Incidence of Aluminum Phosphide Poisoning in India
Aluminum phosphide poisoning has become a major public health crisis in India, particularly in northern and rural regions, accounting for approximately 50% of all acute poisoning cases in some areas, with mortality rates ranging from 30-70%. 1, 2
Epidemiological Data
- In a prospective study from 1985, aluminum phosphide poisoning represented approximately half of all acute poisoning cases admitted to a single center over one year 1
- The problem is most prevalent in the rural belt of Northern India, where aluminum phosphide is widely used as a grain fumigant 2
- Among 104 confirmed cases in one Indian hospital from 2007-2008, only 31 patients (30%) survived, demonstrating the extremely high mortality rate 3
- Aluminum phosphide has become "the most common agricultural poisoning in suburban and rural India" with persistently high mortality rates 3
Clinical Significance and Mortality
- Ingestion of as little as 150-500 mg can be fatal, and all exposures require ICU-level care 4
- The mortality rate remains extremely high despite aggressive supportive care, with 6 deaths among 16 patients (37.5%) in one prospective series 1
- Profuse vomiting, severe upper abdominal pain, and shock are the most common presenting features 1
- Ingestion of "unexposed" tablets from freshly opened bottles carries significantly higher risk of fatal outcome compared to partially degraded tablets 1
Multi-Organ Toxicity Profile
Cardiovascular complications dominate the clinical picture and drive mortality:
- Severe hypotension requiring continuous vasopressor support develops rapidly 4, 5
- Life-threatening arrhythmias, toxic myocarditis, and congestive heart failure are common 6
- Rare cases of ST-segment elevation myocardial infarction can occur, sometimes delayed up to 48 hours after ingestion 6
Other organ systems affected include:
- Severe metabolic acidosis requiring sodium bicarbonate administration 4, 5
- Acute renal failure and rhabdomyolysis with myoglobinuria 4
- Hepatic injury as part of multi-organ failure 5
- Respiratory failure requiring mechanical ventilation 4
Long-Term Complications in Survivors
Approximately one-third of survivors develop serious esophageal complications:
- Single short-segment esophageal strictures occurred in 10 of 31 survivors (32%) in one series 3
- Tracheo-esophageal fistula developed in 2 of 31 survivors (6.5%) 3
- All survivors of aluminum phosphide poisoning must undergo barium swallow and endoscopic examination for early detection of these complications 3
- Esophageal strictures typically respond to Savary-Gilliard bougie dilation over 6-10 sessions 3
Critical Management Principles
The only effective treatment is aggressive supportive care initiated immediately:
- Fluid resuscitation and vasopressor support are essential 5
- Continuous cardiac monitoring with calcium gluconate (100-200 mg/kg/dose) available for life-threatening arrhythmias 4
- Sodium bicarbonate (1-2 mEq/kg IV push) for severe metabolic acidosis 4
- Early continuous renal replacement therapy (CRRT) may improve survival in severe cases 7
- Intravenous magnesium sulfate is recommended as specific therapy 2
Critical pitfalls to avoid:
- Physical restraints without adequate sedation worsen outcomes 4
- Phosphine gas released from aluminum phosphide is highly toxic to healthcare providers; ensure proper ventilation of treatment areas 4
- Do not administer sodium bicarbonate and calcium through the same IV line 4
Public Health Impact
Aluminum phosphide poisoning represents an escalating public health emergency in India:
- The widespread availability of aluminum phosphide as a grain fumigant in agricultural regions has made it a preferred agent for self-poisoning 1, 2
- The extremely high mortality rate and lack of specific antidote make this a devastating problem requiring urgent public health intervention 2
- Restricted access to aluminum phosphide and improved storage regulations are needed to reduce the incidence of poisoning 1