What is the treatment for aluminium phosphide poisoning?

Treatment 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 150-500 mg ingestion can be fatal. 1

Immediate Decontamination and Safety

• Perform gastric lavage with diluted potassium permanganate solution immediately upon presentation 2
• 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 and Hemodynamic Support

The cornerstone of management is aggressive fluid resuscitation and vasopressor support initiated immediately. 3

• Administer crystalloid solutions with continuous hemodynamic monitoring 2, 4
• Use norepinephrine or other vasopressors for refractory hypotension 4
• For life-threatening arrhythmias, give calcium gluconate (100-200 mg/kg/dose) via slow infusion with continuous ECG monitoring 1
• Consider veno-arterial ECMO for cardiogenic shock and cardiovascular collapse in centers with capability 5
• Intra-aortic balloon pump may be considered for severe cardiac failure 6

Metabolic Acidosis Management

• Administer sodium bicarbonate (1-2 mEq/kg IV push) for severe metabolic acidosis 1
• Do not administer sodium bicarbonate and calcium through the same IV line 1
• Monitor arterial blood gases continuously for pH and bicarbonate levels 7

Respiratory Support

• Consider CPAP ventilation for patients with adequate consciousness and without contraindications 1
• Intubate and mechanically ventilate patients with respiratory failure 7, 4
• Avoid succinylcholine or mivacurium for intubation if cholinesterase inhibition is suspected 1

Adjunctive Pharmacologic Therapy

• Intravenous magnesium sulfate should be administered as a membrane stabilizer 2, 6
• N-acetylcysteine may provide cardioprotective effects 4, 6
• Consider trimetazidine as a cardioprotective agent 6
• Thiamine, vitamin C, and hydrocortisone may decrease likelihood of fatal outcome 6

Renal Support and Rhabdomyolysis

• Monitor serum creatinine kinase and potassium to detect rhabdomyolysis 1
• Treat rhabdomyolysis with adequate hydration and urine alkalinization if myoglobinuria develops 1
• Initiate continuous renal replacement therapy (CRRT) or hemodialysis for acute kidney injury and metabolic acidosis 5

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) at 5 mg/kg with careful monitoring, using high-flux dialysis membranes for clearance of aluminum-DFO complexes 1
• For aluminum levels >200 μg/L: Do NOT administer DFO due to high risk of acute aluminum neurotoxicity; instead perform intensive dialysis with high-flux membranes (daily hemodialysis for 4-6 weeks) 1
• Do not administer intravenous iron if DFO is given, to limit formation of ferroxamine 1
• Use reduced DFO dosing (5 mg/kg) with expanded intervals between treatments to minimize risk of fatal mucormycosis (91% mortality rate in dialysis patients) 1

Multi-Organ Monitoring

• Monitor liver function tests (AST, ALT) for hepatic injury 7
• Track creatine phosphokinase for rhabdomyolysis 7
• Perform continuous cardiac monitoring for arrhythmias, particularly ventricular tachycardia 7, 6
• Treat ventricular arrhythmias with lidocaine and magnesium sulfate 5

Critical Pitfalls to Avoid

• All exposures require ICU-level care regardless of initial presentation 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 is contraindicated due to hemodynamic instability, need for continuous vasopressor support, and severe metabolic derangements requiring bedside intensive care 3
• Patients can rapidly progress to multisystem organ failure and cardiovascular collapse within hours, requiring high index of suspicion and prompt referral to tertiary care centers with ECMO and CRRT capability 5, 4