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Thomas AV, Johnson ML, Tincher AM, Zackariya S, Khan H, Rizvi U, Thomas SG, Noveroske TW, Fulkerson DH, Moore EE, Walsh MM. Brodifacoum contamination of synthetic cannabinoid causing unexplained coagulopathy in multiple trauma: A case report. Trauma Case Rep 2024; 51:101007. [PMID: 38590923 PMCID: PMC11000161 DOI: 10.1016/j.tcr.2024.101007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2024] [Indexed: 04/10/2024] Open
Abstract
An 18-year-old female presented to the emergency department after a motor vehicle collision. Initial imaging revealed a liver laceration. Subsequent labs showed significantly elevated prothrombin time, international normalized ratio, and activated partial thromboplastin time. Thromboelastography demonstrated a flatline tracing. The patient denied use of anticoagulation but admitted to synthetic cannabinoid use. It was believed the patient had taken synthetic cannabinoid contaminated by brodifacoum. She was therefore given prothrombin complex concentrate and vitamin K with blood products. The patient underwent sequential embolization, laparotomy, thoracotomy, and repair of the vena cava with a shunt. Thirty minutes postoperatively, her coagulation tests and thromboelastography were much improved. Two and a half hours postoperatively, it was determined she had sustained non-survivable injuries. The patient experienced brain death due to prolonged hypotension as a result of hemorrhagic shock with bleeding exacerbated by brodifacoum. To our knowledge, this is the first case reported of a trauma-induced coagulopathy exacerbated by brodifacoum-contaminated synthetic cannabinoid. Her coagulopathy was clearly not due to trauma alone and contributed greatly to the difficulty in controlling hemorrhage. The synthetic cannabinoid-associated coagulopathy rendered her otherwise potentially survivable injuries fatal. Given the frequency of multiple trauma and the recent increase in the prevalence of synthetic cannabinoid, it can be expected that the incidence of trauma complicated by synthetic cannabinoid-associated coagulopathy will increase in the near future. For patients that present with prolonged prothrombin time and/or activated partial thromboplastin time, it is important to inquire about recent synthetic cannabinoid use.
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Affiliation(s)
| | | | - Anna M. Tincher
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Saniya Zackariya
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Hassaan Khan
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Uzma Rizvi
- Department of Mortality/Quality & Safety Data Review, Beacon Health System, South Bend, IN, USA
| | - Scott G. Thomas
- Beacon Medical Group Trauma & Surgical Research Services, South Bend, IN, USA
| | | | | | - Ernest E. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Mark M. Walsh
- Indiana University School of Medicine, Indianapolis, IN, USA
- Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
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2
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Hydock KL, DeClementi C, Fish PH. Second-generation Anticoagulant Rodenticide Poisoning in a Captive Andean Condor (Vultur gryphus). J Avian Med Surg 2017; 31:256-261. [PMID: 28891692 DOI: 10.1647/2016-196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
A 28-year-old female Andean condor (Vultur gryphus) housed in an outside exhibit at the National Aviary in Pittsburgh, PA, began showing signs of weakness. Toxicosis with an anticoagulant rodenticide was suspected because its mate had died 1 day earlier from possible brodifacoum poisoning. A rapid decline in the packed cell volume, despite vitamin K1 treatment, necessitated a blood transfusion with blood from bald eagles (Haliaeetus leucocephalus) and Steller's sea eagles (Haliaeetus pelagicus). Supportive therapy after transfusion included vitamin K1 (5 mg/kg IM q12h) as well as enrofloxacin, vitamin B complex, selenium and vitamin E, and subcutaneous fluids as needed. After a 39-day treatment period, a tapering dosage of vitamin K1 was initiated, and treatment ended after 17 weeks. However, 2 weeks later, the bird suffered from a potential relapse. It was successfully treated with a repeat tapering vitamin K1 regimen lasting a total of 4 months.
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Wojciechowski VV, Calina D, Tsarouhas K, Pivnik AV, Sergievich AA, Kodintsev VV, Filatova EA, Ozcagli E, Docea AO, Arsene AL, Gofita E, Tsitsimpikou C, Tsatsakis AM, Golokhvast KS. A guide to acquired vitamin K coagulophathy diagnosis and treatment: the Russian perspective. ACTA ACUST UNITED AC 2017; 25:10. [PMID: 28416008 PMCID: PMC5393004 DOI: 10.1186/s40199-017-0175-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/06/2017] [Indexed: 01/05/2023]
Abstract
Abstract Physicians often come across with cases of vitamin K antagonists–dependent coagulopathy for reasons such as accidental use of the vitamin K antagonists (VKA), excessive administration of prescribed anticoagulants of indirect action or not reported administration of vitamin K antagonists due to memory impairment and/or other mental disorders, even deliberate use thereof (attempt to murder or suicide). Rodenticide-poisoning (coumarins, warfarins) via food or occupational accidents are difficult to diagnose. This article discusses different types of acquired vitamin K-dependent coagulopathy. Differential diagnosis is primarily based on patient statements before additional causes of vitamin K deficiency are explored. Even when pathological vitamin K deficiency is not determined, appropriate and urgent medical treatment is necessary: administration of fresh frozen plasma or concentrated factors of the prothrombin complex, administration of vitamin K remedies along with symptomatic therapy. With early diagnosis and prescription of appropriate therapy, prognosis is favorable. Graphical abstract Reasons for vitamin K antagonists–dependent coagulopathy cases![]()
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Affiliation(s)
- Valery V Wojciechowski
- Department of Hospital Therapy and Pharmacology, Amur State Medical Academy, 675000, Blagoveshchensk, Russia
| | - Daniela Calina
- Department of Clinical Pharmacy, University of Medicine and Pharmacy of Craiova, Petru Rares, 200349, Craiova, Romania
| | | | - Alexander V Pivnik
- Department of Hematology-Oncology and Secondary Immunodeficient Diseases, D.D. Pletnev Moscow Clinical Research and Practical Centre of Health Department, 111123, Moscow, Russia
| | - Alexander A Sergievich
- School of Arts, Culture and Sports, Far Eastern Federal University, 690022, Vladivostok, Russia
| | - Vladimir V Kodintsev
- School of Biomedicine, Far Eastern Federal University, 690022, Vladivostok, Russia
| | - Ekaterina A Filatova
- Department of Hematology, Amur Regional Clinical Hospital, 675000, Blagoveshchensk, Russia
| | - Eren Ozcagli
- Department of Pharmaceutical Toxicology, Faculty of Pharmacy, Istanbul University, Beyazit, Istanbul, 34116, Turkey
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, Petru Rares, 200349, Craiova, Romania
| | - Andreea Letitia Arsene
- Department of Pharmaceutical Microbiology, Faculty of Pharmacy, "Carol Davila" University of Medicine and Pharmacy, 6, TraianVuia Street, sector 2, 020956, Bucharest, Romania
| | - Eliza Gofita
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, Petru Rares, 200349, Craiova, Romania
| | - Christina Tsitsimpikou
- Department of Hazardous Substances, General Chemical State Laboratory of Greece, Mixtures & Articles, 16 An. Tsocha Str, Athens, 115121, Greece
| | - Aristidis M Tsatsakis
- SEC Nanotechnology, Far Eastern Federal University, 690022, Vladivostok, Russia. .,Forensic Sciences and Toxicology Department, Medical School, University of Crete, P.O. Box 1393, 71003, Heraklion, Crete, Greece. .,Scientific Educational Center of Nanotechnology, Federal Scientific Center of Hygiene, Far Eastern Federal University, F.F. Erisman, Moscow, 690950, Russian Federation.
| | - Kirill S Golokhvast
- SEC Nanotechnology, Far Eastern Federal University, 690022, Vladivostok, Russia.
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Lee JH, Kim H, Han HS, Lee KH, Kim ST. A Case of Superwarfarin Intoxication without a Definitive History of Brodifacoum Exposure. THE KOREAN JOURNAL OF HEMATOLOGY 2009. [DOI: 10.5045/kjh.2009.44.1.53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ju-Hee Lee
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Hyun Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Hye-Suk Han
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Ki Hyeong Lee
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
- Department of Internal Medicine, Chungbuk National University School of Medicine, Cheongju, Korea
- Department of Internal Medicine, Chungbuk National University Medical Research Center, Cheongju, Korea
| | - Seung Taik Kim
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
- Department of Internal Medicine, Chungbuk National University School of Medicine, Cheongju, Korea
- Department of Internal Medicine, Chungbuk National University Medical Research Center, Cheongju, Korea
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Caravati EM, Erdman AR, Scharman EJ, Woolf AD, Chyka PA, Cobaugh DJ, Wax PM, Manoguerra AS, Christianson G, Nelson LS, Olson KR, Booze LL, Troutman WG. Long-acting anticoagulant rodenticide poisoning: An evidence-based consensus guideline for out-of-hospital management. Clin Toxicol (Phila) 2008; 45:1-22. [PMID: 17357377 DOI: 10.1080/15563650600795487] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The objective of this guideline is to assist poison center personnel in the out-of-hospital triage and initial management of patients with suspected exposure to long-acting anticoagulant rodenticides (LAAR). An evidence-based expert consensus process was used to create this guideline. It is based on an assessment of current scientific and clinical information. The panel recognizes that specific patient care decisions may be at variance with this guideline and are the prerogative of the patient and health professionals providing care. The grade of recommendation is in parentheses. 1) Patients with exposure due to suspected self-harm, abuse, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the doses reported (Grade D). 2) Patients with symptoms of LAAR poisoning (e.g., bleeding, bruising) should be referred immediately to an emergency department for evaluation regardless of the doses reported (Grade C). 3) Patients with chronic ingestion of LAAR should be referred immediately to an emergency department for evaluation of intent and potential coagulopathy (Grade B). 4) Patients taking anticoagulants therapeutically and who ingest any dose of a LAAR should have a baseline prothrombin time measured and then again at 48-72 hours after ingestion (Grade D). 5) Patients with unintentional ingestion of less than 1 mg of LAAR active ingredient can be safely observed at home without laboratory monitoring. This includes practically all unintentional ingestions in children less than 6 years of age (Grade C). 6) Pregnant patients with unintentional exposure to less than 1 mg of LAAR active ingredient should be evaluated by their obstetrician or primary care provider as an outpatient. Immediate referral to an ED or clinic is not required (Grade D). 7) Patients with unintentional ingestion of 1 mg or more of active ingredient and are asymptomatic should be evaluated for coagulopathy at 48-72 hours after exposure (Grade B). 8) Physicians' offices or outpatient clinics must be able to obtain coagulation study results in a timely manner, preferably in less than 24 hours, for patients who require outpatient monitoring (Grade D). 9) Gastrointestinal decontamination with ipecac syrup or gastric lavage is not recommended (Grade D). 10) Transportation to an emergency department should not be delayed for administration of activated charcoal (Grade D). 11) Patients with dermal exposures should be decontaminated by washing the skin with mild soap and water (Grade D). 12) The administration of vitamin K is not recommended prior to evaluation for coagulopathy (Grade D).
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Affiliation(s)
- E Martin Caravati
- American Association of Poison Control Centers, Washington, District of Columbia 20016, USA.
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Eaton V, Kaesler SB. Superwarfarin Poisoning. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2005. [DOI: 10.1002/j.2055-2335.2005.tb00303.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Vaughn Eaton
- Flinders Medical Centre; Bedford Park South Australia
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Abstract
Anticoagulant pesticides are used widely in agricultural and urban rodent control. The emergence of warfarin-resistant strains of rats led to the introduction of a new group of anticoagulant rodenticides variously referred to as 'superwarfarins', 'single dose' or 'long-acting'. This group includes the second generation 4-hydroxycoumarins brodifacoum, bromadiolone, difenacoum, flocoumafen and the indanedione derivatives chlorophacinone and diphacinone. Most cases of anticoagulant rodenticide exposure involve young children and, as a consequence, the amounts ingested are almost invariably small. In contrast, intentional ingestion of large quantities of long-acting anticoagulant rodenticides may cause anticoagulation for several weeks or months. Occupational exposure has also been reported. Anticoagulant rodenticides inhibit vitamin K(1)-2,3 epoxide reductase and thus the synthesis of vitamin K and subsequently clotting factors II, VII, IX and X. The greater potency and duration of action of long-acting anticoagulant rodenticides is attributed to their: (i) greater affinity for vitamin K(1)-2,3-epoxide reductase; (ii) ability to disrupt the vitamin K(1)-epoxide cycle at more than one point; (iii) hepatic accumulation; and (iv) unusually long biological half-lives due to high lipid solubility and enterohepatic circulation. Substantial ingestion produces epistaxis, gingival bleeding, widespread bruising, haematomas, haematuria with flank pain, menorrhagia, gastrointestinal bleeding, rectal bleeding and haemorrhage into any internal organ; anaemia may result. Spontaneous haemoperitoneum has been described. Severe blood loss may result in hypovolaemic shock, coma and death. The first clinical signs of bleeding may be delayed and patients may remain anticoagulated for several days (warfarin) or days, weeks or months (long-acting anticoagulants) after ingestion of large amounts. There are now sufficient data in young children exposed to anticoagulant rodenticides to conclude that routine measurement of the international normalised ratio (INR) is unnecessary. In all other cases, the INR should be measured 36-48 hours post exposure. If the INR is normal at this time, even in the case of long-acting formulations, no further action is required. If active bleeding occurs, prothrombin complex concentrate (which contains factors II, VII, IX and X) 50 units/kg, or recombinant activated factor VII 1.2-4.8 mg or fresh frozen plasma 15 mL/kg (if no concentrate is available) and phytomenadione 10mg intravenously (100 microg/kg bodyweight for a child) should be given. If there is no active bleeding and the INR is < or =4.0, no treatment is required; if the INR is > or =4.0 phytomenadione 10mg should be administered intravenously.
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Affiliation(s)
- Barbara E Watt
- National Poisons Information Service (Birmingham Centre), City Hospital, Birmingham, UK
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Tsutaoka BT, Miller M, Fung SM, Patel MM, Olson KR. Superwarfarin and Glass Ingestion with Prolonged Coagulopathy Requiring High-Dose Vitamin K1Therapy. Pharmacotherapy 2003; 23:1186-9. [PMID: 14524650 DOI: 10.1592/phco.23.10.1186.32755] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 23-year-old man was brought to the emergency department after eating four boxes of brodifacoum-containing rodenticide over a 4-day interval and pieces from approximately two bottles of glass over the previous 2 weeks. He was asymptomatic but his prothrombin time was markedly elevated with an international normalized ratio (INR) of 37.8. A plain abdominal film showed diffuse radiopaque foreign bodies, presumably glass, in the large and distal small intestines. Treatment for ingested glass consisted of stool softeners and bulk-forming laxatives. The patient developed mild gingival bleeding and received fresh frozen plasma (FFP) infusions and vitamin K1 orally. At a vitamin K1 dosage of 300 mg/day, the INR corrected to less than 2.0 and the patient was discharged taking that dosage. He returned 26 days later with hematuria and flank pain, and his INR was 189. He was administered FFP and packed red blood cells, and his vitamin K1 dosage was increased to 800 mg/day; his INR returned to baseline. Compliance with taking the vitamin K1, which required ingestion of 60-160 tablets/day, was a serious problem, requiring numerous follow-up calls and visits to the patient at home and work. At 5-month follow he was doing well. Compliance with large daily doses of vitamin K1 for treatment of "superwarfarin" ingestion may be poor because of the duration of treatment and large number of pills required. A more concentrated formulation may be advantageous for management of patients with brodifacoum poisoning.
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Affiliation(s)
- Ben T Tsutaoka
- California Poison Control System, San Francisco Division, Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California 94143-1369, USA
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The Humaneness of Rodent Pest Control. Anim Welf 2003. [DOI: 10.1017/s0962728600025355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
AbstractRat and mouse control methods potentially affect the welfare of many millions of animals every year. Here, the humaneness of the methods used in the UK and the USA is assessed in terms of their speed and mode of action, the appearance and behaviour of affected animals, experiences of human victims, long-term effects on animals that survive exposure, and welfare risks to non-target animals. Several methods emerge as relatively humane: cyanide, alpha-chloralose, electrocution traps and well-designed snap traps all usually kill swiftly and with little distress. Preventative methods such as rodent-proofing are also humane, as well as an essential — and probably under-used — component of effective control. However, anticoagulant poisons, the most common means of controlling rodents, generally take several days to kill, during which time they cause distress, disability and/or pain. Sub-lethally affected animals are also likely to experience haemorrhages and their sequelae, and carnivores feeding on affected rodents may be secondarily poisoned. The acute rodenticides zinc phosphide and calciferol are also generally inhumane, the former typically causing severe pain for several hours, and the latter, pain and illness for several days. Sticky boards, to which rodents become adhered by the feet and fur until they are killed or simply eventually die, also raise very serious welfare concerns. This evidence highlights remarkable paradoxes in the way society treats different classes of animal, and argues for more education, legislation and research targeted at reducing the vast numbers of rodents currently killed inhumanely.
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