A 24-year-old woman comes to the emergency department due to bloody emesis. She had 2 episodes of vomiting bright red blood and feels lightheaded and dizzy. The patient was recently diagnosed with factitious disorder after being hospitalized multiple times for a myriad of symptoms and undergoing several invasive procedures. Physical examination shows scattered ecchymoses. The abdomen is soft and nontender. Rectal examination shows maroon-colored, guaiac-positive stool. After much questioning, she admits to having ingested rat poison several days ago. Immediate treatment of this patient should include which of the following?

Question

A 24-year-old woman comes to the emergency department due to bloody emesis.  She had 2 episodes of vomiting bright red blood and feels lightheaded and dizzy.  The patient was recently diagnosed with factitious disorder after being hospitalized multiple times for a myriad of symptoms and undergoing several invasive procedures.  Physical examination shows scattered ecchymoses.  The abdomen is soft and nontender.  Rectal examination shows maroon-colored, guaiac-positive stool.  After much questioning, she admits to having ingested rat poison several days ago.  Immediate treatment of this patient should include which of the following?

Quizplus · Accepted Answer

11ec160b_3c3d_8a7d_9249_7f8f43706e31_MD0001_00 Most available rodenticides contain brodifacoum ("superwarfarin"), a long-acting 4-hydroxycoumarin derivative. By ingesting rodenticide, this patient depleted her vitamin K-dependent clotting factors, thereby causing an acquired coagulopathy (similar to warfarin toxicity) that led to bleeding (gastrointestinal hemorrhage with hematemesis and guaiac-positive stools, ecchymoses). The anticoagulant effect is generally seen approximately 48 hours following ingestion, which represents the time required for depletion of the coagulation factors. To treat life-threatening bleeding in the setting of coumarin or warfarin toxicity, rapid replenishment of clotting factors II, VII, IX, and X is generally performed through intravenous administration of fresh frozen plasma (FFP), which contains all coagulation factors and other proteins present in the original unit of blood. Additional vitamin K should also be given. Vitamin K alone can be used in patients with abnormal coagulation tests (eg, prolonged prothrombin or partial thromboplastin times) but no bleeding. (Choice A) Cryoprecipitate (precipitate obtained from FFP by centrifugation/thawing) contains factor VIII, factor XIII, von Willebrand factor, and fibrinogen. Therefore, it would not be of significant benefit when vitamin K-dependent clotting factors (II, VII, IX, and X) require replenishment. (Choice B) Desmopressin increases plasma levels of von Willebrand factor and factor VIII; it is used in management of hemophilia A and von Willebrand disease. (Choice D) Rat poison or warfarin does not affect platelet count. (Choice E) Protamine sulfate is used to treat heparin overdose. It binds to heparin, forming a complex that has no anticoagulant activity. Educational objective: Most available rodenticides contain brodifacoum, a long-acting 4-hydroxycoumarin derivative. A patient who has ingested a quantity of rodenticide sufficient to cause coagulopathy and abnormal bleeding (similar to warfarin toxicity) requires immediate treatment with fresh frozen plasma in addition to vitamin K.

A 24-Year-Old Woman Comes to the Emergency Department Due to Bloody