Liver poisoning due to yellow phosphorus from rat poison

Phosphorus is an important element found in nature and widely used in industry. It comes in two forms – red and yellow phosphorus. Red phosphorus is not volatile, not soluble, and cannot be absorbed efficiently by the human body, making it non-toxic. However, yellow (or white) phosphorus is just the opposite. It is easily absorbed by the gastrointestinal tract, making it a local and systemic toxin. Once absorbed, it can damage the liver, kidneys, heart, and organs of the digestive system, leading to death in many cases.

Unfortunately, yellow phosphorus (YP) is widely used in industry. It’s a key component in military ammunition, fire matchsticks, fertilizers, firework crackers, and rodenticides, or rat poison. Inhaling or ingesting YP can have deadly consequences. The most common brands of rat poison in India are Warfarin and Ratol. Warfarin is relatively non-toxic to humans unless consumed in large quantities. However, rodents have developed resistance against Warfarin, which makes it ineffective. So farmers have turned in a big way to Ratol, which contains 3% by weight of YP. This is a cheap and highly effective rat poison that is easily available over the counter.

In the last couple of decades, there have been innumerable instances of consumption of rat poison, either accidentally or with the intention of taking one’s life, in developing countries. Closer home, such instances have been reported from Gujarat, Rajasthan, Karnataka, and Nepal. Accidental consumption by children happens because the product comes as an orange-yellow paste applied on bread slices to be consumed by rats. But it is appealing to children who mistake it for toothpaste (one instance) or butter (few instances).

Symptoms and Consequences

Between 1 to 8 hours of consuming the rat poison, the person starts vomiting orange-yellow matter with a strong garlicky smell depending on the quantity ingested. Depending on when the person was rushed for emergency medical care, there can be a wide range of symptoms (Source: multiple sources including Indian Journal of Pharmacology)

• Liver-related: Initially, there are mild asymptomatic conditions such as elevated liver enzymes and bilirubin in the blood. If the person does not respond to medication, he/she progresses towards stage-1 hepatic encephalopathy and in a couple of days to stage-3. This can lead to acute hepatic failure, deranged liver functionality, and coagulopathy.
• Kidney-related: The person may show acute tubular necrosis followed by acute renal failure.
• Heart-related: The person may develop hypotension (low BP), tachycardia (rapid heartbeat), arrhythmias (irregular heartbeat), and cardiogenic shock (inadequate pumping of blood by the heart)
• Central Nervous System–related: The person may show signs of confusion, hallucinations, and psychosis. In some instances, the person has slipped into coma.

Treatment Options

Depending on the time interval between consumption and start of treatment, the dosage consumed, and symptoms being exhibited, the doctors will pursue one or more of the following:

• (IV) fluids with 10% dextrose, ranitidine injection, vitamin K and other supportive drugs
• oral lactulose
• N-acetylcysteine or NAC, although some doctors are divided about its efficacy
• Gastric lavage (stomach pumping) with 1:5000 ratio of potassium permanganate. This converts the YP into harmless metallic oxides, which are broken down by the liver and eliminated by the body
• Transfusion of fresh frozen plasma and packed red blood cells
• Liver transplantation in case of acute hepatic failure

Preventive Care

In spite of the above measures, many patients have died due to multiple-organ failure. This is a testimony to how toxic the poison is, the main reason being that YP has no strong antidote. It has to be converted into other compounds or pumped out, or its effect delayed. That is what the above treatment options try to achieve.

This means prevention is better than cure when it comes to yellow phosphorus. The following steps must be taken in case of non-military or domestic settings.

• Matchsticks: Keep the matchsticks as far from your face as possible while lighting them. Minimize their usage. Use electronic lighters to light the gas stove and lighters for cigarettes. While lighting oil lamps, light a candle or agarbathi and use that for the lamps.
• Firework crackers: While completely avoiding the use of fireworks is the best measure, you can minimize exposure to the smoke by keeping a distance. Avoid fireworks that emit a lot of smoke. And not to mention, wear a double mask throughout lighting crackers.
• Fertilizers: Keep them out of reach of children or adults with depression or suicidal tendencies.
• Rat poison: As in the case of fertilizers, keep them out of reach of children or adults with depression or suicidal tendencies. This should be locked up safely with just one or 2 adults, who are at no risk of suicide, having access. Do not stock them. Purchase small doses and use them completely. Dispose of the tube/container as it is in a dustbin (preferably for hazardous chemicals), and do not empty the remaining contents in the soil or water.
• Alternate methods: While rodenticides such as Ratol are effective against rats, they pose a grave risk to human life. Instead of such chemicals, you should try rat traps that come as metal cages. Sticky rat-trap pads have become popular in recent years as they are very effective. Many farmers use cats as a natural solution to the problem.

Takeaway

Farming or agriculture comes with various challenges, one of them being rodents that devour raw crops or stored produce. Rodenticides may be effective, but they are toxic and fatal to human beings when consumed accidentally or for the purpose of taking one’s life. One should explore alternate methods for eliminating rodents and not rely completely on these toxic chemicals. The age-old slogan ‘better safe than sorry’ holds true here too.

 

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