warfarin and Poisoning

Topics: Adsorption; Animals; Antidotes; Body Temperature; Cat Diseases; Cats; Charcoal; Dog Diseases; Dogs; Emetics; Gastric Lavage; Glycols; Insecticides; Lead Poisoning; Organophosphorus Compounds; Poisoning; Respiration, Artificial; Thallium; Warfarin

In this study, an analytical strategy to identify brucine, strychnine, methomyl, carbofuran (alkaline compounds), phenobarbital, and warfarin (acid compounds) using thin-layer chromatography (TLC) screening with ultraviolet (UV) detection at 254 nm in stomach content is shown. The optimum mobile phase was found to be a chloroform: ethyl acetate: diethylamine (0.5:8.5:1) mixture for alkaline substances while a mixture of chloroform: acetone (9:1) has given better results for acidic substances. As for extraction, an equal proportion between distillated water and crude material (1:1) is required. For alkaline compounds, a filtration system was created in order to avoid any interferences from the biological matrix while for acidic compounds only centrifugation (4000 rpm/10 minutes) was required to obtain an appropriate sample. After the respective pretreatments, a one-step liquid-liquid extraction (LLE) has been employed for alkaline substances using a 3 mL of chloroform: ethyl ether (2:1) mixture for 2 min while acidic analytes used 3 mL of chloroform only during 5 min. For both methodologies described, the respective organic layers were dried down and re-suspended with 50 µL of methanol for further TLC plate application. The methodologies have been developed, successfully validated and applied to gastric contents from real case samples of suspected animal poisoning. Positive results from TLC/UV screening were confronted with HPLC-UV and confirmed by GC-MS.

Topics: Alkaloids; Animals; Carbamates; Cat Diseases; Cats; Chromatography, Thin Layer; Dog Diseases; Dogs; Gastrointestinal Contents; Phenobarbital; Poisoning; Warfarin

Warfarin- and superwarfarin-type anticoagulants are commonly used as rodenticides. Exposure to these agents, especially superwarfarins with long-acting anticoagulant effect, can cause life-threatening coagulopathy in humans. Most superwarfarin poisoning cases had an obvious history of exposure, though occult cases without exposure history have also been reported. The current study aims to examine anticoagulant-type rodenticide poisoning in Hong Kong and to identify the similarities and differences between patients with known exposure history and those whose exposure is recognized only through laboratory testing.. The present study was conducted in a tertiary referral clinical toxicology laboratory in Hong Kong. This was a retrospective cohort study of all patients with biochemically confirmed anticoagulant-type rodenticide exposure, from 2010 to 2014.. Superwarfarin was the most common group of anticoagulant-type rodenticides identified (87.8%), in which bromadiolone and brodifacoum were the most frequently encountered. Among the 41 cases identified, 31 had an obvious exposure history, and 10 were occult poisoning in which the context of exposure remained unidentified. All occult poisoning patients without exposure history presented with bleeding events. These occult poisoning cases often went unrecognized by frontline clinicians, leading to delayed investigation and initiation of treatment. This group of patients was associated with a longer time to diagnose coagulopathy (p < 0.001) and confirm rodenticide poisoning (p < 0.05), a higher rate of international normalized ratio (INR) rebound after initiation of antidote (p < 0.001), and a longer time needed for normalizing INR (p < 0.05).. Occult superwarfarin poisoning is an important yet under-recognized differential cause of unexplained coagulopathy. A high index of clinical suspicion and availability of specialized toxicological test for superwarfarins play a vital role in diagnosis and early initiation of appropriate management. The underlying cause of such poisoning remains obscure and warrants further study.

Topics: 4-Hydroxycoumarins; Adolescent; Adult; Aged; Aged, 80 and over; Anticoagulants; Blood Coagulation Disorders; Cohort Studies; Female; Hemorrhage; Hong Kong; Humans; Infant; International Normalized Ratio; Male; Middle Aged; Poisoning; Retrospective Studies; Rodenticides; Vitamin K; Warfarin; Young Adult

Superwarfarin, a common component of rat poison, can cause long-lasting, severe coagulopathy and life-threatening hemorrhage when ingested. We report a case of intentional rat poison consumption with subsequent hemorrhage and hypotension requiring rapid coagulopathy reversal and resuscitation in the emergency department. In addition to traditional blood products, prothrombin complex concentrate was administered. Although prothrombin complex concentrate is increasingly used for severe hemorrhage in anticoagulated patients, it may be particularly useful in superwarfarin ingestions given the extreme, persistent coagulapathies that can occur.

Topics: Anticoagulants; Blood Coagulation Factors; Humans; Male; Middle Aged; Poisoning; Vitamin K; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Aryl Hydrocarbon Hydroxylases; Coagulants; Cytochrome P-450 CYP2C9; Female; Genotype; Humans; Poisoning; Treatment Outcome; Vitamin K; Warfarin

We report a patient who attempted suicide by taking warfarin as a coumarin rodenticide twice, and showed oral bleeding and an abnormally prolonged bleeding tendency after 10 days. He was conscious. His body temperature was 36.6 degrees C, the respiratory rate was 23/min, and blood pressure was 142/87 mmHg. A bite wound showing continuous bleeding was observed on the right side of the oral cavity. CT of the head and upper gastrointestinal endoscopy showed no intracranial and gastrointestinal bleeding,respectively. The PT and INR were extremely high, and complete blood count revealed anemia. Blood chemistry showed hypoproteinemia. Occult blood was strongly positive. Routine urine examination and electrocardiography showed neither abnormal nor characteristic findings. In drug/ poison screening tests, GC/MS analysis revealed warfarin artifacts in serum and urine samples. Warfarin was isolated from each sample, converted to a TMS derivative, and quantified by SIM analysis of GC/MS. During the clinical course, KaytwoN (vitamin K) was intravenously administered at a dose of 20 mg since the INR at the first consultation was 20.89. After admission to the ICU, 20 mg Kaywan (vitamin K) was orally administered, and the INR after 5 hours improved to 2.32. Kaywan administration (20 mg/day) was initiated, and he improved and was discharged 5 days after admission. The definite cause could be clarified by drug/poison analysis, and effective treatment could be performed.

Topics: Antifibrinolytic Agents; Coumarins; Gas Chromatography-Mass Spectrometry; Humans; Male; Middle Aged; Poisoning; Rodenticides; Suicide, Attempted; Treatment Outcome; Vitamin K; Warfarin

Superwarfarin poisoning is considered a significant public health problem in the US. In 2004, there were 16,054 cases of poisoning; most were accidental ingestions of rat bait by children but 4576 patients required hospital treatment, 23 patients had major adverse outcomes and 1 patient died. Similar information is unavailable for the UK. The National Poisons Information Service is presently auditing cases. The case of a farmer who presented with haematuria, 9 days after spilling a rodenticide containing a superwarfarin over himself is reported here. He was physically well except for mild abdominal tenderness. He had grossly deranged clotting studies (prothrombin time (PT) >200 s, activated partial thromboplastin time (APTT) 56 s) that were rapidly corrected with fresh frozen plasma and vitamin K. He was sent home after 5 days without follow up. Unfortunately, he presented again 2 days later, again with haematuria and an international normalised ratio (INR) >10. He required inpatient treatment with high-dose vitamin K for 1 week. Upon discharge, he required daily vitamin K and INR monitoring for a further month. The original inpatient team had not identified the specific poison (chlorophacinone). They were unaware that superwarfarins are more potent and longer acting than warfarin, with toxic effects for weeks or even months, and that large doses of vitamin K are often required.

Topics: Hematuria; Humans; International Normalized Ratio; Male; Middle Aged; Poisoning; Prothrombin Time; Recurrence; Rodenticides; Vitamin K; Warfarin

Topics: Adolescent; Adult; Delayed-Action Preparations; Female; Humans; Male; Middle Aged; Poisoning; Rodenticides; Warfarin

Topics: Adverse Drug Reaction Reporting Systems; Animals; Anticoagulants; Antifibrinolytic Agents; Dog Diseases; Dogs; Drug Hypersensitivity; Drug Labeling; Humans; Injections, Intravenous; Poisoning; Rodenticides; United States; United States Food and Drug Administration; Vitamin K 1; Warfarin

To examine patients who presented to a hospital emergency department with evidence of warfarin toxicity, and to review the available published literature to determine what guidelines are available for management of this problem.. A retrospective analysis of all adult patients who presented to The Geelong Hospital Emergency Department between 1 January 1996 and 30 June 1998 with international normalized ratio > 6 due to warfarin toxicity.. A total of 84 patients with international normalized ratio > 6 were included in the study. The average age was 68.3 years. Fifty-three per cent were women. The international normalized ratio was between 6 and 10 in 33 patients (39%), and greater than 10 in 51 patients (61%). Major bleeding occurred in 16.7% of patients, minor bleeding in 17.8%. Sixty-five per cent had no bleeding. Seven patients died, four of those with bleeding. Patients with an international normalized ratio > 10 were more likely to receive fresh frozen plasma (77.6% vs 28.6%; P < 0.001) and in greater amounts (3.0 units vs 0.8 units; P < 0.001) than those with an international normalized ratio of 6-10. There were also more episodes of major bleeding, although not significant. Patients with major bleeding were older (mean 75.4 years vs 67.5 years; P = 0.04), more likely to be admitted (P = 0.046), were more often given fresh frozen plasma (P = 0.003) and in greater amounts (3.28 units vs 2.0 units; P = 0.02).. Warfarin toxicity is a common problem, and variation in management is not surprising considering the lack of consensus in the literature on this topic. Current recommendations are summarized and a simple flowchart for management of this problem is provided.

Topics: Adult; Aged; Aged, 80 and over; Algorithms; Anticoagulants; Emergency Treatment; Female; Hemorrhage; Humans; Male; Middle Aged; Plasma; Poisoning; Practice Guidelines as Topic; Retrospective Studies; Risk Factors; Victoria; Vitamin K; Warfarin

From 1971 through 1997, we documented 51 cases (55 individual animals) of poisoning of non-target wildlife in New York (plus two cases in adjoining states) (USA) with anticoagulant rodenticides--all but two of these cases occurred in the last 8 yrs. Brodifacoum was implicated in 80% of the incidents. Diphacinone was identified in four cases, bromadiolone in three cases (once in combination with brodifacoum), and chlorophacinone and coumatetralyl were detected once each in the company of brodifacoum. Warfarin accounted for the three cases documented prior to 1989, and one case involving a bald eagle (Haliaeetus leucocephalus) in 1995. Secondary intoxication of raptors, principally great horned owls (Bubo virginianus) and red-tailed hawks (Buteo jamaicensis), comprised one-half of the cases. Gray squirrels (Sciurus carolinensis), raccoons (Procyon lotor) and white-tailed deer (Odocoileus virginianus) were the most frequently poisoned mammals. All of the deer originated from a rather unique situation on a barrier island off southern Long Island (New York). Restrictions on the use of brodifacoum appear warranted.

Topics: 4-Hydroxycoumarins; Animals; Animals, Wild; Anticoagulants; Bird Diseases; Deer; Hemorrhage; Indans; New York; Phenindione; Poisoning; Raccoons; Raptors; Rodenticides; Sciuridae; Warfarin

Suicide attempts are frequent during adolescence. Intentional ingestion of rat poison is not well known in France. The complications of this are prolonged and may be serious.. An adolescent, 15 years old, with clinical hemorrhagic syndrome, had coagulation deficiency. Rat poison had been found in serum. The young girl recognized later that the ingestion of these toxins was intentional.. Suicide attempt with rat poison is exceptional, but we have to mention it when vitamin K-dependent factors failed without any other explication.

Topics: Adolescent; Animals; Factor VII; Factor X; Female; Humans; Poisoning; Prothrombin; Rats; Rodenticides; Suicide, Attempted; Vitamin K 1; Warfarin

Because of the emergence of warfarin resistance in rodents, second-generation anticoagulants named "superwarfarins" were developed and marketed in over-the-counter rodenticide products. The availability of these compounds has resulted in accidental or intentional human ingestions, which cause severe bleeding. The methods for diagnosis and treatment of patients using superwarfarins are different from those for patients taking the regular warfarins. We report a case of intentional superwarfarin ingestion that caused petechiae and hematuria. Although the patient denied taking anticoagulant, the persistence of vitamin K-dependent factor deficiency led us to investigate the serum for anticoagulant rodenticides. We found high levels of brodifacoum, a superwarfarin compound. This case emphasizes the need for suspicion of superwarfarin poisoning in patients who show unexplained bleeding due to deficiency of vitamin K-dependent factors and resistance to treatment.

Topics: 4-Hydroxycoumarins; Adult; Blood Coagulation Tests; Hematuria; Humans; Male; Poisoning; Rodenticides; Vitamin K Deficiency; Warfarin

Topics: Acute Disease; Aftercare; Child; Humans; Poisoning; Warfarin

A case of intercerebral hematoma due to warfarin-induced coagulopathy is presented. The 39-year-old woman had spread a warfarin-type rat poison around her house weekly using her bare hands, with no washing post application. Percutaneous absorption of warfarin causing coagulopathy, reported three times in the past, is a significant risk if protective measures, such as gloves, are not used. An adverse drug interaction with piroxicam, which she took occasionally, may have exacerbated the coagulopathy.

Topics: Administration, Cutaneous; Adult; Cerebral Hemorrhage; Drug Interactions; Female; Humans; Piroxicam; Poisoning; Rodenticides; Warfarin

Topics: Acute Disease; Humans; Infant; Male; Poisoning; Prothrombin Time; Time Factors; Treatment Failure; Warfarin

Topics: Animals; Antidotes; Blood Transfusion; Cattle; Cattle Diseases; Cyanides; Drug Combinations; Insecticides; Lead Poisoning; Nitrates; Poisoning; Thiosulfates; Warfarin

Topics: Animals; Animals, Domestic; Cats; Dogs; Poisoning; Rodent Control; Swine; Warfarin

Topics: Animals; Animals, Zoo; Bird Diseases; Birds; Deer; Fish Diseases; Fishes; Fluorine; Fluoroacetates; Lead Poisoning; Mercury Poisoning; Monkey Diseases; Mycotoxins; Pest Control; Plant Poisoning; Poisoning; Rodenticides; Warfarin; Xenarthra

Topics: Animals; Chickens; Poisoning; Poultry Diseases; Warfarin

Topics: Animals; Cats; Dogs; Poisoning; Surveys and Questionnaires; Warfarin

Topics: Adult; Aged; Alkaline Phosphatase; Aspartate Aminotransferases; Bilirubin; Blood Coagulation Factors; Child; Factor IX; Factor VII; Factor X; Female; Hemophilia B; Hepatitis A; Hepatitis B Antigens; Humans; Liver Diseases; Liver Function Tests; Male; Middle Aged; Poisoning; Prothrombin; Warfarin

Topics: Animals; Dog Diseases; Dogs; Female; Poisoning; Vitamin K 1; Warfarin

Topics: Animals; Poisoning; Swine; Swine Diseases; Vitamin K; Warfarin

Topics: Animal Feed; Animals; Chromatography; Chromatography, Paper; Diagnosis, Differential; Methods; Poisoning; Rodenticides; Ultraviolet Rays; Warfarin

Topics: Blood Coagulation Tests; Criminals; Diagnosis; Factor IX; Factor VII; Factor X; Geriatrics; Hemorrhagic Disorders; Humans; Poisoning; Prothrombin Time; Toxicology; Vitamin K; Warfarin

Topics: Coumarins; Humans; Poisoning; Warfarin