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Acute Brodifacoum Poisoning: A Case Report of Intentional Ingestion of Rat
Poison Containing Brodifacoum
Hanna, M, OMSIII, Rivard, G, DO
Central Maine Medical Center, Lewiston, ME
Introduction: Current formulations of the commonly used rat poison, D-Con, contain a
second generation of anticoagulants called brodifacoum, often referred to as a
“superwarfarin.” This potent anticoagulant is long acting with effects lasting weeks to
months after the ingestion. According to the CDC, intoxication of rat poison can
“manifest as epistaxis, gingival bleeding, hematemesis, hematuria, hematochezia,
menometrorrhagia, ecchymosis, petechial hemorrhages, intracranial hemorrhages, or
bleeding.” Unfortunately, since there are currently no restrictions on the sale of these
poisons they are readily available. This case shows some of the possible side effects
that these poisons can cause when ingested intentionally.
Case: A 22 year old schizophrenic male presented worsening lethargy, weakness,
epistaxis, and finally an episode of syncope. He denied any history of trauma. Physical
exam was significant only for several large hematomas on his arms, legs, and back.
Routine toxicology screening came back negative. Laboratory studies were significant
for a hemoglobin of 6.1 and an INR too high to be detected. A detailed medical history
revealed that he had recently attempted suicide by drinking ethylene glycol. This
prompted further questions about other possible substances that he might have
ingested. Patient admitted to ingesting 3 and ½ boxes of D-Con rat poison 7 to 10 days
prior to his syncopal episode. After 4 units of fresh frozen plasma and 7 units of packed
red blood cells his hemoglobin levels rose to above 7 and the patient was transferred to
a larger medical facility. At transfer, his INR was down to 9.01. Poison Control was
consulted and the half-life of this poison was determined to be multiple weeks to
months. To prevent excessive bleeding during this time, the patient was started on
300mg of Vitamin K orally and would continue this for months while his INR remained
high.
Discussion: In 2010, there were 38,364 suicides in the United States, according to the
CDC. This case illustrates how important it is to expand our differential toxicology
diagnosis when treating patients with known suicidal ideation. There are many legal
substances that are readily available to someone who is willing to attempt suicide by
ingestion. Given the ease of access, rat poison should be placed high on the list of
differentials for possibly suicidal patients who come in with sudden coagulopathies.