Management Guidelines for Aluminum Phosphide Poisoning
Aluminum phosphide poisoning requires immediate aggressive supportive care as there is no specific antidote, with mortality rates of 70-100% even with ingestion of small amounts.
Initial Management
Decontamination
- Perform gastric lavage with diluted potassium permanganate (1:10,000 solution) 1
- Consider combination with coconut oil and sodium bicarbonate for gastric lavage 2, 1
- Administer activated charcoal 1
Hemodynamic Support
- Initiate aggressive fluid resuscitation with crystalloids 2, 3
- Start vasopressors early for refractory hypotension 2, 4
- Consider intra-aortic balloon pump for refractory cardiogenic shock 1
Specific Interventions
Magnesium Sulfate
- Administer intravenous magnesium sulfate to reduce cardiac arrhythmias 5, 2, 4, 1
- Magnesium sulfate acts as a membrane stabilizer and has shown effectiveness in case reports 5
Acid-Base Management
- Early administration of sodium bicarbonate for metabolic acidosis 1
- Monitor arterial blood gases frequently to guide therapy
Cardioprotective Agents
- Consider trimetazidine to preserve oxidative metabolism and reduce ventricular ectopy 5, 1
- N-Acetylcysteine may have a role as an antioxidant 5, 3
- Additional cardioprotective agents to consider: vitamin C, thiamine, and hydrocortisone 5
Monitoring and Supportive Care
Cardiac Monitoring
- Continuous ECG monitoring for early detection of arrhythmias 4
- Monitor for signs of cardiotoxicity including ST segment changes and elevated troponin 4
Respiratory Support
- Early intubation and mechanical ventilation for respiratory distress 3
- Monitor for development of pulmonary edema
Renal Function
- Monitor renal function closely as acute kidney injury is common 5
- Consider renal replacement therapy for severe renal failure
Special Considerations
Healthcare Worker Safety
- Ensure adequate ventilation in treatment areas to prevent secondary exposure 6
- Healthcare workers should use appropriate personal protective equipment when handling patients with aluminum phosphide poisoning 6
- Air-purifying respirators with organic vapor filters provide protection against phosphine gas 6
Pitfalls and Caveats
- No specific antidote exists for aluminum phosphide poisoning
- Mortality remains extremely high despite aggressive management
- Avoid calcium-containing compounds in management as they may worsen outcomes
- Aluminum hydroxide should only be used for short periods (1-2 days) due to risk of aluminum toxicity 7
- Early recognition and intensive supportive care are crucial for survival
- Secondary exposure to healthcare workers is possible but typically causes mild symptoms when proper ventilation is maintained 6