What is the management and treatment of aluminum phosphide poisoning?

Management of Aluminum Phosphide Poisoning

The management of aluminum phosphide (AlP) poisoning requires immediate supportive care as there is no specific antidote, with focus on hemodynamic stabilization, gastric decontamination, and treatment of metabolic acidosis to reduce mortality. 1, 2

Initial Assessment and Stabilization

• Ensure proper ventilation of treatment areas as phosphine gas released from AlP is highly toxic and can affect healthcare providers 1
• Verify elevated serum aluminum levels if aluminum toxicity is suspected, particularly in patients with renal failure 1
• Perform immediate gastric lavage with diluted potassium permanganate, coconut oil, and sodium bicarbonate for recent ingestions 2
• Initiate continuous cardiac monitoring for early detection of arrhythmias, as ECG abnormalities occur in up to 82.7% of cases 3

Respiratory Management

• Consider early intubation and mechanical ventilation for patients with respiratory distress or decreased level of consciousness 4
• Implement continuous positive airway pressure (CPAP) ventilation for patients with adequate consciousness and without contraindications 1
• Monitor arterial blood gases frequently to assess for metabolic acidosis, which is present in 82.3% of cases 3

Cardiovascular Support

• Administer aggressive fluid resuscitation to manage refractory hypotension, which is a hallmark of AlP toxicity 4, 5
• Initiate vasopressors (e.g., norepinephrine) early for hemodynamic support in cases of cardiogenic shock 4
• Consider magnesium sulfate intravenously as a membrane stabilizer to reduce cardiac arrhythmias 6, 2

Management of Metabolic Complications

• Correct metabolic acidosis with sodium bicarbonate administration 2
• Monitor and treat hyperkalemia if present, using calcium gluconate for cardiac membrane stabilization in life-threatening arrhythmias 7
• Administer N-acetylcysteine, vitamin C, and thiamine as potential cardioprotective agents 6

Specific Considerations for Aluminum Toxicity

• For confirmed aluminum toxicity with levels >60μg/L but <200μg/L, administer deferoxamine (DFO) at 5 mg/kg 1
• Do not administer DFO if serum aluminum levels are >200μg/L due to risk of neurotoxicity; instead, perform intensive dialysis with high-flux membranes 7, 1
• If DFO is administered, avoid intravenous iron to limit formation of feroxamine 7
• Use high-flux dialysis membranes for more effective clearance of aluminum-DFO complexes 7

Monitoring and Follow-up

• Monitor serum creatinine kinase and potassium to detect rhabdomyolysis 1
• Treat rhabdomyolysis with adequate hydration and urine alkalinization if myoglobinuria develops 1
• Watch for signs of hepatic injury, as elevated liver enzymes are common (AST >2000 U/L, ALT >2000 U/L) 5
• Continue intensive monitoring for at least 72 hours, as deterioration can occur despite initial stabilization 5

Pitfalls and Caveats

• Delayed hospital arrival (>2 hours post-ingestion) significantly worsens prognosis; 65.3% of cases experience such delays 3
• Mortality rates remain high (70-100%) even with small ingestions (150-500 mg), emphasizing the need for aggressive early intervention 6
• Aluminum hydroxide should be limited to 1-2 days when used as a phosphate binder to avoid cumulative aluminum toxicity 7
• DFO therapy can precipitate fatal mucormycosis; use reduced dosing (5 mg/kg) and expanded intervals between treatments to minimize risk 7