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54 year old female presented with:
C/O:
Dizziness
Hemoptysis Of 5 Days Duration
Epistaxis
Vertigo
Facial Swelling
ON EXAMINATIONMultiple Ecchymoses over Chest both Lower Limbs
Hematoma noted around Tonsil region
Jaundice:Mild Anemic:MildLN:NilCyanosis:NilClubbing:NilOedema:NilDehydration:Nil
VITALS:P:80/minBP:100/70mmHgR/R:20/minT:36.6c
MEDICAL h/o:HTN+,no DM,PTB,Hepatitis
SURGICAL h/o:non significant
ALLERGIC h/O:non significant
PERSONAL h/o:Alcoholic+
INVESTIGATIONS
COMPLETE BLOOD COUNT:
WBC:17.32X10*9/L(N=77.9%),L(14.1%),
RBC:2.44X10*12/L,HB:203g/L,HCT:60.2%,MCV:101.2fl
PLT:322X10*9/L
RENAL FUNCTION TEST:
Urea:6.8mmol/L,Cr:122umol/L
Na:140mmol/L,K:3.7mmol/L
Coagulation Profile
Prothrombin Time(PT): >120s
APTT:>180s
INR>10
Thromboplastin Time:16.2s
Fibrinogen:4.26g/L
D Dimer:Negative
Differential Diagnosis
Coagulation Abnormalities? Cause
Hemoptysis of unknown origin
WARFARIN Toxicity
Chronic Liver Disease
Moderate Anemia
Hemophilia
Composition of Rat Poisoning( Rodenticide)
CLASS(Anticoagulant) EXAMPLES
COUMARINS First Generation:Warfarin,CoumatetralylSecond Generation : Difenacoum,Bromadilolone
1,3 INDANDIONES Diphanicone,Pindone
INDIRECT Sometimes, anticoagulant rodenticides are potentiated by an antibiotic or bacteriostatic agent. The aim of this association is that the antibiotic suppresses intestinal symbiotic microflora, which are a source of vitamin K
These are generally Chronic(death usually occurs after few weeks after consumption of lethal dose,rarely sooner).
These acts by blocking Vitamin K cycle leading to inability to produce coagulation factor II,VII.IX,X.
Phosphide Used Rodentocide
Metal phosphides have been used as a means killing of rodents and are considered single-dose fast acting rodenticides (death occurs commonly within 1–3 days after single bait ingestion). A bait consisting of food and a phosphide (usually zinc phosphide) is left where the rodents can eat it.
AVAILABLE PHOSPHIDES:ALUMINIUM PHOSPHIDESMAGNESIUM PHOSPHIDESZINC PHOSPHIDES
Calciferols (vitamins D), cholecalciferol (vitamin D3) and ergocalciferol (vitamin D2)
They affect Calcium and Phosphate homeostasis.
On larger doses consumption causes Hypervitaminosis.
Hypercalcemia tends to affect Cardiac Muscle(affecting Contractility),Blood Vessels(leading to bleeding due to capillary damage) and Possibly ARF.
They are also synergetic with anticoagulants.
A suggested algorithm for the management of a warfarin- treated patient whose international
normalized ratio (INR) exceeds 4.
Garcia D A , and Crowther M A Circulation. 2012;125:2944-
2947
Copyright © American Heart Association, Inc. All rights reserved.
The prothrombin time (PT) and its derived measures of prothrombin ratio (PR) and international normalized ratio (INR) are measures of the extrinsic pathway of coagulation. This test is also called "ProTime INR" and "PT/INR".
DISCUSSIONS
What is the role of Calcium Gluconate in the treatment, since the composition of Rodentocide also may consists of excessive Calcium?
Vitamin K dependent coagulation factor(II,VII,IX,X),can it be tranfused directly?
What Should be the target INR in management of this patient?
Random Blood Glucose Level is high is it not worthy sending Fasting & PP Blood Sugar?
Reference
http://circ.ahajournals.org/content/125/23/2944.full
www.aapf.org
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