What are the treatment guidelines for aluminium phosphide poisoning?

Aluminum Phosphide Poisoning Treatment Guidelines

Aluminum phosphide poisoning requires immediate ICU-level supportive care with aggressive hemodynamic support, as there is no specific antidote and mortality rates range from 30-77% even with optimal treatment. 1, 2, 3

Immediate Resuscitation and Decontamination

• Perform gastric lavage with diluted potassium permanganate solution immediately upon presentation to reduce phosphine gas absorption 4
• Administer coconut oil via nasogastric tube to coat the stomach and potentially reduce further phosphine gas release 4
• Ensure proper ventilation of treatment areas as phosphine gas is highly toxic to healthcare providers 1
• Recognize that ingestion of as little as 150-500 mg (one tablet) can be fatal, requiring ICU-level care for all exposures 1, 2

Cardiovascular Support

• Initiate aggressive fluid resuscitation with crystalloid solutions and vasopressor support (norepinephrine) immediately for hypotension 1, 5, 4
• Administer calcium gluconate (100-200 mg/kg/dose) via slow IV infusion with continuous ECG monitoring for life-threatening arrhythmias or cardiac membrane stabilization 1
• Do not administer sodium bicarbonate and calcium through the same IV line 1
• Consider veno-arterial ECMO for patients with refractory cardiogenic shock and cardiovascular collapse as this provides critical time for cardiac recovery 3, 6
• ECMO should be initiated early (within hours) when conventional vasopressor support fails, with successful outcomes reported after 3-16 days of support 3, 6

Respiratory Management

• Intubate and mechanically ventilate patients with respiratory failure or declining consciousness 2, 5
• Consider CPAP ventilation for patients with adequate consciousness and no contraindications 1
• Avoid succinylcholine or mivacurium for intubation if cholinesterase inhibition is suspected 1

Metabolic and Renal Support

• Administer sodium bicarbonate (1-2 mEq/kg IV push) for severe metabolic acidosis, which develops rapidly and is a hallmark of toxicity 1, 2, 5
• Monitor arterial blood gases frequently as severe metabolic acidosis (pH <7.2) is common and requires continuous correction 2, 3
• Initiate continuous renal replacement therapy (CRRT) or hemodialysis for severe metabolic acidosis secondary to acute kidney injury 3
• Treat hyperkalemia with calcium gluconate for cardiac membrane stabilization in life-threatening arrhythmias 1

Multi-Organ Failure Management

• Monitor for and treat rhabdomyolysis with adequate hydration and urine alkalinization if myoglobinuria develops 1
• Monitor serum creatinine kinase and potassium to detect rhabdomyolysis early 1
• Monitor hepatic function as severe hepatotoxicity (AST/ALT >2000 U/L) commonly develops 2
• Administer N-acetylcysteine as supportive therapy for potential hepatoprotection 5

Arrhythmia Management

• Administer intravenous magnesium sulfate for ventricular arrhythmias 3, 4
• Use lidocaine for refractory ventricular arrhythmias 3
• Maintain continuous cardiac monitoring as ECG changes (inverted T waves, arrhythmias) are early signs of toxicity 2

Aluminum Toxicity Considerations (If Applicable)

• Measure serum aluminum levels if aluminum toxicity is suspected, particularly in dialysis patients 1
• For serum aluminum levels >200 μg/L, do NOT administer deferoxamine (DFO) due to high risk of acute aluminum neurotoxicity; instead perform intensive daily hemodialysis with high-flux membranes for 4-6 weeks 1
• For serum aluminum levels between 60-200 μg/L, administer DFO at 5 mg/kg with careful monitoring, followed by high-flux dialysis 1
• Do not administer intravenous iron if DFO is given to limit formation of ferroxamine 1
• Be aware that DFO therapy carries a 91% mortality risk from mucormycosis in dialysis patients; 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, 7
• Do not delay ICU admission or ECMO referral in severe cases, as rapid progression to multiorgan failure occurs within hours 1, 3
• Avoid aluminum hydroxide as a phosphate binder for more than 1-2 days to prevent cumulative aluminum toxicity 1
• Do not consider hyperbaric oxygen therapy—it has no role in aluminum phosphide poisoning and hemodynamic instability precludes safe transport 8
• Recognize that supportive care is the only effective treatment; there is no specific antidote 2, 5, 4

Disposition and Monitoring

• All patients require ICU-level care with continuous hemodynamic monitoring for at least 72-96 hours 2, 3
• Prompt referral to a tertiary care center with ECMO and CRRT capability is recommended for severe cases 3
• Monitor for delayed complications including hepatic failure, renal failure, and cardiac dysfunction over several days 2, 3