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Poison Control: 2021 Brodifacoum-Contaminated Synthetic Cannabinoid Outbreak: Overview of Identification and Management of the Exposed Patient
2021 Brodifacoum-Contaminated Synthetic Cannabinoid Outbreak: Overview of Identification and Management of the Exposed Patient
By Molly Stott, Pharm.D.
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By Chiemela Ubani, Pharm.D.
By Alexandra Funk, PharmD, DABAT
Florida Poison Information Center – Tampa
By Justin Arnold, DO, MPH, FACEP, FACMT
Florida Poison Information Center – Tampa
Edited by Dawn Sollee, Pharm.D., DABAT, FAACT
Director, Florida/USVI Poison Information Center- Jacksonville, UF Health Jacksonville
What happened during the 2021 brodifacoum outbreak?
In December 2021, patients started presenting to emergency departments across Hillsborough County with profound and persistent coagulopathies in which standard treatments were inadequate. It was later determined that these patients had been exposed to brodifacoumcontaminated synthetic cannabinoids. To date, there have been a total of 55 cases resulting in six deaths. The Florida Poison Information Center Tampa collaborated with local and state health departments and hospitals to develop a course of action for the identification and management of these patients.
What is brodifacoum? What are synthetic cannabinoids?
Brodifacoum belongs to a class of agents that was developed to overcome warfarin resistance in rats. Brodifacoum is a vitamin K antagonist and works similarly to warfarin by inhibiting vitamin K 2,3-epoxide reductase.1 Inhibition of this enzyme inhibits the regeneration of vitamin K 2,3-epoxide to vitamin K. Vitamin K is an integral cofactor for factors VII, IX, X, II and proteins C and S.1,2,3 By preventing its activation, the coagulation cascade is impaired, thus resulting in coagulopathy. These rodenticides are referred to as “superwarfarins” or long-acting anticoagulant rodenticides (LAARs). Brodifacoum is the most potent agent in this class; it is over 100x more potent than warfarin and can last from 2-12 months.2,4 Synthetic cannabinoids are a class of lab-derived cannabinoids that are full agonists of the Cannabinoid receptor 1 (CB1) and CB2 receptors throughout the body, but more specifically in the brain. Synthetic cannabinoids are commonly referred to as “K2”, “Spice” or “Cloud 9” and are a common drug of abuse.5
How to identify patients possibly exposed to brodifacoum
Most commonly, patients exposed to brodifacoum will present to the emergency department with unexplained bleeding. Hematuria is the most common type of bleeding seen, but other common types of bleeding include epistaxis, vaginal, and gastrointestinal bleeding. Patients will also have unmeasurably high PT/ INR levels. In addition, most exposed patients have a history of drug use or reported using synthetic cannabinoids in the days to weeks prior to their presentation. Laboratory tests to detect brodifacoum are not readily available in the acute setting, so the diagnosis of brodifacoum exposure is clinical in nature and dependent on a high index of suspicion. Contact your local poison center if you are suspecting a patient exposed to brodifacoum.
What is the approach to treatment?
A baseline CBC and PT/INR should be immediately obtained in addition to consultation with your local poison control center.
