Liver Transplantation for Acute Liver Failure Due to Yellow Phosphorus Poisoning - A Comprehensive Review.

Yellow phosphorus or metal phosphide (YP-MP) rodenticide poisoning has been a known cause of acute liver failure (ALF) in many countries of Asia and North and South America over the last decade. It is a highly toxic compound and is a well-known cause of intentional or accidental poisoning in both adults and children. In lower doses, it causes gastrointestinal symptoms and mild hepatic injury, and patients may spontaneously recover. In higher doses, hepatic necrosis and fatty infiltration may cause significant injury and may even lead to ALF, characterized by hepatic encephalopathy, coagulopathy, and lactic acidosis. Cardiotoxicity, rhabdomyolysis, and neutropenia are other well-documented complications. If untreated, it may lead to multi-organ dysfunction and death. Plasmapheresis and continuous renal replacement therapy (CRRT) have been used with limited success in patients who do not recover spontaneously. However, patients who develop ALF often need liver transplantation (LT). Liver transplantation has been successfully performed in ALF due to YP-MP poisoning in several countries, with good results in both adult and pediatric patients. Separate criteria for LT are important to ensure early and rapid listing of critical patients on the waiting list. The success rates of LT for ALF due to YP-MP rodenticide poisoning are very promising, provided there are no contra-indications to transplant. Plasma exchange, CRRT, or cytosorb can be used as a bridge to transplant in selected patients. In the long term, only with an increase in public awareness and sale restrictions can we prevent the intentional and accidental poisoning caused by this easily available, highly toxic compound.

Análisis de un protocolo basado en la norma USEPA 1.213 para la evaluación regulatoria de la eficacia de las cebaderas en el control seguro de roedores pequeños / Analysis of a protocol based on the USEPA 1.213 standard for the regulatory evaluation of the efficacy of the bait station system in the safe control of small rodents

Varios rodenticidas modernos son formulados con compuestos anticoagulantes superwarfarínicos. Debido a su alta toxicidad en humanos, los cebos suelen ser formulados con otros ingredientes destinados a generar respuestas de rechazo en el caso de ingestión accidental o intento de suicidio; aun así, las unidades hospitalarias reportan anualmente numerosos casos de intoxicaciones con rodenticidas. Se han desarrollado cebaderas con el propósito de brindar al usuario alta eficacia y seguridad extendida. Dado que en muchos países existe experiencia limitada para la evaluación regulatoria de cebos combinados con cebaderas, en este trabajo se presenta un protocolo adaptado a partir de la guía USEPA- 1.213/1990, el cual se propone para verificar la aptitud de las cebaderas para controlar roedores en ambientes hogareños, ocupacionales y otros espacios urbanos. Se incluye una discusión de aspectos técnicos que se espera que sean de ayuda para los asesores de las agencias regulatorias intervinientes al interpretar los resultados en términos de eficacia y seguridad. El sistema cebadera-cebo examinado mostró alta letalidad en ratas adultas jóvenes. La inspección, carga y recarga de producto fresco se realizó en forma simple, rápida y segura; sólo excepcionalmente se observó dispersión del cebo fuera de la cebadera. Sin embargo, debe tenerse en cuenta que el sistema que solicita un registro ante la autoridad regulatoria debe ser adecuado a la especie que se busca controlar, considerando las diferencias de peso corporal entre ratas y ratones, entre machos y hembras, y entre animales jóvenes y adultos, lo cual determina la facilidad de ingreso al interior del dispositivo (cebadera) donde se coloca el cebo contenido en su embalaje unitario original. (AU)

Several modern rodenticides are formulated with anticoagulant superwarfarin compounds. Due to their high toxicity in humans, these baits are usually formulated with other ingredients intended to generate rejection responses in the case of accidental ingestion or suicide attempt. However, hospital units report numerous cases of poisoning with rodenticides every year. Box-like bait stations have been developed to provide the user with high efficacy and extended safety. Given that in many countries there is limited experience for the regulatory consideration of bait stations, this work presents a protocol adapted from the USEPA-1.213/1990 guideline, proposed to verify the aptitude of these devices to control wild rodents in home, work, and other urban spaces. The work includes a discussion of technical issues that are expected to be helpful to advisors of the regulatory agencies involved in interpreting the results in terms of efficacy and safety. The bait-station system examined showed high efficacy in young adult rats. The inspection, loading and reloading of fresh product were carried out in a simple, fast and safe way; bait dispersal outside the station was only rarely observed. However, it must be taken into account that the system that require a registration by the regulatory authority must be appropriate to the species sought to be controlled. This is important due to differences in body weight between rats and mice, between males and females, and between young and aged animals, which determines the ease of entry into the station where the bait contained in its original unitary packaging is placed. (AU)

Unique granulated leucocytes in peripheral blood in yellow phosphorous poisoning: An interesting tool for monitoring therapeutic response.

Yellow phosphorus is one of the most commonly used rodenticides in India for household pest control. It is available as pastes containing 2% to 5% of yellow phosphorus. Yellow phosphorous-containing rodenticides are easily available and account for one of the most common causes of suicidal poisoning in India. We describe a case of yellow phosphorus poisoning in a 17-years-old child who recovered from hepatic encephalopathy and showed unique peripheral smear findings in the form of spurious monocytosis and hypergranulosis of these granulocytes.

Reversible leukoencephalopathy caused by 2 rodenticides bromadiolone and fluoroacetamide: A case report and literature review.

RATIONALE: With the easy access, rodenticide poisoning has been a public health problem in many countries. Characteristics of central nervous system (CNS) lesions induced by rodenticides are scarcely reported. PATIENT CONCERNS: We presented a case of a 40-year-old man with seizure and consciousness disorder, coagulation dysfunction, and symmetric lesions in white matter and corpus callosum. DIAGNOSIS: He was diagnosed with rodenticide poisoning due to bromadiolone and fluoroacetamide. INTERVENTIONS: He was treated with vitamin K, hemoperfusion, acetamide, and calcium gluconate. OUTCOMES: His leukoencephalopathy was reversed rapidly with the improvement of clinical symptoms. LESSONS: This report presented the impact of rodenticide poisoning on CNS and the dynamic changes of brain lesions, and highlighted the importance of timely targeted treatments.

Homicidal Pesticide Poisoning - An Overview.

Pesticides are chemical or biological agents used to repel or kill pests. Pesticides are potent and lethal toxic substances that are also being infamously used for homicidal purposes due to their easy availability and rapid action. In this review, we look at 21 articles related to homicidal pesticide poisoning in the literature with an emphasis on fatal doses, routes of administration, and profiles of victims and perpetrators. Organophosphates and rodenticides were the most commonly used classes of pesticides, and ingestion was the most common route of administration; however, other modes of administration, such as through intraperitoneal injection, were also reported. Interestingly, we have noticed that victims involved in homicidal poisoning were mostly in close relationships with perpetrators. Most perpetrators were either spouses or other immediate family members. Abiding by the regulations that govern the production, sale, and use of pesticides and proper documentation of the related trail can help control the prevalence of homicidal pesticide poisoning. Recognition of the distinct morbid anatomy of the poisoning cases, alongside a high index of suspicion in cases that fit the profile, is essential for forensic analysis.

Acute toxic encephalopathy following bromadiolone intoxication: a case report.

BACKGROUND: Clinically, bromadiolone poisoning is characterized by severe bleeding complications in various organs and tissues. Bromadiolone-induced toxic encephalopathy is extremely rare. Here, we report a special case of bromadiolone-induced reversible toxic encephalopathy in a patient who had symmetrical lesions in the deep white matter. CASE PRESENTATION: A 23-year-old woman mainly presented with dizziness, fatigue, alalia and unsteady gait after the ingestion of bromadiolone. The laboratory examinations showed normal coagulation levels. Brain magnetic resonance imaging (MRI) showed apparent diffusion restriction in the bilateral deep white matter. The clinical manifestations and MRI alterations were reversible within one month of treatment with vitamin K. The neuropsychological assessment showed no neurodegenerative changes at the 2-year follow-up. CONCLUSION: With the increased use of bromadiolone as a rodenticide, more cases of ingestion have been reported annually over the past several years. Bromadiolone-induced toxic encephalopathy has no special clinical manifestations and is potentially reversible with timely treatment. Because of the reversible restricted diffusion on diffusion-weighted images (DWI) and low apparent diffusion coefficient (ADC) values, transient intramyelinic cytotoxic oedema is thought to be the cause rather than persistent ischaemia. The underlying pathophysiological mechanism is still unknown and may be coagulant-independent. This clinical case extends the current knowledge about neurotoxicity in cases of bromadiolone poisoning and indicates that MRI is useful for the early detection of bromadiolone-induced toxic encephalopathy.

Severe Vitamin K-dependent Coagulopathy from Rodenticide-contaminated Synthetic Cannabinoids: Emergency Department Presentations.

INTRODUCTION: Synthetic cannabinoids are a rapidly expanding subset of designer drugs widely available in the United States since 2008. In Illinois during the spring of 2018, over 160 documented cases of bleeding and prolonged coagulopathy occurred secondary to contaminated synthetic cannabinoids. METHODS: We conducted a retrospective cohort study consisting of 38 patients to describe the initial emergency department (ED) presentation, diagnosis, and treatment. RESULTS: Through serum testing we found that three long-acting anticoagulant rodenticides (LAAR) were detected in patients who had inhaled these tainted products: brodifacoum, difenacoum, and bromodialone. DISCUSSION: This study encompasses the largest ED presentation of LAAR poisoning via the inhalational route known to date. CONCLUSION: The emergency physician should be aware of the potential for tainted coingestants as the cause of undifferentiated coagulopathy.

Retrospective evaluation of the effects and outcome of bromethalin ingestion: 192 Dogs (2010-2016).

OBJECTIVE: To evaluate the frequency of clinical signs, dose ingested, and outcome in a large group of dogs with bromethalin ingestion. DESIGN: Retrospective cohort study of dogs from 2010 to 2016. SETTING: Three university teaching hospitals and 1 private practice. ANIMALS: A total of 192 dogs with bromethalin ingestion. MEASUREMENTS AND MAIN RESULTS: Total 192 cases were identified, of which 25 dogs developed clinical signs. Five cases initially had severe neurological signs and were euthanized. A sum of 187 dogs survived to discharge. The total ingested dose was recorded in 59 dogs with a median (interquartile range) 0.2 mg/kg (0.28 mg/kg). The remaining 133 dogs had confirmed ingestion reported by owners (witnessed ingestion or colored feces) but the total dose could not be calculated. The median (interquartile range) time to presentation for all dogs was 2 hours (4.8 h). A majority of patients were treated on an outpatient basis (121/192) and 71 of 192 were treated as inpatients with 58 of 71 receiving fluid diuresis. Decontamination was performed in 179 dogs including emesis induction (14), activated charcoal administration (42), and both (123). Emesis was successful in 128 dogs and apomorphine was the most common emetic agent (121). Mild to severe clinical signs at admission were reported in 19 cases including vomiting (6), tremors (5), lethargy (4), ataxia (3), weakness (2), diarrhea (2), collapse (2), and and anorexia (2). One case developed ataxia and tremors within 72 hours of admission. CONCLUSIONS AND CLINICAL RELEVANCE: Symptoms of bromethalin toxicosis are uncommon, and most ingested doses are well below the reported dose expected to cause clinical signs. In this patient population, prognosis was excellent unless severe clinical signs were noted, which carried a high euthanasia rate. Effects of treatment on outcome could not be evaluated due to the low number of patients that developed clinical signs.

Análise crítica da indicação da lavagem gástrica em intoxicações atendidas em um hospital de ensino / Critical analysis of gastric lavage indication for poisoning cases attended in a university hospital

Objetivo: Avaliar a indicação da lavagem gástrica no tratamento de intoxicações causadas por ingestão. Métodos: Todos os casos de intoxicação causada por ingestão que foram atendidos em dois hospitais do interior de São Paulo e submetidos à lavagem gástrica no período de 1° de janeiro de 2011 a 31 de dezembro de 2015 foram avaliados retrospectivamente quanto à indicação do procedimento, considerando o tempo entre ingestão e atendimento, a toxicidade da substância e as contraindicações para o procedimento. Resultados: Dos 587 casos atendidos, 338 (57,6%) foram submetidos à lavagem gástrica. Dentre esses casos, constatou-se a realização equivocada do procedimento em 95,8% casos. Conclusão: O número de pacientes submetidos à lavagem gástrica neste trabalho foi considerado elevado, mesmo quando orientado pelo centro de atendimento. Apesar da falta de evidências de que a lavagem gástrica traga benefícios nos casos de intoxicação, ela é largamente utilizada em virtude do desconhecimento das indicações e contraindicações desse procedimento por parte dos profissionais de saúde

Objective: To evaluate the indication of gastric lavage in the treatment of poisoning caused by ingestion. Methods: All cases of poisoning caused by ingestion that were treated in two hospitals in inland cities of São Paulo and subjected to gastric lavage from January 1, 2011 to December 31, 2015 were retrospectively assessed as for the indication of the procedure, considering the time between ingestion and care, substance toxicity, and procedure contraindications. Results: Of the 587 cases treated, 338 (57.6%) underwent gastric lavage. The procedure was considered incorrect in 95.8% of cases. Conclusion: The number of patients undergoing gastric lavage in this study was considered high, even when instructed by the center of attendance. Despite the lack of evidence that gastric lavage brings benefits in cases of poisoning, it is widely used due to the lack of knowledge by health professionals of the indications and contraindications of this procedure.

Evaluating a Rapid Field Assessment System for Anticoagulant Rodenticide Exposure of Raptors.

Anticoagulant rodenticides (ARs) are commonly used to control rodent pests. However, worldwide, their use is associated with secondary and tertiary poisoning of nontarget species, especially predatory and scavenging birds. No medical device can rapidly test for AR exposure of avian wildlife. Prothrombin time (PT) is a useful biomarker for AR exposure, and multiple commercially available point-of-care (POC) devices measure PT of humans, and domestic and companion mammals. We evaluated the potential of one commercially available POC device, the Coag-Sense® PT/INR Monitoring System, to rapidly detect AR exposure of living birds of prey. The Coag-Sense device delivered repeatable PT measurements on avian blood samples collected from four species of raptors trapped during migration (Intraclass Correlation Coefficient > 0.9; overall intra-sample variation CV: 5.7%). However, PT measurements reported by the Coag-Sense system from 81 ferruginous hawk (Buteo regalis) nestlings were not correlated to those measured by a one-stage laboratory avian PT assay (r = - 0.017, p = 0.88). Although precise, the lack of agreement in PT estimates from the Coag-Sense device and the laboratory assay indicates that this device is not suitable for detecting potential AR exposure of birds of prey. The lack of suitability may be related to the use of a mammalian reagent in the clotting reaction, suggesting that the device may perform better in testing mammalian wildlife.

Sudden nasal bleeding and brodifacoum: A case of accidental exposure or attempted homicide?

A 50-year-old man was admitted to the emergency department with abrupt massive epistaxis. An accurate anamnesis and physical evaluation could not reveal any other anomalies, while coagulation tests showed potentially life threatening prolonged prothrombin time, with activated partial thromboplastin and thrombin time, with fibrinogen and antithrombin III within limits. Despite the prompt pharmacological and compressive local treatment, bleeding continued and the patient was therefore hospitalized. Highly specific coagulation and toxicological testing-among others high-performance liquid chromatography assessment on plasma-were performed, leading to the unexpected identification of brodifacoum. Police and criminal justice authorities revealed the source of exposure to brodifacoum after several months of investigation, residing in his everyday life. Brodifacoum is a long-lasting anticoagulant, acting as a vitamin K antagonist, and belongs to the family of superwarfarins. Brodifacoum use is authorized as rodenticide in many countries worldwide, but has been reported as cause of severe coagulopathies in humans, both intentional or involuntary, even consumed as a contaminant of herbal drugs, such as cannabis. The original contribution of this case to the knowledges of human brodifacoum intoxication resides in the multidisciplinary approach and the collaborative interplay of clinical and toxicology experts as well as judicial authorities.

Forensic implications of pituitary macroadenoma: An autopsy case report.

Pituitary adenomas are the most common tumours of the sellar region. Functional pituitary adenomas are related with immense assorted variety in their endocrine manifestations secondary to hypo or hyperfunction of the pituitary gland and mass impact. They can have a slow but severe impact on vision due to compression of the optic nerves, optic chiasm and cavernous sinus. Hereby, we discuss a case of a 29-year-old female patient who presented to the emergency with an alleged history of chest pain after ingestion of rat poison (zinc phosphide) in an attempt to commit suicide. Autopsy finding revealed a large mass that was present in the pituitary fossa impinging onto the optic chiasma. On further inquiry of the law enforcing agencies, it was found that the patient was undergoing treatment for psychiatric illness, and she had also complained of vision loss for the past few months. The parents of the deceased lodged a case of homicide by the husband. This case demonstrates the psycho-social and forensic implications of a pituitary tumour. The role of collaborative efforts of the autopsy team and the law enforcing agencies are emphasised.

Brodifacoum Poisoning Linked to Synthetic Marijuana Use in Wisconsin.

INTRODUCTION: Recent outbreaks of brodifacoum-induced coagulopathy resulting from the use of synthetic cannabinoids represents a growing public health concern. Brodifacoum is a commonly used and commercially available rodenticide that has anticoagulant properties. As new, unregulated synthetic cannabinoids enter the market, the potential for further outbreaks continues to rise. CASE PRESENTATION: We report a case of severe bleeding secondary to inhalation of synthetic cannabinoids contaminated with brodifacoum. The patient had been evaluated for several months of ongoing, unexplained vaginal bleeding and developed hematemesis and rectal bleeding 2 weeks after her last reported use. DISCUSSION: There have been previous reports of hemorrhage after exposure to synthetic marijuana in rare cases, including an outbreak of severe bleeding and reported synthetic marijuana use in the Midwestern region of the United States in 2018. CONCLUSION: While hemorrhaging after exposure to synthetic cannabinoids has been reported previously, we use this case to increase awareness of the potentially deadly exposures to brodifacoum from synthetic cannabinoids use in Wisconsin. By increasing awareness, emergency department physicians and state agencies can collaborate more effectively when responding in these cases.

[A case of acute osteofascial compartment syndrome caused by rodenticide poisoning].

Acute osteofascial compartment syndrome is a series of symptoms and signs caused by acute ischemia of muscles and nerves in osteofascial compartment. If it is not treated in time, it can lead to tissue necrosis. It is rare that it is caused by rodenticide poisoning. Such patients are often difficult to diagnose and treat early and have poor prognosis. In May 2018, a patient with acute osteofascial compartment syndrome caused by anticoagulant rodenticide poisoning was admitted to the Twelfth Hospital of Guangzhou City. After systematic treatment, he finally recovered and discharged. The early manifestations of this patient were mainly coagulation dysfunction, and finally acute osteofascial compartment syndrome. 5 days later, the diagnosis was made, and the operation of incision decompression and vacuum sealing drainage (VSD) was performed.

Sudden Cardiac Arrest in an Asymptomatic Zinc Phosphide-Poisoned Patient: A Case Report.

Zinc phosphide is a gray to black powder mainly used as a rodenticide. In contact with gastric fluid, it releases phosphine which is the main toxic material of this compound. Phosphine interferes with oxidative respiratory cycle of the cells, but is generally expected to manifest its toxicity with prodromal signs and symptoms including abdominal pain, nausea and vomiting, metabolic acidosis, and increased liver function tests. A 64-year-old man was referred to our center with the history of ingestion of three full table spoons of zinc phosphide powder with only a mild GI discomfort. Abdominal X-ray revealed radiopaque material in epigastric and abdominal right upper quadrant. Despite treatment with polyethylene glycol and completely normal vital signs and lab tests, he experienced sudden cardiac arrest 19 h after admission. Autopsy showed clues of focal myopathy and fibrosis with evidences of ischemia and congestion in cardiac tissue, pulmonary edema, shrunken bilateral kidneys, and nutmeg yellow liver. Toxicology panel confirmed the presence of phosphine and zinc phosphide in the gastric fluid. The patient deteriorated suddenly despite being completely symptom-free during the hours preceding cardiovascular arrest. Since the cardiopulmonary injury is the most rampant cause of early death, checking of the cardiac enzymes and cardiac monitoring could be beneficial for early detection and efficient management of these patients.

Plasma fluoroacetic acid concentrations: Symptoms, hematological, and biochemical characteristics in patients with fluoroacetic acid poisoning in the emergency department.

Fluoroacetic acid (FAcOH) was once a highly toxic rodenticide widely used in the world. In the past, studies on the toxicity of FAcOH have focused on animal experiments. The toxicity of FAcOH to humans and the changes of FAcOH in plasma have not been studied. Therefore, the present study aimed to describe the changes of plasma FAcOH concentrations, hematological, and biochemical characteristics in patients with FAcOH intoxication. According to clinical symptoms, 68 patients from the emergency department were divided into different groups: convulsion group, unconsciousness group, death group, and control groups. Plasma FAcOH concentrations, hematological, and biochemical parameters were investigated. Results demonstrated that patients in the convulsion group and the unconsciousness group had a significant increase (p < 0.01) in the level of neuron-specific enolase (NSE), creatine kinase MB (CKMB), glucose (GLU), and white blood cell count (WBC) and a significant decrease (p < 0.01) in serum potassium compared with the control group, respectively. Moreover, patients in the death group had a significant increase (p < 0.01) in the level of NSE, CKMB, N-terminal pro-brain natriuretic peptide, GLU, and WBC and a significant decrease (p < 0.01) in serum potassium and total calcium compared with the survival group. The concentrations of FAcOH in plasma in the convulsion group, the unconsciousness group, and the death group were 72.31 ± 42.29, 118.33 ± 55.41, and 163.78 ± 43.32 µg/mL, respectively. These changes and the plasma FAcOH concentrations may increase our understanding of the toxicity of FAcOH to humans and may help doctors to judge the clinical prognosis of patients with FAcOH intoxication.

Avian interspecific differences in VKOR activity and inhibition: Insights from amino acid sequence and mRNA expression ratio of VKORC1 and VKORC1L1.

Worldwide use of anticoagulant rodenticides (ARs) for rodents control has frequently led to secondary poisoning of non-target animals, especially raptors. In order to suggest some factors that may help considering the mechanism of the incidents, this study focused on the avian vitamin K 2, 3-epoxide reductase (VKOR) that is the target protein of ARs. We addressed the interspecific differences in VKOR activity and inhibition related to amino acid sequence and mRNA expression of VKORC1 and VKORC1-like1 (VKORC1L1). Poultry have been considered to be more tolerant to ARs than mammals. However, VKOR activity of owls, hawks, falcon and surprisingly, canaries, was lower and inhibited by warfarin more easily than that of chickens and turkeys. The amino acid sequence of VKORC1 and VKORC1L1 implied that the value of Ki for VKOR activity to ARs could depend on the amino acid at position 140 in the TYX warfarin-binding motif in VKORC1, and other amino acid mutations in VKORC1L1. The mRNA expression ratio of VKORC1:VKORC1L1 differed between turkey (8:1) and chicken (2:3) liver. VKORC1L1 has been reported to be resistant to warfarin compared to VKORC1. Hence, both the Ki of specific VKORC1 and VKORC1L1, and the mRNA expression ratio would cause avian interspecific difference of the VKOR inhibition. Our study also suggested the high inhibition of VKOR activities in raptors and surprisingly that in canaries as well. These factors are the most likely to contribute to the high sensitivity to ARs found in raptors.

Effects of vitamin K1 treatment on plasma concentrations of long-acting anticoagulant rodenticide enantiomers following inhalation of contaminated synthetic cannabinoids.

Background: An outbreak of synthetic cannabinoid (SC)-associated coagulopathy and bleeding in Illinois, USA was determined to be due to inhalation of SC contaminated with brodifacoum (BDF), difenacoum (DiF), and bromadiolone (BDL), highly potent long-acting anticoagulant rodenticides (LAARs). Treatment with high-dose vitamin K1 (VK1) prevented mortality; however, plasma LAAR levels were not measured risking recurrence of coagulopathy and bleeding due to premature discontinuation. The goal of this study was to determine if plasma LAAR levels were reduced following standard of care treatment to normalize coagulopathy.Methods: Blood samples were collected from a cohort of 32 patients, and ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis used to quantify plasma LAAR levels including enantiomers.Results: BDF was detected in 31 samples; 30 also contained DiF and 18 contained BDL. Initial plasma levels were 581 ± 87, 11.0 ± 1.9, and 14.9 ± 5.9 ng/mL for BDF, DiF, and BDL, respectively (mean ± SE). At discharge plasma, BDF levels remained elevated at 453 ± 68 ng/mL. Plasma half-lives for BDF, DiF, and BDL were 7.5 ± 1.3, 7.2 ± 1.9, and 1.8 ± 0.3 days, respectively. The half-life for trans-BDF enantiomers (5.7 ± 0.8 days) was shorter than for cis-enantiomers (7.6 ± 1.9 days). BDF half-lives were shorter, and coagulopathy normalized faster in patients receiving intravenous VK1 as compared to oral VK1. Patients prescribed VK1 at discharge had fewer re-admittances.Conclusions: These results demonstrate that plasma LAAR levels at discharge were elevated in poisoned patients despite normal coagulation, and that the route of VK1 administration affected LAAR pharmacokinetics and INR normalization. We propose plasma LAAR levels and coagulation be monitored concomitantly during follow-up of patients with LAAR poisoning. KEY POINTSIn patients treated with high-dose vitamin K1 for LAAR poisoning, plasma levels remained 40-fold above safe levels upon discharge from hospital.LAAR half-lives, normalization of coagulopathy, and readmittances were reduced by treatment with intravenous vitamin K1.