What is the treatment for aluminium phosphide poisoning?

Treatment of Aluminum Phosphide Poisoning

The treatment of aluminum phosphide poisoning requires immediate supportive care with gastric decontamination, aggressive fluid resuscitation, and cardiovascular support, as there is no specific antidote available. 1

Clinical Presentation and Diagnosis

Aluminum phosphide (ALP) is a highly toxic pesticide that releases phosphine gas when it comes in contact with moisture or stomach acid. This poisoning presents with:

• Early symptoms: Vomiting, abdominal pain, dizziness, and dyspnea 2
• Progression to: Refractory shock, metabolic acidosis, cardiac arrhythmias, and multi-organ failure 3
• SLUDGE syndrome: Salivation, lacrimation, urination, defecation, GI upset, emesis, bronchorrhea, and bronchospasm 1

Treatment Algorithm

1. Immediate Interventions

• Decontamination:
  • Remove contaminated clothing
  • Perform gastric lavage with diluted potassium permanganate (1:10,000) 4
  • Consider coconut oil and sodium bicarbonate lavage 4
  • Use proper personal protective equipment to prevent secondary exposure 1

2. Hemodynamic Support

• Fluid resuscitation: Aggressive IV fluids to manage hypotension
• Vasopressors: For refractory shock
• Inotropic support: To maintain cardiac output 2

3. Cardiac Management

• Magnesium sulfate: IV administration (initial dose 1-2g) to stabilize cardiac membrane and prevent arrhythmias 3, 5
• Continuous cardiac monitoring: For early detection of arrhythmias
• Consider lidocaine: For ventricular arrhythmias 5

4. Respiratory Support

• Oxygen supplementation: To maintain adequate oxygenation
• Mechanical ventilation: For respiratory failure 2
• Consider ECMO: For severe cases with refractory cardiorespiratory failure 5

5. Management of Metabolic Abnormalities

• Sodium bicarbonate: For severe metabolic acidosis
• Consider CRRT/hemodialysis: For severe metabolic acidosis and acute kidney injury 5

6. Organ Support

• N-Acetylcysteine: As an antioxidant to reduce oxidative stress 3
• Vitamin C and thiamine: As adjunctive therapy 3
• Hydrocortisone: To support adrenal function and reduce inflammation 3
• Trimetazidine: As a cardioprotective agent 3

Prognostic Factors

• Amount ingested: Higher doses associated with worse outcomes 6
• Freshness of tablets: Fresh tablets are more lethal 6
• Time to treatment: Early intervention improves survival 6
• Presence of vomiting: Early vomiting may reduce absorption and improve outcomes 6

Important Considerations and Pitfalls

• No specific antidote: Treatment is primarily supportive
• Rapid deterioration: Patients can deteriorate quickly, requiring intensive monitoring
• Secondary exposure risk: Healthcare workers must use appropriate PPE to prevent secondary poisoning 1
• Avoid succinylcholine: For intubation as it may cause prolonged paralysis 1
• High mortality: Despite treatment, mortality remains high (30-100%) 5

Emerging Therapies

• Extracorporeal membrane oxygenation (ECMO): For severe cases with cardiovascular collapse 5
• Continuous renal replacement therapy (CRRT): For managing severe metabolic acidosis and renal failure 5
• Intra-aortic balloon pump: For cardiovascular support in refractory cases 3

Early recognition and aggressive supportive care are crucial for improving outcomes in aluminum phosphide poisoning, with special attention to cardiovascular support and management of metabolic abnormalities.