What is the treatment for aluminum phosphide (AlP) poisoning?

Management of Aluminum Phosphide (AlP) Poisoning

The treatment of aluminum phosphide poisoning requires immediate aggressive supportive care as there is no specific antidote, with focus on rapid decontamination, hemodynamic support, and management of metabolic acidosis to reduce mortality.

Initial Management

• Rapid decontamination is critical and should be performed as soon as possible after ingestion 1:

  • Gastric lavage with potassium permanganate solution (1:10,000) to oxidize phosphine gas 2, 3
  • Administration of activated charcoal and sorbitol suspension to reduce absorption 2
  • Oral administration of coconut oil (50-60 ml) which may help prevent phosphine absorption 2, 3

• Avoid physical restraints without adequate sedation as this can worsen outcomes 4

Hemodynamic Support

• Aggressive fluid resuscitation to maintain blood pressure 1, 3
• Inotropic support with vasopressors for persistent hypotension 1
• Continuous hemodynamic monitoring in an intensive care setting 3
• Management of shock is critical as cardiovascular collapse is a common cause of death 1

Acid-Base Management

• Intravenous sodium bicarbonate administration to correct metabolic acidosis 2, 3
• Arterial blood gas monitoring to guide bicarbonate therapy 1
• Metabolic acidosis is a poor prognostic sign and requires aggressive correction 1

Electrolyte Management

• Intravenous magnesium sulfate (1-2 g initially, followed by 1 g every 3-4 hours) has shown benefit in some cases 3
• Calcium gluconate administration may help stabilize cell membranes 2
• Monitor and correct electrolyte imbalances, particularly potassium and magnesium 1

Respiratory Support

• Early intubation and mechanical ventilation for respiratory distress or failure 1
• Oxygen therapy to maintain adequate tissue oxygenation 1
• Phosphine gas inhibits cellular oxygen utilization, making respiratory support crucial 5

Organ Support

• Monitor for and manage multi-organ dysfunction, particularly:
  • Hepatic dysfunction (monitor liver enzymes) 1
  • Renal failure (may require renal replacement therapy) 1
  • Cardiac dysfunction (ECG monitoring for arrhythmias) 1

Pitfalls and Caveats

• AlP poisoning has a very high mortality rate, especially with deliberate ingestions 1, 5
• One tablet of phostoxin containing 3 grams of AlP can be lethal 1
• Phosphine gas released from AlP is highly toxic and can affect healthcare providers; ensure proper ventilation of treatment areas 6
• There is no specific antidote for AlP poisoning; treatment is primarily supportive 3
• The mechanism of toxicity involves inhibition of oxidative phosphorylation and cellular hypoxia 5
• Spontaneous ignition has been reported in some cases, requiring careful handling 7

Prognosis

• Poor prognostic factors include:

  • Delayed presentation (>6 hours after ingestion) 2
  • Severe metabolic acidosis 1
  • Shock requiring multiple vasopressors 1
  • Multi-organ dysfunction 1

• Early aggressive intervention may improve survival rates 2, 3