but were no longer detectable 7-24 days after the last exposure. Two foxes presented very severe external haemorrhages, requiring the administration of the antidote vitamin-K1. Bromadiolone residues in faeces and their relationships with exposure and other direct-markers that were measured are discussed. Liver residues and the toxicity data of our study will help to interpret data from fox carcasses collected by wildlife disease surveillance networks. These findings provide a basis for programs aiming to monitor the exposure of wild fox populations to bromadiolone using non-invasive methods based on standard sampling and analysis of residues in faeces.

Intramural tracheal haematoma causing acute respiratory obstruction in a dog

Respiratory obstruction resulting from a discrete haematoma within the dorsal tracheal membrane was seen in an 11-year-old neutered female greyhound that had been involved in a fight two days earlier. There was no history or evidence of rodenticide toxicity or other coagulopathy, and it is suggested that the tracheal haematoma resulted from trauma. A right third intercostal thoracotomy was performed and this allowed resection of the haematoma from within the dorsal membrane of the cranial thoracic trachea, relieving the obstruction with no subsequent signs of dyspnoea. Intramural haematoma should be considered as a rare differential diagnosis for dogs presenting with acute respiratory obstruction.

Effect of the anticoagulant, pindone, on the breeding performance and survival of merino sheep, Ovis aries

The effect of the anticoagulant, pindone, on the breeding performance and survival of relatively free-ranging merino sheep was assessed. Pindone (2-pivalyl-1, 3-indandione) was administered orally as a single (10, 3, or 2 mg pindone kg(-1) over three consecutive days) or multiple exposure (dosing regime repeated after a further 8 days). Prothrombin times (PT) increased up to 4-fold in treated sheep, and haemorrhage occurred in some instances, particularly with the double dose treatment. Deaths of sheep also occurred, usually when the sheep were placed under added stress, particularly that associated with shearing. The breeding performance of pregnant ewes dosed with pindone was reduced, mainly due to an increase in stillborn and nonviable lambs (i.e. deaths within 2 days of birth). The motility of sperm in treated rams was also affected. Pindone persisted in the blood (maximum, 13.2 mg L(-1)) for up to 14 days after the last dose, and the half-life (t1/2) was estimated at approximately 5 days depending upon the dosing regime. Other tissue residues ranged from 17 (fat) to 39 (liver) mg kg(-1). The implications of these findings for ongoing responsible use of pindone (anticoagulants) in pest control programs are also discussed.

Haemorrhage in seven cats with suspected anticoagulant rodenticide intoxication

Clinical features were evaluated in seven adult cats (six males, one female) with haemorrhage and presumptive anticoagulant rodenticide intoxication. Haemorrhage appeared as thoracic haemorrhage, otic bleeding, haematoma, melena, haematochezia, and petechiation. The most common other presenting signs were lethargy, anorexia, and tachypnoea or dyspnoea. Six cats were anaemic, four cats were mildly thrombocytopenic (58000-161000/ microL), and three had slightly decreased plasma protein or albumin values. The prothrombin time (30.3->100 s, reference range: 16.5-27.5 s) and activated partial thromboplastin time values (32.6->100 s; reference range: 14-25 s) were markedly prolonged in all cats. All cats received vitamin K(1)subcutaneously or orally (3.7-5 mg/kg body weight initially) and depending on severity of signs five cats were transfused with fresh whole blood. Plasma coagulation times improved in all cats and returned to normal in 1-5 days. Rodenticide poisons represent an important but relatively rare cause of haemorrhage in cats and can be effectively treated.

An unusual cause of abdominal pain

A 36-year-old woman presented to the Emergency Room because of abdominal pain associated with hematuria and red blood blending to stool. On admission, the physical examination revealed abdominal tenderness and diffuse cutaneous hematoma. The laboratory findings showed abnormal clotting tests with high International Normalised Ratio (INR) and prolonged activated partial thromboplastin time. Hemoperitoneum and ureteral hematoma were noted on the abdomen computed tomography. The patient confessed she had ingested difenacoum for several weeks. All the symptoms resolved with fresh frozen plasma perfusion and vitamin K.

Commercial variants of the prothrombin time test as a screening test of acquired coagulation factor II, VII, and X deficiencies in dogs

The aim of this study was to acquire the single factor sensitivity of three commercial variants of the prothrombin time test (PT(Va1)-Thrombotest, PT(Va2)-Normotest, PT(Va3)-Hepato Quick) for canine plasma. For this purpose, 38 samples from animals with coumarin intoxication followed by vitamin K(1) treatment who had a reduced activity of the coagulation factors II, VII, and/or X (experiment 1) as well as 25 plasma samples from animals with moderately reduced activity of the coagulation factors II, V, VII, and/or X caused by a hepatogenic synthesis disorder or disseminated intravascular coagulation (experiment 2), were examined. Measurements for all tests were performed according to the instructions of the manufacturer and also with higher plasma dilution. Furthermore, control measurements were performed with the conventional prothrombin time test (standard test; PT(ST)). The prothrombin time measured with the PT(Va3), which was prolonged in all samples from experiments 1 and 2, especially reflected with high sensitivity the reduced activity of the coagulation factors. The measurements with PT(Va2) and PT(Va1) showed only an insignificantly lower sensitivity (> or =0.88) with a maximum of 1 (experiment 1) and 3 (experiment 2) false negative test results, respectively. Compared to the already high sensitivity, a higher dilution of the sample material did not lead to a significantly higher sensitivity (P>0.05) for any of the tested commercial variants of the prothrombin time assay. While there was no significant difference (P>0.05) between the number of false negative test results in the variants of the prothrombin time assay, in both experiments a significantly higher number of false negative test results was found for the PT(ST) (P<0.001). The results show that, in contrast to the PT(ST), all three tested commercial prothrombin time variants are suitable for the detection of deficiencies of coagulation factors II, VII, and X in canine plasma.

Rodenticides

Rodenticides are second only to insecticides in the prevalence of pesticide exposure. Hundreds of rodenticide products currently exist, yet only a handful of them are involved in most toxicoses of companion animals. The most commonly reported toxicoses in the United States are those caused by anticoagulant rodenticides, bromethalin, cholecalciferol, strychnine, and zinc phosphide. The pathophysiologic findings, diagnosis, and treatment of each of these five rodenticides are discussed.

Plasma superwarfarin levels and vitamin K1 treatment in dogs with anticoagulant rodenticide poisoning

The plasma concentration, plasma half-life (t1/2), and mean residence time (MRT) of rodenticide anticoagulants were determined in 21 dogs in which a preliminary diagnosis of anticoagulant rodenticide poisoning had been made. Brodifacoum, difethialone, and difenacoum were detected by high-performance liquid chromatography (HPLC) in the plasma of 13, 3, and 2 dogs, respectively. At presentation the plasma concentration ranged from below the detection limit (10 ng/L) to 851 ng/L. Toxin could not be detected in 3 dogs, despite these animals showing characteristic coagulation disturbances and a positive response to therapy with vitamin K1. In 7 dogs the estimated t1/2 of brodifacoum ranged from 0.9 to 4.7 (median 2.4) days with a MRT of 1.9 to 3.7 (median 2.8) days. In 2 dogs the individual t1/2 of difethialone was 2.2 and 3.2 days and the MRT was 2.3 and 2.8 days, respectively. Two dogs died during emergency treatment. Treatment in the remaining 19 dogs consisted of the administration of vitamin K1 and supportive therapy. The dose of vitamin K1 was reduced in a stepwise manner as long as the prothrombin time remained within physiological limits. The variation in initial plasma concentrations of the anticoagulants combined with the results of treatment support the idea that an individual therapeutic approach is warranted.

Evaluation of a prothrombin time optimized for the dog on plasmas with defined coagulation factor deficiency due to coumarin intoxication

The sensitivity of the standard prothrombin time (PT) was low when measured on 56 plasmas with a reduced activity of the coagulation factors mainly of the prothrombin complex (factors II, VII and/or X) taken from eight dogs at different times of vitamin K1 therapy after coumarin intoxication. This was demonstrable by use of three different Ca-thromboplastins. With the standard test only plasmas with an excessive decrease of coagulation factor activity (sum of activity decrease of the single factors in relation to the respective reference range [SAD] > 100%) were detectable with sufficient reliability. In contrast, by using a method optimized for dogs (1:20 sample predilution, fibrinogen substitution) and respecting the species specific features of coagulation physiology, pathological PT-values were measured in up to 70% of the samples (dependent on the Ca-thromboplastin) with slight reductions of single factor activity (SAD: 11-25%). Significant differences concerning the sensitivity were seen additionally between the different Ca-thromboplastins. Human placenta thromboplastin in particular, but also rabbit brain thromboplastin, were more sensitive than a preparation of recombinant human tissue factor. The correlation between the PT and the SAD was closer when using the optimized method (r = 0.919-0.954) compared to the standard test (r = 0.771-0.862). In contrast to the standard test, the PT optimized for dogs is, therefore, a reliable screening test to recognize a slight reduction in prothrombin complex. It is especially suitable for monitoring of vitamin K1 therapy after coumarin intoxication.

Hematologic emergencies

The most common life-threatening hematologic emergencies include hemorrhage and severe anemia. Successful treatment of these conditions depends on the emergency veterinarian having a thorough understanding of the possible etiologies of these conditions, and a systematic approach to diagnosis and therapy. Use of blood component therapy can be a life-saving technique in these patients. The goal of this article is to familiarize the emergency veterinarian with a systematic approach to the diagnosis and treatment of hematologic emergencies.

Assessment of the potential toxicity of a poison for rabbits, pindone (2-pivalyl 1, 3 indandione), to domestic animals

The toxicity of pindone, a rabbit poison, to horses, cattle, goats, chickens, dogs and cats was investigated, using extension of prothrombin time (PT) as an index of poisoning. The daily dose of pindone, administered for 5 days, ranged from 0.3 mg/kg for dogs to 2.5 mg/kg for chickens. This range of dose rates was considered to be indicative of the worst possible case that could arise following a campaign of baiting for rabbits. Although significant elevations in PT (more than double baseline values) were noted in all species other than horses, clinical signs of anticoagulant poisoning were not observed in any of the species tested. From the observed PT, cattle and cats appeared to be the most susceptible, and horses the least susceptible, to pindone toxicity. The half-lives of the elevated PT were calculated as 3.1 days for cattle, 2.8 days for goats and chickens, 1.9 days for horses and dogs and less than one day for cats. It is proposed that these half-lives can be used as a guide for determining the duration of treatment of pindone-affected animals.

Platelets and coagulation

Hemostasis is a multiple-component system. In order to function properly it has become highly integrated with several strategies of control. Failure of the system or its control can result in life-threatening hemorrhage requiring transfusion. It is hoped that the information provided in this article has enhanced the reader's understanding of hemostasis in animals, and will enable the reader to make a more educated choice concerning transfusion therapy for the bleeding patient.

Toxicology of selected pesticides, drugs, and chemicals. Anticoagulant, cholecalciferol, and bromethalin-based rodenticides

The control of rodent pests is a continuing goal of mankind. To this end, a multitude of rodenticides have been produced, each designed to kill rodents by exerting their toxic effects on various body systems. As examples, veterinarians have had to manage companion animal poisonings due to anticoagulant, sodium fluoroacetate (compound 1080), thallium, barium carbonate, and zinc phosphide-based rodenticides. Many of these rodenticides were introduced because of their anticipated safety in relation to nontarget species; unfortunately, this has not been the case. Veterinarians must attempt to identify the specific rodenticide involved in poisoning cases. Therapeutic success in these poisonings is often more dependent upon symptomatic and supportive care rather than the use of antidotal therapy.

Abnormal bleeding

Animals with disorders of hemostasis are often presented as emergency patients and, as such, offer a challenge to the attending clinician. This article reviews the basic physiology of hemostasis and laboratory tests used for diagnosis. Guidelines for the evaluation and treatment of patients with bleeding disorders are provided.