What is the treatment for a patient with deliberate self-harm involving yellow phosphorus rodenticide?

Treatment of Yellow Phosphorus Rodenticide Poisoning in Deliberate Self-Harm

Immediately activate emergency medical services and contact Poison Control Center without delay, as yellow phosphorus poisoning causes fulminant hepatic failure with 77.78% of deaths occurring from this complication within 2-8 days of exposure. 1, 2

Immediate Emergency Actions

Do not administer anything by mouth, induce vomiting, or perform gastric lavage unless specifically directed by Poison Control. 1 These interventions are contraindicated because:

• Vomiting increases risk of aspiration of toxic phosphine gas released from yellow phosphorus 1
• No human studies demonstrate clinical benefit from water or milk dilution 1
• Ipecac provides no benefit and causes harm 1

Activated charcoal (1 g/kg) via small-bore nasogastric tube may be administered only if recommended by Poison Control, though evidence for efficacy is limited. 1 The critical window is within 2 hours of exposure—survival rates are 97.87% with gastric decontamination within 2 hours versus 84.62% without (p=0.033). 2

Clinical Presentation Timeline

Expect a characteristic biphasic pattern with a deceptive symptom-free interval:

• First 24 hours: Conspicuous absence of signs and symptoms in most patients, with only initial nausea, vomiting, and diarrhea 3, 2
• 24-72 hours: Symptom-free "latent period" where patients appear stable with normal vitals 3, 2
• After 24-36 hours (range 18-72 hours): 72.73% of patients develop toxidrome with dominant manifestations 2

Never discharge patients during the latent period—this is when they appear deceptively well before catastrophic deterioration. 3

Specific Clinical Manifestations to Monitor

The dominant clinical features in order of frequency are:

• Abdominal pain (52.53%) 2
• Jaundice (22.21%) 2
• Coagulopathy (15.15%) 2
• Multi-organ failure (17.17%) 2
• Hepatic encephalopathy (10.10%) 2
• Refractory shock (10.10%) 2
• Acute kidney injury (7.08%) 2

Laboratory abnormalities include:

• AST/ALT elevation (48-50% of patients) 2
• Bilirubin elevation (22.21%) 2
• PT/INR prolongation (15.15%) 2
• Metabolic acidosis (10.12%) 2
• Serum creatinine elevation (7.08%) 2

Mortality Predictors Requiring Immediate Escalation

The following predict poor outcome and mandate urgent liver transplant evaluation:

• Delayed resuscitation beyond 2 hours 2
• Jaundice development 2, 4
• Hepatic encephalopathy 2, 4
• AST/ALT elevation >1000 IU/L 2
• Metabolic acidosis 2
• Refractory shock 2
• Coagulopathy with features of acute liver failure 4

Mortality is 9.1% overall, with 77.78% of deaths from fulminant hepatic failure occurring at mean 4.22 days post-exposure (range 2-8 days). 2

Supportive Management Strategy

No specific antidote exists—management is entirely supportive with bridge to liver transplantation for acute liver failure. 5, 4

Supportive measures include:

• Continuous renal replacement therapy (CRRT) as bridge to transplant 5
• Plasmapheresis with limited success in non-transplant candidates 5
• Cytosorb therapy in selected patients 5
• Meticulous monitoring for multi-organ dysfunction 4

Liver Transplantation Criteria

Liver transplantation is the definitive treatment for acute liver failure from yellow phosphorus poisoning, with good outcomes in both adults and children when performed without contraindications. 5

Early listing criteria should include:

• Development of hepatic encephalopathy 5, 3
• Coagulopathy unresponsive to vitamin K 5
• Lactic acidosis 5
• Multi-organ dysfunction syndrome 3

Success rates are very promising provided no transplant contraindications exist. 5 Separate expedited criteria for listing are important to ensure rapid evaluation of critical patients. 5

Psychiatric Assessment Requirements

A comprehensive mental health assessment must be undertaken after medical stabilization, as this represents deliberate self-harm. 6

The assessment should include:

• Formulation of factors contributing to self-harm 6
• Risk management plan development 6
• Evaluation by mental health professional 6
• Safety planning interventions 6
• Assessment of suicidal ideation and intent 6

Establish empathic therapeutic relationship during initial assessment, as negative clinical experiences perpetuate cycles of self-harm. 6

Critical Pitfalls to Avoid

Do not:

• Discharge during the 24-72 hour latent period when patients appear well 3, 2
• Delay EMS activation while attempting home interventions 1
• Administer oral fluids or induce vomiting 1
• Underestimate toxicity based on initial benign presentation 2, 4
• Delay transplant evaluation once hepatic encephalopathy develops 5

The deceptive symptom-free interval is the most dangerous period—patients who take discharge against medical advice during this window frequently return in fulminant hepatic failure. 3