Toxin

Bromethalin Poisoning

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Bromethalin Poisoning, Bromethalin

  • Background
  1. Neurotoxic, non-Anticoagulant rodenticide in diphenylamine category of agents
  2. Pale, odorless, crystalline solid
  3. Greater use as Anticoagulant rodentacides are phased out due to resistance
  4. Available in multiple low concentration forms (blocks, pellets at 0.01%) as well as high concentration forms (7.5%)
  • Pathophysiology
  1. Exposures
    1. Ingestions and toxicity in pets (dogs, cats) has been more common than toxicity in humans
      1. https://www.addl.purdue.edu/newsletters/1997/spring/bromoethalin.shtml
    2. Accidental, unintentional pediatric ingestion
      1. Typically low dose ingestion without toxicity
    3. Intentional ingestion for Suicide attempt in adults
      1. Potentially lethal
  2. Mechanism (effects may be delayed up to 24 hours)
    1. Cerebral Edema
    2. Oxidative phosphorylation is uncoupled (in CNS mitochondria), resulting in decreased ATP
    3. Nerve Impulse conduction is interrupted
  3. Pharmacokinetics
    1. Asymptomatic at doses <0.1 mg/kg
  • Findings
  1. Cardiovascular
    1. Tachycardia
  2. Gastrointestinal
    1. Vomiting
    2. Abdominal Pain
  3. Hematologic
    1. Mild bleeding (mild Anticoagulation effects)
  4. Neurologic
    1. Agitation
    2. Tremors
    3. Lethargy
    4. Myoclonic Jerks
    5. Seizures
  • Differential Diagnosis
  • Labs
  1. See Altered Level of Consciousness
  2. See Unknown Ingestion
  3. Standard toxicology labs (e.g. Bedside Glucose, Acetaminophen level, Salicylate level)
  4. Consider INR (if Anticoagulant rodenticide ingestion suspected)
  • Management
  1. See Unknown Ingestion
  2. ABC Management
  3. Activated Charcoal if recent ingestion
  4. Seizures
    1. Benzodiazepines
  5. Cerebral Edema
    1. Hypertonic Saline
    2. Mannitol
  6. Severe ingestions
    1. Consider Intralipid emulsion infusion
  7. Disposition
    1. Low dose ingestions may be discharge home if asymptomatic
    2. Medically observe intentional ingestions up to 24 hours
    3. Admit all symptomatic ingestions
  • References
  1. Tomaszewski (2021) Crit Dec Emerg Med 35(6): 28