α-naphthylthiourea (2) ANTU
Damages pulmonary epithelium causing pulmonary edema; human lethal dose is estimated to be more than 4 g/kg with no known reported human fatalities; SX: dyspnea, cyanosis, noncardiogenic pulmonary edema and effusions, hypothermia; pulmonary edema may be delayed by 24–72 h
Activated charcoal; no known antidote; symptomatic care with oxygen and ventilatory support; monitor ABGs
Combines with sulfhydryl (-SH) groups in many essential cellular proteins and enzymes; estimated fatal dose 1–4 mg/kg; SX: garlic like breath odor, profuse vomiting and diarrhea, hypotension and shock, cardiac dysrhythmias, renal tubular damage, pulmonary edema, delirium, seizures, coma; delayed SX: peripheral neuropathy, alopecia, Mees lines, blood dyscrasias
Consider orogastric lavage as indicated, activated charcoal; whole bowel irrigation if abdominal radiograph is positive; obtain blood, spot urine, and 24 h urine for arsenic; monitor electrolytes, EKG, renal function tests, CBC; antidotes: IM dimercaprol or po succimer; supportive care with IV fluids, pressors, antidysrhythmics, hemodialysis
Barium carbonate (1)
Soluble barium salts lower serum potassium and raise intracellular potassium; estimated lethal dose 20–30 mg/kg; barium sulfate is nontoxic; SX: nausea, vomiting, diarrhea, paresthesias, weakness, paralysis, hypoglycemia, rhabdomyolysis, dysrhythmias, cardiac/respiratory failure
Consider orogastric lavage as indicated; frequent serum potassium levels with IV potassium replacement as necessary; supportive care with antidysrhythmics; no specific antidote; barium level may confirm diagnosis
Has sedative effects similar to chloral hydrate and stimulant effect similar to strychnine; human toxic dose: 1–4 g, infants: 20 mg/kg; SX: increased salivation, sedation, coma, respiratory depression, myoclonis, seizures, hypotension, hypo- or hyperthermia, acidosis
Activated charcoal; no specific antidote; supportive care for respiratory failure, hypotension, rhabdomyolysis; benzodiazepines/phenobarbital for seizures
This solid fumigant rodenticide reacts with moisture in the air to form highly toxic HCN gas. CN inhibits cytochrome oxidase enzymes halting aerobic cellular respiration. Estimated lethal dose of HCN: 50–100 mg. SX: skin flushing, anxiety, tachypnea, tachycardia, headache, progressing to bradycardia, hypotension, agitation, stupor, coma, seizures, and lactic acidosis
Administer 100% oxygen and provide ventilatory support. Consider activated charcoal following ingestion of CN salts. Antidotes to consider include the CN Antidote Kit or the Cyanokit.
White or Yellow
Stearns Chemical Paste® 2.5%
Protoplasmic poison causing direct cell injury leading to multiorgan failure; lethal dose: 1 mg/kg; mixed with peanut butter as bait; (note: red phosphorous found in matches is nontoxic) SX: bloody emesis, burns to GI tract, vomitus and stools may appear “smoking” or luminescent and have a garlic like odor, delirium, coma, shock, hypocalcemia, hypoglycemia, pulmonary edema, hemorrhage, cardiovascular collapse; delayed SX: myocardial, hepatic, and renal damage; dermally may cause partial and full thickness burns
Lavage and activated charcoal are usually not performed as phosphorous is corrosive; no specific antidote; supportive care with IV fluids and blood products; standard burn care; administer narcotics (e.g., morphine) for pain control; N-acetylcysteine may be hepatoprotective; ED staff must wear personal protective equipment to avoid contact with phosphorous
N-3-pyridylmethyl-N′-p-nitro-phenyl urea, Vacor®
Bait 0.5%, 2%
Destroys pancreatic β cells via interference with niacinamide (nicotinamide) metabolism; lethal dose: 5 mg/kg; product introduced in 1975 and withdrawn in 1979; SX: nausea, vomiting (peanut odor), hyperglycemia, diabetic ketoacidosis, sensory motor and autonomic neuropathies, GI perforation, cardiac dysrhythmias; permanent SX: insulin-dependent diabetes mellitus and postural hypotension
Orogastric lavage and activated charcoal; antidote: early IM or IV niacinamide (nicotinamide) may prevent toxicity, however, parenteral products are not available in the United States; niacin (nicotinic acid) may not be effective; treat hyperglycemic ketoacidosis with insulin; monitor for GI perforation; mineralocorticoids (e.g., fludrocortisone) for persistent postural hypotension
Red Squill (3)
Bait 100%, or as 4.5% extract in bait
Contains scillaren A and B, which are cardiac glycosides; two bulbs have been fatal to an adult; intensely nauseating causing rapid vomiting which limits toxicity; SX: large amounts may cause nausea, vomiting, hyperkalemia, A-V block dysrhythmias, however, cardiac toxicity is rare
Activated charcoal following large ingestions; monitor vital signs, serum potassium, and EKG; antidotes: atropine and digoxin immune Fab
Sodium mono-fluoroacetate (1)
SMFA is converted to fluorocitric acid which blocks the tricarboxylic cycle of the Krebs cycle; estimated lethal dose 2–10 mg/kg, however, 1 mg may cause serious toxicity; SMFA is a white crystalline powder combined with nigrosin black dye as a colorant; SX: nausea, vomiting, diarrhea, seizures, acidosis, cardiac dysrhythmias, hypotension, hypocalcemia, hypokalemia, respiratory depression, coma
Orogastric lavage and activated charcoal; supportive care for hypotension, acidosis, dysrhythmias, and seizures; IV calcium gluconate for hypocalcemia; no known effective antidote.
Acts by antagonizing glycine, an inhibitory neurotransmitter in the postsynaptic motor neurons of the spinal cord; lethal dose 1–2 mg/kg, but may be as low as 5–10 mg in a child; SX: rapid onset of nausea, vomiting, apprehension, painful tonic-tetanic spasms, trismus, opisthotonos, “risus sardonicus” (facial grimacing), seizures, respiratory paralysis, lactic acidosis, rhabdomyolysis, hyperthermia, cardiac arrest; patient is conscious with normal mentation until hypoxia or acidosis leads to CNS depression
Activated charcoal; avoid any stimulus that may trigger seizures; treat seizures with benzodiazepines, phenobarbital; severe cases may need paralyzing agents with ventilator support; supportive care for acidosis, respiratory failure, rhabdomyolysis, and renal failure; no specific antidote, multiple dose activated charcoal possibly beneficial
TETS binds noncompetitively and irreversibly to GABA receptors on neuronal cell membranes and blocks chloride channels. Illegally imported from China. Two samples were analyzed to have 6.4% and 13.8%, respectively.
LD50 in mammals: 0.10–0.3 mg/kg; 7–10 mg is lethal in humans.
SX: Refractory seizures, coma, and possible ischemic changes on EKG
Information is limited. No specific antidote is available. Supportive care. Seizures were refractory to benzodiazepines and phenobarbital in one pediatric case. Animal studies in China suggest benefit from IV pyridoxine and DMSA. Patients in China have been treated with charcoal hemoperfusion and hemodialysis
Thallium sulfate (1)
Interferes with oxidative phosphorylation by binding with mitochondria sulfhydryl groups; banned in 1965; lethal dose 1 g; SX: nausea, bloody vomiting, and diarrhea followed by ileus, painful sensory neuropathy, respiratory failure, delirium, seizures, renal failure, optic neuritis, muscle weakness, lethargy, coma; delayed SX: alopecia, Mees lines, neuropathies
Orogastric lavage and activated charcoal as clinically indicated; thallium may appear radio-opaque on an abdominal radiograph, obtain blood and 24 h urine collection for thallium; Prussian blue (Radiogardase®) interrupts enterohepatic and enteroenteric circulation and enhances fecal elimination; multiple dose charcoal may also enhance elimination; supportive care including IV fluids, blood products, hemodialysis
Tres Pasitos (1)
Acts as a reversible inhibitor of cholinesterase enzymes; product is an approved carbamate insecticide sold illegally as a rodenticide; smuggled into the United States from the Dominican Republic; LD50 in rats: 1 mg/kg; Muscarinic SX: “SLUDGEBAM;” Nicotinic SX: tachycardia, mydriasis, weakness, fasciculations, respiratory failure; CNS SX: coma, seizures
Activated charcoal; antidotes: IV atropine sulfate to reverse muscarinic symptoms, benzodiazepines for seizures.