Management of Aluminum Phosphide Poisoning Without ECMO
The treatment of aluminum phosphide (AlP) poisoning without ECMO requires aggressive supportive care including gastric decontamination, hemodynamic support with fluids and vasopressors, correction of metabolic acidosis, and cardiac protection with magnesium sulfate and other cardioprotective agents. 1, 2
Initial Management
- Immediate gastric decontamination with diluted potassium permanganate (1:10,000) should be performed if the patient presents within 1 hour of ingestion 3
- Administration of coconut oil or sodium bicarbonate via nasogastric tube may help reduce phosphine gas formation in the stomach 3
- Activated charcoal administration may be beneficial, though evidence is limited 2
Hemodynamic Support
- Aggressive fluid resuscitation with crystalloids to combat refractory hypotension 4
- Early initiation of vasopressors (norepinephrine preferred) for persistent hypotension despite fluid resuscitation 4
- Continuous cardiac monitoring is essential as dysrhythmias are common 1
Metabolic Acidosis Management
- Sodium bicarbonate administration for severe metabolic acidosis (pH < 7.2) 2
- Monitor arterial blood gases frequently to guide bicarbonate therapy 4
Cardiac Protection
- Intravenous magnesium sulfate (1-2 g initially, followed by infusion) to stabilize cardiac membranes and prevent arrhythmias 1, 3
- Trimetazidine may provide cardioprotective effects by improving myocardial metabolism 1
- N-Acetylcysteine administration may help reduce oxidative stress 1
Respiratory Support
- Early intubation and mechanical ventilation for respiratory distress or decreased level of consciousness 4
- Maintain adequate oxygenation with high FiO2 initially 2
Additional Supportive Measures
- Vitamin C and thiamine administration may help reduce oxidative stress 1
- Hydrocortisone may be beneficial in managing shock 1
- Continuous renal replacement therapy for acute kidney injury and severe metabolic acidosis 2
Monitoring and Follow-up
- Frequent monitoring of cardiac function with echocardiography 5
- Regular assessment of liver and kidney function 2
- Monitor for rhabdomyolysis with CPK measurements 2
Pitfalls and Caveats
- AlP poisoning has a high mortality rate (70-100%) even with small ingestions (150-500 mg), requiring immediate and aggressive intervention 1
- Avoid physical restraints without adequate sedation as this can worsen outcomes 6
- The absence of metabolic acidosis on initial presentation does not rule out severe poisoning; continuous monitoring is essential 4
- Delayed presentation (>6 hours after ingestion) is associated with poorer outcomes 5
While ECMO has shown promise in managing refractory cardiogenic shock in AlP poisoning 5, the above protocol provides the best alternative approach when ECMO is unavailable. Early and aggressive supportive care focusing on hemodynamic stabilization, correction of metabolic acidosis, and cardiac protection remains the cornerstone of management.