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 HighlightsClinical case of a 15-year-old girl who attempted suicide through polypharmacy ingestionIngestion of multiple substances, including chewable rat poison, acetaminophen, ibuprofen, and amlodipineDiscussion of toxicology related to long-acting anticoagulant rodenticides (LAARs) like brodifacoumSymptoms and clinical presentation following acute ingestion, including metabolic acidosis and elevated lactateDiagnostic evaluation and laboratory findings, including coagulation studies and liver function testsManagement strategies for LAAR poisoning, including the use of vitamin K and supportive careImportance of monitoring for delayed coagulopathy and serial INR testingConsideration of calcium channel blocker toxicity in the context of the patient's clinical instabilityOverview of the mechanisms of action of LAARs and their impact on vitamin K-dependent clotting factorsKey take-home points regarding the recognition and management of rodenticide ingestion in pediatric patientsReferencesReference: 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.