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A prospective study of acute, unintentional, pediatric superwarfarin ingestions managed without decontamination
Marianne Ingels1, Chi Lai, Winnie Tai
1California Poison Control System, San Diego Division, San Diego, CA, USA.
Insights
Children ingesting small amounts of superwarfarin rodenticides need no immediate decontamination or vitamin K. Most children do not develop bleeding complications, suggesting watchful waiting is safe for these ingestions.
Area of Science:
- Toxicology
- Pediatric Emergency Medicine
Background:
- Superwarfarin rodenticides pose a risk of prolonged coagulopathy after ingestion.
- Current management often includes gastrointestinal decontamination and vitamin K prophylaxis.
Purpose of the Study:
- To determine the incidence of clinically significant bleeding in children with acute, unintentional superwarfarin ingestions.
- To evaluate the necessity of gastrointestinal decontamination and prophylactic vitamin K in these cases.
Main Methods:
- Prospective study of children under 6 years with acute superwarfarin ingestions.
- Exclusion of patients receiving gastrointestinal decontamination or prophylactic vitamin K.
- Follow-up via telephone and/or 48- to 96-hour prothrombin time/international normalized ratio (INR) testing.
Main Results:
- None of the 463 patients with follow-up experienced clinically important coagulopathy.
- Two patients had elevated INRs (1.5 and 1.8) without symptoms.
- Minor bleeding events (nosebleeds, blood-streaked stools) occurred in a few patients with normal INRs.
Conclusions:
- Children with acute, unintentional superwarfarin ingestions (less than 1 box) can be managed without gastric decontamination or prophylactic vitamin K.
- Laboratory testing for coagulopathy should be reserved for patients with clinically apparent bleeding abnormalities.
Study Objective:
We determine the incidence of clinically important bleeding in children with superwarfarin rodenticide ingestions not treated with gastrointestinal decontamination or prophylactic vitamin K.
Methods:
We prospectively studied patients younger than 6 years of age who reported to our poison center with acute unintentional superwarfarin ingestions. Patients who received gastrointestinal decontamination or prophylactic vitamin K were excluded. Forty-eight- to 96-hour prothrombin time or international normalized ratio (INR) blood tests were recommended, and telephone contact was attempted at least 3 days after ingestion.
Results:
A total of 595 consecutive patients were enrolled during the 16-month study period. Fifty patients were excluded: 8 who were known to have ingested 1 pellet or less; 25 who received activated charcoal; 15 who were treated with induced emesis; and 2 who received prophylactic vitamin K. The resulting study group contained 545 patients. Eighty-two patients were lost to follow-up. Follow-up was obtained for 463 patients, including 222 by telephone contact alone, 62 by 48- to 96-hour INR, and 179 by both methods. None of the patients had clinically important coagulopathy. Two patients had an INR of 1.5 or greater (1.5 and 1.8) without symptoms. Single nosebleeds were reported in another 2 patients with normal 48-hour INRs. Another child had a small amount of blood crusted in the nose with no other symptoms and no laboratory work available. One child with a normal 48-hour INR had blood-streaked stools that were thought to be caused by an anal fissure.
Conclusion:
Children with acute unintentional superwarfarin ingestions of less than 1 box may be managed without gastric decontamination or prophylactic vitamin K. Laboratory testing for coagulopathy should be reserved for cases involving clinically evident bleeding abnormalities.