Highly toxic rodenticides: Appearance, minimum lethal dose, clinical manifestations, and management

Substance	Appearance	Minimum lethal dose	Clinical findings	Management
Thallium	Odorless, tasteless powder Radiopaque	8 mg/kg	Early: abdominal pain, vomiting, constipation, tachycardia, hypertension, and chest pain Intermediate: painful stocking-glove paresthesias, ptosis, nystagmus, ataxia, chorea, delirium, psychosis, coma, alopecia, erythema of palms and soles Other: Acute kidney injury, hepatotoxicity, anemia with thrombocytopenia, hyperchloremic metabolic acidosis	Gastric lavage* Administer activated charcoal* Enhance elimination with multiple dose activated charcoal or Prussian blue Early initiation of renal replacement therapy (hemodialysis, charcoal hemoperfusion, or continuous renal replacement)
Sodium monofluoroacetate or fluoroacetamide	Odorless, tasteless, white powder	2 mg/kg	Respiratory distress, refractory shock, agitation, hypocalcemia with seizures and cardiac arrhythmias, severe lactic acidosis, vomiting, diarrhea, and abdominal pain, paresthesias	Gastric lavage* Administer activated charcoal* Treat hypocalcemia and metabolic acidosis Consult a regional poison center or medical toxicologist regarding proposed antidotes
Strychnine^¶	Colorless, odorless, bitter when dissolved in water.	1 mg/kg	Rapid onset of hyperreflexia, clonus, stiffness of facial and neck muscles, repetitive grimacing (risus sardonicus), trismus, opisthotonus	Control muscle activity with high benzodiazepines (high doses may be required) and, if not responsive, phenobarbital and, in intubated patients, propofol Endotracheal intubation and paralysis for rhabdomyolysis, severe acidosis, or hyperthermia IV hydration and monitoring for rhabdomyolysis
Zinc or aluminium phosphide	Gray or black powder; Gray, green, or turquoise pellets or tablets Radiopaque	~50 mg/kg (Not well established)	Vomiting with fishy odor, hematemesis, chest and abdominal pain, refractory shock, brady- and tachyarrhythmias, hemorrhagic pulmonary edema	Supportive care Treat hypomagnesemia
White (yellow) phosphorus	Yellow, waxy solid compound	1 mg/kg	Perioral, mucosal, and skin burns, vomiting, diarrhea, garlic odor on breath, phosphorescent emesis or stool, delayed liver failure, acute kidney injury Lung irritation with inhalation	Flammable in air, soak clothing with water and avoid contact with elemental phosphorus emesis, or stools^¥ Irrigate skin burns with water and cover with soaked gauze Monitor for and treat hypocalcemia and hyperkalemia Supportive care
Arsenic^Δ	White powder, odorless and tasteless Radiopaque	1 mg/kg	Acute: Vomiting, watery diarrhea, garlic odor on breath, QTc prolongation, torsades de pointes, coma, seizures Chronic: Refer to UpToDate topic on Arsenic poisoning	Irrigate skin as needed Chelation with British anti-Lewisite after acute poisoning Chelation with meso-2,3-dimercaptosuccinic acid (DMSA) or 2,3-dimercapto-1-propane sulfonate (DMPS)^§ after chronic poisoning Renal replacement therapy in patients with renal failure
Barium carbonate	White powder	20 mg/kg	Vomiting, diarrhea, abdominal pain, severe hypokalemia with weakness, paralysis, and ventricular arrhythmias, hypertension	Magnesium sulfate orally^◊ Potassium supplementation (high doses may be required) Renal replacement therapy for refractory hypokalemia or paralysis
Vacor	Similar to cornmeal, peanut odor	5 mg/kg	Hyperglycemia, ketoacidosis, postural hypertension, weakness, cranial neuropathy, lethargy, delirium	Administer activated charcoal* Nicotinamide^◊ IV fluids, mineralocorticoids, and dihydroergotamine for orthostatic hypotension
Tetramine (banned but available, especially in China)	Odorless, tasteless, white powder	<0.1 mg/kg	Refractory status epilepticus	Gastric lavage* Administer activated charcoal* Manage status epilepticus^‡
Aldicarb (banned, but available, especially in Latin America)	Sulfur odor, solid pellets, gray to black	<0.8 mg/kg	Bronchorrhea, bronchospasm, bradycardia, salivation, diarrhea, vomiting, small pupils, urination; weakness and paralysis with high doses	With topical exposure, remove clothing and irrigate exposed areas in well-ventilated area^† Atropine and pralidoxime^◊ Administer activated charcoal*
Alpha-chloralose	White powder	Not established in humans	Respiratory depression, coma, myoclonus	Gastric lavage* Supportive care
Salmonella-based (most available in South America, withdrawn from Europe and US markets)	Rice grains	Not established in humans	Salmonella enteritis and invasive Salmonella disease	Refer to UpToDate topics on management of non-typhoid Salmonella enteritis

* Patients with altered mental status or other potential airway compromise should undergo endotracheal intubation prior to gastric lavage or administration of activated charcoal. Refer to UpToDate topics on gastrointestinal decontamination in adults and children for a description of the gastric lavage procedure, dosing for activated charcoal, and additional precautions necessary to avoid complications such as aspiration.
¶ Refer to UpToDate topics on strychnine poisoning.
Δ Refer to UpToDate topics on arsenic poisoning.
◊ For dosing of these antidotes refer to UpToDate topics on rodenticide poisoning or, for atropine and pralidoxime, organophosphate and carbamate poisoning.
§ Not available as an approved medication in the United States.
¥ Ensure all elemental phosphorus on clothing, in emesis, or in stools is kept wet to avoid fire or explosion.
‡ Refer to UpToDate topics on status epilepticus. First line therapy consists of benzodiazepines. Second line therapy with phenobarbital rather than other medications is suggested. High dose pyridoxine (eg, 70 mg/kg, maximum dose 5 g) has also been associated with cessation of refractory status epilepticus after tetramine poisoning when combined with intramuscular administration of 2,3-dimercaptopropane-1- sulfonate (DMPS). However, DMPS is not an approved medication in the United States
† Health care providers may develop secondary poisoning from inhalation or dermal exposure. Special care should be taken when touching the patient or handling emesis, stools, or contaminated clothing or bed linens.

Prepared with data from selected UpToDate topics and the following sources:

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Tromme I, Van Neste D, Dobbelaere F, et al. Skin signs in the diagnosis of thallium poisoning. Br J Dermatol 1998; 138:321.
Proudfoot AT, Bradberry SM, Vale JA. Sodium fluoroacetate poisoning. Toxicol Rev 2006; 25:213. 5. Proudfoot AT. Aluminium and zinc phosphide poisoning. Clin Toxicol (Phila) 2009; 47:89.
Chugh SN, Kumar P, Aggarwal HK, et al. Efficacy of magnesium sulphate in aluminium phosphide poisoning--comparison of two different dose schedules. J Assoc Physicians India 1994; 42:373.
Beuhler MC. Phosphorus. In: Goldfrank's Toxicologic Emergencies, 9th, Nelson LS, Lewin NA, Howland MA et al. (Eds), McGraw Hill Medical, New York 2011. p.1440.
Koch M, Appoloni O, Haufroid V, et al. Acute barium intoxication and hemodiafiltration. J Toxicol Clin Toxicol 2003; 41:363.
Johnson D, Kubic P, Levitt C. Accidental ingestion of Vacor rodenticide: the symptoms and sequelae in a 25-month-old child. Am J Dis Child 1980; 134:161.
Whitlow KS, Belson M, Barrueto F, et al. Tetramethylenedisulfotetramine: old agent and new terror. Ann Emerg Med 2005; 45:609.
Nelson LS, Perrone J, DeRoos F, et al. Aldicarb poisoning by an illicit rodenticide imported into the United States: Tres Pasitos. J Toxicol Clin Toxicol 2001; 39:447.
Thomas HM, Simpson D, Prescott LF. The toxic effects of alpha-chloralose. Hum Toxicol 1988; 7:285. 13. Painter JA, Mølbak K, Sonne-Hansen J, et al. Salmonella-based rodenticides and public health. Emerg Infect Dis 2004; 10:985.

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Highly toxic rodenticides: Appearance, minimum lethal dose, clinical manifestations, and management