Clinical profile and outcome of rodenticide poison in Hassan institute of medical science, Hassan

 

 

Abstract              Background and Aim of the study: Rodenticide is the most freely accessible and most commonly involved in poisoning either intentionally or accidentally. The mortality rates vary depending on the content of rodenticide. There is no specific antidote for rodenticide poisoning. The lack of antidote and progressive damage of the tissues due to this poisoning makes the management more difficult and challenging. This poisoning is very common in our part. Hence, this study is taken up to evaluate the clinical profile of the patients with this poison and outcome of the patients. Material and Methods: Source of data: All in-patients admitted in medicine department with rodenticide poisoning were included in the study. Study period- from November 2016 to October 2017. Inclusion criteria: Age >18 years. History of rodenticide poisoning only. Exclusion criteria Mixed poisoning cases. The data and information pertaining to the cases was collected and recorded in a predesigned proforma. Wherever possible the attendants of the patient are asked to get the poison package or the package information leaflet of the poison to confirm the poison. Complete Hemogram, renal function tests, liver function tests, prothrombin time, ECG were done for all the patients. Other investigation like Arterial Blood Gas Analysis was performed only when indicated hence it is not performed for all the patients. Results: 75 patients with rodenticide poisoning studied, male patients dominated the study, majority of the patients belonged to 18-40 years. Zinc phosphide (48%) and aluminium phosphide (26.6%) poison were frequently consumed in our study, compared to yellow phosphorous (18.6%) and super warfarins (6.6%), more deaths were seen in aluminium phosphide and zinc phosphide patients. Conclusion: Our study concluded that high mortality was seen in aluminium phosphide and zinc phosphide compared to yellow phosphorous and super warfarin. Younger generation needs to be educated about rodenticide poison and its consequences.

Key Word: Rodenticide, Poisoning, Aluminium phosphide, Zinc phosphide.

 

INTRODUCTION

Suicidal consumption of rodenticides is common in India ¹. The composition of different rodenticides varies and different rodenticides have different toxicity. Many of them are hepatotoxic and can cause acute liver failure². In the absence of definite antidote mortality in poisoning due to rodenticide is high ². Rodenticides, more commonly referred to as rat poisons, are of following common types-anticoagulants, metal phosphides (aluminium phosphide, zinc phosphide), yellow phosphorus. Other types include Calciferols and Barium carbonate. Each one of them has different methods of action. Hence they have different toxicological profiles with variable fatality rates in humans when consumed by accident or intentionally³. Anticoagulants commonly used as a rodenticide are Bromadiolone. It is a second generation 4-hydroxycoumarin derivative and Vitamin K antagonist. It is commonly referred to as “Super Warfarin” due to its potency. It inhibits Vitamin K epoxide reductase which is required for regeneration of Vitamin K thus preventing the maturation of vitamin K dependant clotting factors. Metal phosphides commonly used are aluminium phosphide (ALP) and zinc phosphide. Aluminium phosphide is used as a fumigant while zinc phosphide is used as bait. Aluminium Phosphide is used as a solid fumigant used for grain storage. It is also cheap and easily available. They are colloquially referred to as “Rice Tablets”. It is available in the tablet form in sizes of around 2cm diameter and 0.5 cm thickness. Sizes vary between different manufacturers. When exposed to water or moisture in the air it releases phosphine gas which is cytotoxic. The toxicity of aluminium phosphide is attributed to the liberation of phosphine gas, a cytotoxic compound that causes free radical mediated injury, inhibits vital cellular enzymes and is directly corrosive to tissues⁴. inc phosphide is used as in bait in concentration of 0.75-2.0% the baits have strong and pungent garlic like odour due to phosphine gas⁵. Phosphine is produced on exposure to water and it mediates the toxicity. Yellow Phosphorus (white phosphorus) is commonly available as a paste which is spread over bait. “RATOL” is the most popular brand. Phosphorus is a general protoplasmic poison causing cardiac, hepatic, renal, and multi organ failure. Calciferols (alone or with anticoagulants) are used as rodenticides. It acts by causing hypercalcemia by increasing absorption from the intestines and by mobilising skeletal reserves. It leads to renal failure, cardiac abnormalities, hypertension, CNS depression, anorexia, vomiting, diarrhoea, and lethargy⁴. The mortality rate for aluminium phosphide poisonings vary from 40-80% according to various studies⁶.Mortality rates of yellow phosphorus poisoning varies from 23-73%⁷.The mortality rate of zinc phosphide poisoning is around 37-100%⁸. Rodenticde poison are a heterogeneous substances with different toxicities to humans and rodents, there are variety of rodenticides used over years⁹.Some of these compounds have been abandoned for serious human toxicity, they are Aluminium phosphide, zinc phosphide, strychnine, arsenic, thallium, yellow phosphorous and zinc phosphide⁷.

 

MATERIAL AND METHODS

Study design- Descriptive observational study Source of data: All in-patients admitted in medicine department in HIMS teaching hospital with rodenticide poisoning were included in the study. Study period- from November 2016 to October 2017.Instituational ethical committee clearance was taken prior to the study.

INCLUSION CRITERIA: Age >18 years. History of rodenticide poisoning only.

EXCLUSION CRITERIA Mixed poisoning cases. The data and information pertaining to the cases were collected and recorded in a predesigned proforma. Wherever possible the attendants of the patient are asked to get the poison package or the package information leaflet of the poison to confirm the poison. Complete Hemogram, renal function tests, liver function tests, prothrombin time, ECG were done for all the patients. Other investigation like Arterial Blood Gas Analysis was performed only when indicated hence it is not performed for all the patients. The obtained information was analysed through descriptive statistical method. All patients with rodenticide poisoning in our study were given supportive care. Gastric lavage was done and blood investigations were sent from the casualty, patients were given intravenous fluids, proton pump inhibitors, injection vitamin K was given for PT(prothrombin time) prolonged cases and FFP was given if there was a bleeding manifestation. Patients were shifted to ICU if required.

 

RESULTS

75 patients with rodenticide poisoning studied, male 45 (60%) patients dominated the study (Figure 1), majority of the patients belonged to 18-40 years 57(76%) (Figure2). Rodenticide was consumed intentionally in 73 (97.3%) cases where as 2(2.6%) cases had taken accidentally. Zinc phosphide(36) 45% and aluminium phosphide(20) 26% poison were frequently consumed rodenticides in our study, compared to yellow phosphorous(14) 18% and super warfarins(5) 6.6%(figure 3), more deaths were seen in aluminium phosphide 8 cases out of 20(40%) (figure 5) and zinc phosphide patients 12(33.3%) cases out of 36(figure 4). Liver function abnormalities were seen in aluminium phosphide 5cases (25%), zinc phosphide 10(27.7%) and yellow phosphorous 6 cases(42%) Figure(6).Most common symptoms were nausea and vomiting 56(74.6%) cases and abdominal pain in 18(24%) cases. Ictreus was seen in 22 patients (29.3%). Bleeding complication was seen in 8 cases (10.6%); altered sensorium was seen in 12 cases (16%).

DISCUSSION

Rodenticides are toxic to liver and heart. Rodenticides containing aluminium or zinc phosphide are hepatotoxic and can cause acute fulminant hepatic failure. Patients admitted with aluminium and zinc phosphide often develop hepatic necrosis, renal failure, metabolic acidosis and refractory hypotension¹⁰. In the absence of antidote for aluminium phosphide poisoning with mortality rates ranges from 40-80% ¹¹. All The patients with rodenticide poisoning were given gastric lavage and skin decontamination in casualty, haematological and biochemical investigations were sent, patients were started on supportive care which involved intravenous fluids, injection vitamin K if PT INR was prolonged. Fresh frozen plasma was given if there was active bleeding, blood sugars and electrolyte abnormalities were monitored, if necessary patient was treated in ICU and parenteral nutrition initiated for hepatic enchelopathy. In our study male 45 (60%) patients dominated the study which is similar to other studies^12,13 and majority of the patients belonged to 18-40 years 57(76%) similar to other studies done by Banjeerji et al ^14,15.We also noticed Zinc phosphide(36) 45% and aluminium phosphide poisons(20) 26% frequently consumed rodenticides in our study, which is similar to study by Smitha et al² and we had more deaths in aluminium phosphide 8 cases out of 20(40%) (figure 5) and zinc phosphide patients 12(33.3%) cases out of 36, because majority of the poison consumed was aluminium and zinc phosphide and there is no specific antidote for the rodenticide, mortality depends on type and quantity of poison consumed .As majority of patients were young (18 to40 years) these young generation has to be educated about the poison and its consequences. More research is needed in the field of treatment in rodenticide poison as only few researches are done.

 

CONCLUSION

Our study concluded that, high mortality was seen in aluminium phosphide and zinc phosphide compared to yellow phosphorous and super warfarin. Younger generation needs to be educated about rodenticide poison and its consequences.

 

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