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

Management of Aluminum Phosphide (Celphos) Poisoning

Aluminum phosphide poisoning requires immediate ICU-level care with aggressive supportive management, as there is no specific antidote and mortality remains extremely high (58-100%) even with ingestion of as little as 150-500 mg. 1, 2

Immediate Safety and Decontamination

• Ensure healthcare provider safety first by using appropriate personal protective equipment, as phosphine gas released from aluminum phosphide is highly toxic and can contaminate caregivers 1
• Ensure proper ventilation of treatment areas to prevent secondary exposure to phosphine gas 1
• Perform extensive gastric lavage with a mixture of coconut oil and sodium bicarbonate solution to prevent further phosphine gas release 3, 4
• Remove all contaminated clothing and perform thorough skin decontamination if external exposure occurred 1

Cardiovascular Support

Cardiovascular collapse is the primary cause of death and requires aggressive hemodynamic support:

• Initiate vasopressor therapy immediately for refractory shock, with norepinephrine and/or epinephrine as first-line agents 1, 2
• Administer calcium gluconate (100-200 mg/kg/dose) via slow IV infusion with continuous ECG monitoring for life-threatening arrhythmias and cardiac membrane stabilization 1
• Consider magnesium sulfate as a membrane stabilizer, which has shown promise in case reports of successful management 2, 4
• Monitor continuously for ventricular tachycardia, supraventricular tachycardia, and other fatal arrhythmias that commonly occur 5, 2

Metabolic Management

• Treat severe metabolic acidosis with sodium bicarbonate (1-2 mEq/kg IV push) 1
• Never administer sodium bicarbonate and calcium through the same IV line to avoid precipitation 1
• Monitor for and treat hyperkalemia with calcium gluconate for cardiac protection 1
• Ensure adequate hydration and consider urine alkalinization if rhabdomyolysis develops 1

Respiratory Management

• Perform early endotracheal intubation for life-threatening poisoning, as respiratory failure is common 1
• Consider continuous positive airway pressure (CPAP) ventilation for patients with adequate consciousness and no contraindications 1
• Avoid succinylcholine or mivacurium for intubation if cholinesterase inhibition is suspected 1

Adjunctive Therapies with Emerging Evidence

While no specific antidote exists, several agents have shown potential benefit in case reports:

• Trimetazidine (cardioprotective agent) may reduce fatal outcomes 2
• N-acetylcysteine, thiamine, vitamin C, and hydrocortisone have been used with some success 2
• Magnesium sulfate has demonstrated benefit in multiple case series 2, 4

Monitoring and Duration of Care

• Admit all exposures to ICU-level care regardless of initial presentation, as deterioration can be rapid 1, 3
• Maintain close observation for at least 48-72 hours even in apparently stable patients 6
• Monitor serum creatinine kinase and potassium to detect rhabdomyolysis 1
• Average ICU stay is approximately 5-6 days for survivors 3

Advanced Interventions for Refractory Cases

• Consider venoarterial extracorporeal membrane oxygenation (VA-ECMO) for refractory cardiogenic shock if available 2
• Intra-aortic balloon pump has been used successfully in select cases 2
• High-flux hemodialysis may be beneficial if aluminum toxicity is suspected (serum aluminum >60 μg/L) 1

Critical Pitfalls to Avoid

• Do not delay ICU admission - all exposures require intensive monitoring as clinical deterioration is unpredictable and often rapid 1, 3
• Avoid 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 prevent cumulative aluminum toxicity 1
• Contact poison control (1-800-222-1222 in the US) for expert guidance on case-specific management 6

Prognosis

Despite aggressive management, survival rates remain poor at approximately 40-42% in recent case series, with most deaths occurring from refractory cardiovascular collapse within the first 24-48 hours 3, 4. Early initiation of supportive care and intensive monitoring offer the best chance for survival in the absence of a specific antidote.