Rat-killer paste (3% yellow phosphorus) causes a deceptive latent phase followed by acute liver failure on days 3-5. Admit every ingestion, monitor INR and liver tests daily, refer early to a liver unit, and consider plasma exchange as a bridge; transplantation for King's criteria.
At the bedside
Timed steps- 1
GI phase
Day 0-1Vomiting, garlic odour, abdominal pain; may be minimal. Do not discharge.
- 2
Latent phase
Day 1-3Apparent recovery; monitor INR, bilirubin, ALT, glucose, creatinine at least daily.
- 3
Hepatic phase
Day 3-5Jaundice, rising INR, encephalopathy, hypoglycaemia, cardiotoxicity (arrhythmias, shock), AKI.
- 4
Support
TreatALF care (liver failure module): glucose, lactulose, ICP precautions; NAC is used empirically.
- 5
Plasma exchange
BridgeTPE improved survival in an Indian series (overall 79%; all 23 patients not meeting King's criteria survived). Refer early for liver transplant assessment.
Yellow phosphorus ALF (empirical)
N-acetylcysteine
- Dose
- 150 mg/kg over 1 h, then 50 mg/kg over 4 h, then 100 mg/kg over 16 h; often continued
References
- 1
- 2
Rat paste ingestion
Step 1 of ~4
Admit; daily INR, LFT, glucose, creatinine
Based on Eapen CE, Venkataraman J. Educational use; follow local protocol.
Evidence
- Varghese 2020: observational TPE series in yellow phosphorus ALF.
- Eapen 2021: Indian management constraints and recommendations.
🇮🇳 India notes
- A leading cause of drug/toxin ALF in south and west India (Tamil Nadu, Kerala, Maharashtra); several states have moved to restrict sale.
References
- 1
- 2
Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.