Unmet clinical laboratory need in patients hospitalized for acute poisoning from long-acting anticoagulant rodenticides

• Published in: Toxicology communications Vol. 5; no. 1; pp. 93 - 96
• Main Authors: van Breemen, Richard B., Hafner, John W., Nosal, Daniel G., Feinstein, Douglas L., Rubinstein, Israel
• Format: Journal Article
• Language: English
• Published: England Taylor & Francis 01.01.2021; Taylor & Francis Ltd; Taylor & Francis Group
• Subjects: Anticoagulants; bleeding; blood transfusion; Cannabinoids; clotting factor concentrate; INR; Laboratories; Liquid chromatography; Mass spectroscopy; Patients; Plasma; Rodenticides; synthetic cannabinoids; Toxicology; vitamin K1; blood transfusion; bleeding; clotting factor concentrate; INR; vitamin K1; synthetic cannabinoids
• ISSN: 2473-4306; 2473-4306
• DOI: 10.1080/24734306.2021.1925444

The importance of real-time, quantitative toxicology data available for physicians treating poisoned patients was illustrated during the 2018 outbreak in Illinois of severe coagulopathy caused by inhaling illicit synthetic cannabinoids products contaminated with commercially-available brodifacoum, difenacoum, and bromadiolone, three potent, long-acting anticoagulant rodenticides (LAARs). Identification and quantification of these life-threatening toxins in blood samples of hospitalized patients required toxicology testing with liquid chromatography-tandem mass spectrometry (LC-MS/MS) that was not available in clinical laboratories of hospitals at the time of the outbreak. This highly-sensitive, quantitative assay can provide critical information to guide patient care during and after hospitalization, including identification of offending LAARs, estimates of the ingested dose, and dosage and discontinuation of oral vitamin K 1 therapy after hospital discharge once plasma LAARs concentrations decreased to a safe level (<10 ng/mL). Accordingly, we propose an action plan to enable treating physicians to quantify plasma concentrations of several LAARs simultaneously in poisoned patients. It involves rapid (<15 min), sensitive, and validated LC-MS/MS methods developed, tested and validated in our laboratory. This will allow treating physicians to request quantitative plasma LAARs testing, report test results in the patient's hospital discharge summary, and recommend regular monitoring of plasma LAARs concentrations in the outpatient setting.