Of Rats & Men: Approach to Coumadin Overdose in the PICU

In this episode of PICU Doc on Call, hosts Dr. Monica Gray and Dr. Pradip Kamat discuss a 15-year-old girl who attempted suicide by ingesting rat poison, acetaminophen, ibuprofen, and amlodipine. The episode focuses on long-acting anticoagulant rodenticides (LAARs), such as brodifacoum, which inhibit vitamin K epoxide reductase, causing delayed coagulopathy. Key topics include clinical presentation, diagnostic evaluation, and management, emphasizing vitamin K1 as the primary antidote and prothrombin complex concentrate or fresh-frozen plasma for major bleeding. The patient stabilized with aggressive supportive care, including vasoactive agents and NAC therapy, alongside psychiatric intervention. Listen to learn more!

Show Highlights

• Clinical case of a 15-year-old girl who attempted suicide through polypharmacy ingestion
• Ingestion of multiple substances, including chewable rat poison, acetaminophen, ibuprofen, and amlodipine
• Discussion of toxicology related to long-acting anticoagulant rodenticides (LAARs) like brodifacoum
• Symptoms and clinical presentation following acute ingestion, including metabolic acidosis and elevated lactate
• Diagnostic evaluation and laboratory findings, including coagulation studies and liver function tests
• Management strategies for LAAR poisoning, including the use of vitamin K and supportive care
• Importance of monitoring for delayed coagulopathy and serial INR testing
• Consideration of calcium channel blocker toxicity in the context of the patient's clinical instability
• Overview of the mechanisms of action of LAARs and their impact on vitamin K-dependent clotting factors
• Key take-home points regarding the recognition and management of rodenticide ingestion in pediatric patients

References

Reference: King N, Tran MH. Long-Acting Anticoagulant Rodenticide (Superwarfarin) Poisoning: A Review of Its Historical Development, Epidemiology, and Clinical Management. Transfus Med Rev. 2015 Oct;29(4):250-8.

Reference 2: Feinstein DL, Akpa BS, Ayee MA, et al. The emerging threat of superwarfarins: history, detection, mechanisms, and countermeasures. Ann N Y Acad Sci. 2016 Jun;1374(1):111-22.