Management of Aluminum Phosphide Poisoning
Aluminum phosphide poisoning requires immediate ICU-level supportive care with aggressive hemodynamic support, as there is no specific antidote and even small ingestions (150-500 mg) can be fatal. 1
Immediate Resuscitation and Stabilization
Airway and Respiratory Management
- Intubate early if consciousness is impaired or respiratory failure develops, avoiding succinylcholine or mivacurium if cholinesterase inhibition is suspected 1
- Consider CPAP ventilation for patients with adequate consciousness and no contraindications 1
- Ensure proper ventilation of treatment areas, as phosphine gas released from aluminum phosphide is highly toxic to healthcare providers 1
Gastrointestinal Decontamination
- Perform gastric lavage with diluted potassium permanganate solution if available 2
- Administer coconut oil to potentially slow phosphine gas release 2
- Do not induce vomiting or use activated charcoal, as these are ineffective for aluminum phosphide 3, 4
Cardiovascular Support
Hemodynamic Management
- Initiate aggressive fluid resuscitation with crystalloid solutions immediately 1, 4
- Start vasopressor support (norepinephrine) early for refractory hypotension and shock 4, 2
- Provide continuous cardiac monitoring with ECG, as arrhythmias develop rapidly 1, 5
- Administer calcium gluconate (100-200 mg/kg/dose) via slow IV infusion with ECG monitoring for life-threatening arrhythmias 1
Membrane Stabilizers and Cardioprotective Agents
- Give magnesium sulfate IV to reduce cardiac arrhythmias and stabilize cell membranes 3, 5, 2
- Consider trimetazidine for cardioprotection 3
- Administer N-acetylcysteine as an antioxidant 3, 4
- Consider thiamine, vitamin C, and hydrocortisone as adjunctive cardioprotective therapy 3
Metabolic Management
Acidosis Correction
- Administer sodium bicarbonate (1-2 mEq/kg IV push) for severe metabolic acidosis 1, 2
- Do not administer sodium bicarbonate and calcium through the same IV line 1
- Monitor arterial blood gases continuously 5, 4
Hyperkalemia Management
- Treat life-threatening hyperkalemia with calcium gluconate for cardiac membrane stabilization 1
- Monitor serum potassium levels closely 1
Renal and Multi-Organ Support
Rhabdomyolysis Management
- Monitor serum creatinine kinase levels to detect rhabdomyolysis 1
- Provide adequate hydration and urine alkalinization if myoglobinuria develops 1
- Monitor for acute renal failure requiring dialysis 3, 5
Aluminum Toxicity Considerations (if applicable)
- Measure serum aluminum levels if aluminum toxicity is suspected, particularly in dialysis patients 1
- For serum aluminum levels 60-200 μg/L, administer deferoxamine (DFO) at 5 mg/kg with careful monitoring 1
- For serum aluminum levels >200 μg/L, DO NOT administer DFO due to risk of acute aluminum neurotoxicity; instead perform intensive dialysis with high-flux membranes 6, 1
- If DFO is used, avoid administering intravenous iron to limit feroxamine formation 1
- Use high-flux dialysis membranes for more effective clearance of aluminum-DFO complexes 1
- Be aware that DFO therapy can precipitate fatal mucormycosis with 91% mortality; use reduced dosing (5 mg/kg) and expanded intervals 1
Critical Pitfalls to Avoid
- Never use physical restraints without adequate sedation, as this worsens outcomes 1
- Do not use aluminum hydroxide as a phosphate binder for more than 1-2 days to avoid cumulative aluminum toxicity 1
- Hyperbaric oxygen therapy has no role in aluminum phosphide poisoning and should not be used 7
- All exposures require ICU-level care regardless of initial presentation 1
- Delays in hospital arrival significantly worsen prognosis 8
Monitoring Requirements
- Continuous ECG monitoring for arrhythmias (atrial fibrillation, ventricular tachycardia, ST changes) 5
- Serial cardiac troponin levels if cardiotoxicity suspected 5
- Arterial blood gas analysis for metabolic acidosis 4, 8
- Liver function tests for hepatobiliary impairment 3
- Renal function monitoring for acute kidney injury 3, 5