RODENTICIDE INTOXICATION

Case Study Week 8

Sarra Borne VETE 405

Sarra Borne UID 000493586 VETE 405: Pharmacology and Pharmacy Assignment: Case Study Week 8: Rodenticide Intoxication in a Dog October 16, 2013

Mr. Gallagher brings in his dog Linus, a 3-year-old neutered Smooth Rat Terrier. Linus has a nose bleed that wont stop. Linus nose started bleeding during breakfast which was four hours ago. Linus is up to date on his vaccinations and was acting normally yesterday, but is tired and not himself today. Linus is an indoor/outdoor dog, so it is unknown if his recent urination and defecation are normal. Examination of Linus reveals his vital signs are temperature is 101.8 oF, pulse 145 bpm, and a respiratory rate of 50 bpm. Linus mucous membranes are pale pink with a CRT of 2 seconds. Linus appears somewhat depressed although his neurologic examination is normal. Hydration, movement and abdominal palpation all appear

normal. Linus heart and lungs auscultate normally. Linus has moderate epistaxis and has blood on his face, front legs and chest that appears to be from his nose. Linus coughs during the examination and expectorates small spots of blood onto the table. On questioning Mr. Gallagher reveals that there is rat poison kept in the garage, and area that Linus does not usually go into. He is unsure if any has been eaten and needs to consult with his wife. Technician evaluations would include evaluation of mucous membrane color and capillary refill time, obtaining a current weight, recording vital signs, and recording pertinent history. A complete blood count, activated clotting time (ACT), prothrombin time (PT) and activated partial thromboplastin time (PTT) are ordered. Blood is collected from the lateral saphenous vein using a 22g needle. The cephalic veins are saved for potential
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Sarra Borne UID 000493586 VETE 405: Pharmacology and Pharmacy Assignment: Case Study Week 8: Rodenticide Intoxication in a Dog October 16, 2013

intravenous catheterization.

The jugular vein is contraindicated in a suspected

rodenticide poisoning. If clotting factors are impaired it is important to use a vein on an extremity where a pressure bandage can be applied. The ACT or activated clotting time test is performed by adding a fresh whole blood sample to a blood tube that contains diatomaceous earth. The tube is incubated at 98.6o F for 3 minutes, then a clean venipuncture is performed on an unthrombosed vessel. The first few drops of blood are discarded to eliminate tissue thromboplastin, then approximately 2 ml is added to the ACT tube. A stopwatch is started as soon as the blood first enters the tube. The tube is inverted several times to mix the diatomaceous earth and the blood and the tube is returned to the incubator. After 30 seconds, the ACT tube is gently examined for clot formation. repeated every 10 seconds until a clot is formed. This procedure is

The ACT time is the time from

collection of blood in the tube until initial clot formation. In the dog, the normal is 60 to 110 seconds. Linus ACT is 230 which is outside the normal range. This indicates an abnormality in the intrinsic and common pathway of the clotting pathway. It evaluates the same pathways as the PTT. (Battaglia, 2001) The PT and PTT are collected into a blue topped collection tube containing sodium citrate. This tube should be placed on a blood rocker for 5 minutes to allow the sodium citrate to properly mix with the blood cells. Linuss PT is 17.2 seconds (normal range 7 -10 seconds), and his PTT is 57 seconds (normal range 14 -20 seconds). Both Linus PT and PTT are elevated. The PT measures extrinsic and common clotting pathway activity, whereas the PTT measures the intrinsic and common clotting pathway

Sarra Borne UID 000493586 VETE 405: Pharmacology and Pharmacy Assignment: Case Study Week 8: Rodenticide Intoxication in a Dog October 16, 2013

activity. Prolongation of PT and PTT is seen when clotting factors are depleted below 30% of normal. (Battaglia, 2001) Mr. Gallagher has consulted with his wife and determined that a box of rat poison has indeed been ripped up and moved from its usual storage area. He reports that the active ingredient in the rodenticide is bromadiolone. Based on the laboratory findings and clinical signs, the veterinarian is confident that Linus has indeed ingested bromadiolone which is a vitamin K antagonist. Vitamin K antagonist rodenticides bind the vitamin K factor, which inhibits the synthesis of prothrombin (factor II) as well as factors VII, XI and X. (Battaglia, 2001) The depletion of these factors slow all

coagulation pathways, which include the contact activation pathway (or intrinsic), the tissue factor pathway (or extrinsic) and the common clotting pathway. Partial results from Linus CBC are as follows RBC 4.8 x 106/ul WBC 9.2 x 106/ul PCV 27% HGB 11.2 g/dl Reticulocytes 8 seen out of 1000 RBC Platelets 243 x 103/ul

The veterinarian requests that the platelet count be verified. In this case a blood smear is examined. Then platelets are estimated by counting the average number of platelets seen per 100x oil immersion field in the monolayer. (Cornell University, n.d) Ten fields are counted and the results are averaged, then the following formula is applied. Estimated platelet count/ul = average count in 10 fields x 15,000. If 1000
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Sarra Borne UID 000493586 VETE 405: Pharmacology and Pharmacy Assignment: Case Study Week 8: Rodenticide Intoxication in a Dog October 16, 2013

platelets are counted over 10 fields the estimated platelet count is 1500K or 1,500,000/ul. 1,500,000/ul) Linus has become more depressed and is still experiencing epistaxis. A whole blood transfusion and vitamin K therapy are recommended to Mr. Gallagher who consents. The veterinarians personal dog, Beast, is often used as a blood donor as he has a known history, is up to date on vaccinations and is in excellent health. True canine universal donors have blood type DEA 4 (C) and test negative for the other known canine red blood cell antigens, including DEA 1.1 (A1), DEA 1.2 (A2), DEA 3 (B), DEA 5 (D) and DEA 7 (Tr). (Hemopet, 2013) Linus should be cross-matched to Beast to predict any serum incompatibility. He should also be blood typed, either in clinic or at a reference laboratory to determine his blood type in case he needs any future transfusions. Cross-matching is a two part process. The major cross-match assesses whether there are antibodies in Linus (Estimated platelet count/ul = 1000 /10 fields = 100 x 15,000 =

plasma that might cause a hemolytic reaction to Beasts RBCs. The minor cross-match detects any antibodies in Beasts plasma that might react to Linus RBCs. In both parts of the cross-match incompatibility is signaled by agglutination of RBCs. There are commercially available kits that can be used for cross-matching, or it can be done manually using test tubes or slides. The manual cross-match requires clotted blood from both donor and recipient. The serum is transferred to labeled tubes and the clot is re-suspended in saline to make an approximate 3% solution. These are each washed three times and
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Sarra Borne UID 000493586 VETE 405: Pharmacology and Pharmacy Assignment: Case Study Week 8: Rodenticide Intoxication in a Dog October 16, 2013

centrifuged until the supernatant is clear and colorless. After the final washing, again suspend each washed tube of RBCs in saline. The major cross -match mixes two drops of recipients serum and 2 drops of donors red cell suspension. The minor cross-match mixes 2 drops of donors serum and 2 drops of recipients red cell suspension. The tubes are incubated for 30 minutes, centrifuged for 2 minutes and examined for hemolysis. Significant hemolysis in either tube

indicates incompatibility. If there is no hemolysis, the supernatant should be microscopically examined for agglutination. incompatibility. (Pratt, 1997, p. 83) To collect blood from the donor you need clippers to shave the area, alcohol and chlorhexidine scrub to surgically prepare the venipuncture site, sterile gloves, a blood collection bag containing anticoagulant (usually CPD), several sterile hemostats, collection tubing and an assistant. Fresh whole blood is ideal for Linus since it contains erythrocytes, leukocytes, platelets, coagulation factors, and plasma proteins. All of Agglutination also indicates

these are components that Linus is losing by continuing to bleed. If Linus needed an adjunct transfusion with fresh frozen plasma (FFP) to boost his coagulation factors and plasma proteins further, it would need to be properly thawed before transfusion. This is done in a warm water bath that is 98.6oF (37oC). Baseline measurements of the patients att itude, rectal temperature, pulse rate and quality, respiratory rate, mucous membrane color, capillary refill time, and blood pressure should be obtained before the transfusion is started.

Sarra Borne UID 000493586 VETE 405: Pharmacology and Pharmacy Assignment: Case Study Week 8: Rodenticide Intoxication in a Dog October 16, 2013

The transfusion should be started at approximately 0.25ml/kg for the first 30 minutes, after which the rate can be increased if no reactions are seen. Vital signs should be recorded every 15 minutes for the first 45 minutes of the transfusion, and then every 30 minutes until the transfusion is finished. The

patient should be closely monitored for at least 60 minutes after the transfusion is finished. Blood transfusions should be completed within 4 hours to prevent

functional loss or bacterial growth. (Proulx & Waddell, 2012) The veterinarian prescribes 5 mg/kg of vitamin K SC split into 3 injection sites. Ive decided that Linus weighs 15 lb based on the AKC website (his weight is not mentioned in the article) so he would receive 34 mg total. Vitamin K comes in a 10 mg/ml solution. Linus would receive 1.1 ml in two sites, and 1.2 ml in the third using a 25 g needle. (Plumb, 2011) Prior to discharge Linus is placed on oral vitamin K twice daily with a fatty meal for three week. At a recheck four days later Linus is brighter with no signs of bleeding. His follow up blood work is improved: ACT 85 seconds PT 8.5 seconds PTT 27 seconds

After reviewing the blood work Mr. Gallagher prepares to leave. He asks if Linus needs to continue taking the pills, since Linus is doing well and really hates taking the pills. Mr. Gallagher needs a reminder that bromadiolone is a second generation rodenticide,

Sarra Borne UID 000493586 VETE 405: Pharmacology and Pharmacy Assignment: Case Study Week 8: Rodenticide Intoxication in a Dog October 16, 2013

and can depress clotting factors for three to four weeks, so Linus needs to get his medication as prescribed for the length of time prescribed.

Sarra Borne UID 000493586 VETE 405: Pharmacology and Pharmacy Assignment: Case Study Week 8: Rodenticide Intoxication in a Dog October 16, 2013

References

Battaglia, A. M. (2001). Small animal emergency and critical care: A manual for the veterinary technician. Philadelphia, PA: W.B. Saunders. Cornell University (n.d.). Platelet count. Retrieved from https://ahdc.vet.cornell.edu/clinpath/modules/hemogram/plt_ct.htm Hemopet (2013). The hemopet blood bank. Retrieved from hemopet.org/bloodbank.html Hines, R. (2013). Normal feline & canine blood chemistry values. Retrieved from http://www.2ndchance.info/normaldogandcatbloodvalues.htm Plumb, D. C. (2011). Phytonadione (vitamin K1). In Plumb's veterinary drug handbook (7th ed., pp. 824-826). Ames, Iowa: Wiley-Blackwell. Pratt, P. W. (1997). Laboratory procedures for veterinary technicians (3rd ed.). St. Louis, Mo: Mosby. Proulx, A., & WADDELL, L. S. (2012, March). Blood transfusion basics. Retrieved from http://www.cliniciansbrief.com/column/taxonomy/term/23406/blood-transfusionbasics