Clinical Study On 71 Cases Of Anticoagulant Rodenticide Poisoning

Objective This study aimed to summarize the clinical characteristics and therapeutic effect of anticoagulant rodenticide poisoning to improve the understanding and diagnosis and treatment of this disease.As well as analyze and explore the misdiagnosis causes of anticoagulant rodenticide poisoning to improve the diagnostic accuracy.Methods We retrospectively analyzed 71 cases with anticoagulant rodenticide poisoning admitted to Poisoning and Treatment Center of our hospital during December 2013 to September 2016,including the general information,poisoning causes,poisoning time,hospitalization time,clinical manifestation,hemoglobin and blood coagulation function,toxic test,diagnosis,prognosis.We retrospectively analyzed 27 misdiagnosed cases with anticoagulant rodenticide poisoning admitted to our hospital during December 2013 and September 2016.All patients were followed up 3 months to 1 years after discharge.Results 71 patients with anticoagulant rodenticide poisoning comprised 44 males and 27 females with an average age of 40 years（rang 15 to 79）were hospitalized from December 2013 and September 2016.The average poisoning time was 12 days,the average hospitalization time was 12 days.The main causes of poisoning include suicide（27 cases）,misuse（7 cases）,murder（1 cases）,and unknown reasons（36 cases）.27 cases were from Hebei,16 from Beijing,7 cases from Shanxi,5 cases from Inner Mongolia,each 3 cases from Shandong and Hubei,each 2 cases from Shanxi,Sichuan and Jiangxi,each 1 case from Liaoning,Hunan,Guangxi and Henan.21 cases of patients were come from the city,accounting for 29.58%,50 cases from rural areas,accounting for 70.42%.According to the Poisoning severity score（PSS）,10 patients were mild poisoning,24 patients were moderate poisoning,37 patients were severe poisoning.65 patients were admitted to the toxic test of brodifacoum,and the concentration was 9-5300ng/ml,with an average of 95ng/ml.34 patients were discharged with a reexamination of toxic test,the concentration was 2-2456ng/ml,the average was 162.5ng/ml.70 patients were admitted to the toxic test of bromadiolone,and the concentration was 3-4348ng/ml,with an average of 30ng/ml.6 patients were discharged with a reexamination of toxic test,the concentration was 7-26ng/ml,the average was 16.2ng/ml.The index of blood coagulation function was significantly better than that of admission,which was statistically significant.The average amount of vitamin K₁ intake was 60mg/ d,the dosage was 10mg/ d after discharge,the average vitamin K₁ time of withdrawal was 9 days to 14 months after discharge,the average was 3 months,and the concentration of anticoagulant rodenticide was 0-85ng/ml when vitamin K₁ was stopped,the average was 11ng/ml.42 patients required discharge before getting ideal treatment goals,and the other 29 cases were discharged after getting improved.A total of 140 cases of patients had clinical manifestations of repeated long-term multi-site bleeding,hematuria,gingival bleeding,（ear）nasal bleeding were the main symptoms of the disease,totally 83 cases（59.3%）,there were also subcutaneous ecchymosis（9 cases）,abdominal pain（9 cases）,blood in the stool（8 cases）,vaginal bleeding（5 cases）,limb pain（5 cases）,nausea and vomiting（3 cases）,low back pain（3 cases）,conjunctival hemorrhage（2 cases）,hematemesis,sputum blood and fatigue 1 case each.There were statistically significant differences in the gender,the causes of poisoning,and the indexes of blood coagulation（PT,APTT,PTA）.There was a significant correlation between the time of poisoning and the function of blood coagulation and the amount of toxicant.There was a correlation between the amount of vitamin K₁ and the indexes of blood coagulation function,hemoglobin and the amount of toxicant.Vitamin K₁ withdrawal time was correlated with the amount of toxicant,which had statistically significant differences.2 patients did not use vitamin K₁ after discharged,the outcome was died.The misdiagnosis rate was 38.1%,a total of 43 cases were misdiagnosed.Misdiagnosis time was 1 day to 7 months,the average misdiagnosis time was 24.8 days.Misdiagnosis hospitals: community hospital（clinic）7 cases,17 cases of secondary hospital,tertiary hospital 17 cases,unknown（local hospital）2 cases.The misdiagnosed cases covered 14 diseases,the top four misdiagnosed diseases were: urinary calculi（5 cases）,blood coagulation disorders（5 cases）,urinary infection（3 cases）and gingival bleeding（3 cases）.The others were: 2 cases of epistaxis,2 cases of hematological disease,nitrite poisoning,infectious diseases,venous thrombosis of the lower extremities,appendicitis,vaginal bleeding,lumbar disc herniation,tumor lesions with bleeding 1 case each,16 cases of no definite diagnosis.Clinical manifestations were diverse: 23 cases of hematuria,10 cases of gingival bleeding,8 cases（ears）nasal bleeding,5 cases of limb pain（or disability）,4 cases of menorrhagia,back pain,abdominal pain in 2 cases,1 cases of hematochezia,asymptomatic（coagulopathy）1 case.19 patients showed abnormal coagulation parameters,14 patients with hematologic analysis suggest moderate to severe anemia.All the patients met the criteria of clinical diagnosis of anticoagulant rodenticide poisoning.After confirmed diagnosis,the patients were treated with fluid resuscitation,vitamin K₁,plasma infusion,hemoperfusion and so on.Their outcomes were good.There were no severe allergies and adverse reactions of VK₁ in hospitalized patients.Conclusion 1.In this study,the number of male is more than female;the morbidity of rural areas is more than the city,mainly in young and middle-aged,with an average poisoning time of 12 days.The main causes of poisoning include suicide,misuse,murder,and unknown reasons.2.Anticoagulant rodenticide poisoning was mainly manifested as coagulation dysfunction and spontaneous hemorrhage in different parts of the body.As to the unexplained hematuria,（mouth）bleeding gums,（ears）nasal bleeding and other symptoms demonstrated patients,clinicians should consider the possibility of anticoagulant rodenticide poisoning and arrange the relevant laboratory tests as soon as possible.3.Vitamin K₁ is a specific antagonist of anticoagulant rodenticide poisoning.The dosage of vitamin K₁ and the time of drug use were positively correlated with the concentration of toxin and prothrombin time,but negatively correlated with prothrombin activity and hemoglobin.4.The use of vitamin K₁ should be adequate dosage and duration.The treatment should be adjusting the dosage of vitamin K₁ gradually based on coagulation function and the concentration of anticoagulant rodenticide,the average vitamin K₁ time of withdrawal was 3 months after discharge,may up to 14 months.The average dosage was 10mg/d after discharge,and the average concentration of anticoagulant rodenticide was 11ng/ml when vitamin K₁ was stopped.Pay attention to prevent/treat vitamin K₁ adverse reactions,and timely supplying red blood cells to ameliorated anemia.5.Hemoperfusion is effective in reducing the concentration of toxicant in patients with anticoagulant rodenticide poisoning,which can shorten the total time of treatment,especially for patients with high concentrations of toxic blood.6.Anticoagulant rodenticide poisoning is insidious,with various clinical manifestations.It tends to be misdiagnosed.It implies that clinicians should deepen the understanding of anticoagulant rodenticide poisoning.The possibility of anticoagulant rodenticide poisoning should be considered when blood coagulation disorders that cannot be explained by merely one reason.7.Poison detection is specific for diagnosis of anticoagulant rodenticide poisoning,and coagulation tests and vitamin K₁ treatment can help to differentiate the diagnosis.In order to improve the rate of diagnosis,doctors should be strengthen the understanding of anticoagulant rodenticide poisoning,especially for junior or non-poisoning specialists.