What is the management approach for aluminum phosphide (AlP) poisoning?

Management of Aluminum Phosphide (Celphos) Poisoning

All aluminum phosphide exposures require immediate ICU-level care, as ingestion of as little as 150-500 mg can be fatal, and aggressive supportive management is the cornerstone of treatment since no specific antidote exists. 1

Immediate Decontamination and Stabilization

Gastric Decontamination

• Perform early gastric lavage with diluted potassium permanganate solution (1:10,000) to oxidize phosphine gas and prevent further absorption 2, 3
• Administer coconut oil orally (60-100 mL) immediately after lavage, as it may prevent phosphine absorption by creating a protective barrier in the gastrointestinal tract 2, 4
• Give activated charcoal (1 g/kg) with sorbitol after gastric lavage 3, 4
• Administer oral sodium bicarbonate to neutralize gastric acid and reduce phosphine gas liberation 2, 4

Critical Safety Precautions

• Ensure proper ventilation of treatment areas, as phosphine gas released from aluminum phosphide is highly toxic to healthcare providers 1
• Avoid physical restraints without adequate sedation, as this worsens outcomes 1

Cardiovascular Support

Shock Management

• Initiate aggressive fluid resuscitation with crystalloids for hypotension 2, 3
• Start vasopressors (norepinephrine or dopamine) early for refractory shock despite adequate fluid resuscitation 2, 3
• Consider intra-aortic balloon pump for refractory cardiogenic shock unresponsive to conventional therapy 5, 3
• Extracorporeal membrane oxygenation (ECMO) may be lifesaving in cases of severe cardiovascular collapse 5

Arrhythmia Management

• Administer calcium gluconate (100-200 mg/kg/dose) via slow IV infusion with continuous ECG monitoring for life-threatening arrhythmias 1
• Do not administer sodium bicarbonate and calcium through the same IV line to avoid precipitation 1
• Digoxin may be considered for refractory cardiogenic shock 3

Metabolic and Cardioprotective Therapy

Magnesium Sulfate (Key Intervention)

• Give intravenous magnesium sulfate (2-4 g IV bolus over 10-15 minutes, followed by continuous infusion of 1-2 g/hour) to stabilize cardiac membranes and reduce arrhythmias 2, 5, 3
• Monitor serum magnesium levels and adjust dosing accordingly 2

Acidosis Correction

• Administer sodium bicarbonate (1-2 mEq/kg IV push) for severe metabolic acidosis (pH <7.2) 1, 3
• Continue bicarbonate infusion to maintain pH >7.35 and prevent further phosphine toxicity 3, 4

Additional Cardioprotective Agents

• Trimetazidine (20 mg three times daily orally or via nasogastric tube) may preserve oxidative metabolism and stop ventricular ectopic beats 5, 3
• N-acetylcysteine (150 mg/kg loading dose, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours) as an antioxidant 5
• Vitamin C (1-2 g IV every 6 hours) for antioxidant support 5
• Thiamine (100 mg IV daily) to support cellular metabolism 5
• Hydrocortisone (100 mg IV every 8 hours) for refractory shock 5

Respiratory Management

• Perform early endotracheal intubation for patients with altered mental status, respiratory failure, or inability to protect airway 1
• Consider continuous positive airway pressure (CPAP) ventilation for patients with adequate consciousness and no contraindications 1
• Provide mechanical ventilation with lung-protective strategies for pulmonary edema 3

Renal and Electrolyte Management

Hyperkalemia Treatment

• Administer calcium gluconate for cardiac membrane stabilization in life-threatening arrhythmias from hyperkalemia 1
• Use standard hyperkalemia protocols (insulin-dextrose, beta-agonists, dialysis if severe) 1

Rhabdomyolysis Management

• Monitor serum creatinine kinase and potassium to detect rhabdomyolysis 1
• Provide aggressive hydration and urine alkalinization if myoglobinuria develops 1

Dialysis Considerations

• Initiate hemodialysis with high-flux membranes for severe renal failure or refractory acidosis 1, 3
• High-flux membranes are more effective for clearance of aluminum-deferoxamine complexes if aluminum toxicity is suspected 1

Aluminum Toxicity Management (If Suspected)

• Measure serum aluminum levels if aluminum toxicity is suspected, particularly in dialysis patients 1
• For aluminum levels 60-200 μg/L: Administer deferoxamine (DFO) 5 mg/kg with careful monitoring and use high-flux dialysis membranes 1
• For aluminum levels >200 μg/L: Do NOT administer DFO due to high risk of acute aluminum neurotoxicity; instead perform intensive daily hemodialysis for 4-6 weeks 1
• Avoid intravenous iron if DFO is administered to limit formation of ferroxamine 1
• Limit aluminum hydroxide use as phosphate binder to 1-2 days maximum to avoid cumulative aluminum toxicity 1
• Be aware that DFO therapy can precipitate fatal mucormycosis (91% mortality in dialysis patients); use reduced dosing and expanded intervals to minimize risk 1

Monitoring Requirements

• Continuous cardiac monitoring with serial ECGs to detect arrhythmias, ST changes, and conduction abnormalities 6, 3
• Serial cardiac troponin levels to assess myocardial injury 6
• Arterial blood gas analysis every 2-4 hours initially to monitor acidosis 3
• Serial electrolytes (especially potassium, magnesium, calcium) every 4-6 hours 1, 3
• Liver function tests and renal function tests daily 5, 6
• Serum creatinine kinase for rhabdomyolysis detection 1

Common Pitfalls to Avoid

• Do NOT delay treatment waiting for confirmatory tests; clinical suspicion is sufficient to initiate therapy 3
• Do NOT use succinylcholine or mivacurium for intubation if cholinesterase inhibition is suspected (though this is more relevant for organophosphate poisoning) 7
• Do NOT underestimate the lethality; even small ingestions (150-500 mg) require full ICU care 1
• Do NOT forget proper ventilation of treatment areas to protect healthcare workers from phosphine gas exposure 1