What is the appropriate treatment for a patient suspected of aluminum phosphide poisoning?

Treatment of Aluminum Phosphide (Celphos) Poisoning

There is no specific antidote for aluminum phosphide poisoning; treatment relies entirely on aggressive early supportive care with ICU-level monitoring, as even 150-500 mg ingestion can be fatal. 1

Immediate Decontamination and Stabilization

• Perform gastric lavage with diluted potassium permanganate or coconut oil immediately upon presentation to reduce phosphine gas liberation in the gastrointestinal tract 2
• Ensure proper ventilation of treatment areas as phosphine gas released from aluminum phosphide is highly toxic and can affect healthcare providers 1
• All exposures require ICU-level care regardless of initial presentation, as mortality rates of 70-100% are reported even with small ingestions 3, 4

Cardiovascular Support

• Initiate aggressive fluid resuscitation and vasopressor support immediately for the refractory shock that characteristically develops 1, 5
• Maintain continuous cardiac monitoring with ECG, as life-threatening arrhythmias including ventricular tachycardia and unmasking of Brugada pattern can occur 3, 6
• Administer calcium gluconate (100-200 mg/kg/dose) via slow IV infusion with ECG monitoring for life-threatening arrhythmias or cardiac membrane stabilization 1
• Avoid using succinylcholine or mivacurium for intubation if cholinesterase inhibition is suspected 1

Metabolic Management

• Administer sodium bicarbonate (1-2 mEq/kg IV push) for severe metabolic acidosis, which develops rapidly due to inhibition of oxidative phosphorylation 1, 2
• Do not administer sodium bicarbonate and calcium through the same IV line 1
• Monitor serum creatinine kinase and potassium to detect rhabdomyolysis, which commonly develops 1
• Treat rhabdomyolysis with adequate hydration and urine alkalinization if myoglobinuria develops 1

Respiratory Management

• Consider continuous positive airway pressure (CPAP) ventilation for patients with adequate consciousness and without contraindications 1
• Prepare for mechanical ventilation as respiratory failure frequently develops 4

Adjunctive Therapies with Emerging Evidence

While no specific antidote exists, several membrane stabilizers and cardioprotective agents show promise:

• Intravenous magnesium sulfate has been used successfully in multiple case reports as a membrane stabilizer 3, 2
• Consider trimetazidine, N-acetylcysteine, thiamine, vitamin C, and hydrocortisone as cardioprotective agents, though evidence is limited to case reports 3
• More advanced interventions like intra-aortic balloon pump and extracorporeal membrane oxygenation may be considered in refractory cases 3

Aluminum Toxicity Management (If Suspected)

• Measure serum aluminum levels if aluminum toxicity is suspected, particularly in patients requiring dialysis 1
• For serum aluminum levels 60-200 μg/L with symptoms, administer deferoxamine (DFO) at 5 mg/kg with careful monitoring 1
• Do NOT administer DFO if serum aluminum levels are >200 μg/L due to high risk of acute aluminum neurotoxicity; instead perform intensive dialysis with high-flux membranes (daily hemodialysis for 4-6 weeks) 1, 5
• 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 in dialysis patients; reduced dosing (5 mg/kg) and expanded intervals between treatments minimize this risk 1
• Do not administer intravenous iron if DFO is given, to limit formation of ferroxamine 1

Multi-Organ Failure Monitoring

Monitor for and treat the following complications that commonly develop:

• Hepatic injury (elevated transaminases) 4
• Acute renal failure (elevated creatinine and BUN) 3, 4
• Rhabdomyolysis (elevated CPK) 4
• Coagulopathy (prolonged PT) 4
• Leukocytosis 4

Critical Pitfalls to Avoid

• Never use physical restraints without adequate sedation as this worsens outcomes 1
• Do not delay supportive care waiting for laboratory confirmation—clinical suspicion is sufficient to initiate treatment 2
• Hyperbaric oxygen therapy has NO role in aluminum phosphide poisoning and should not be considered, as it is only indicated for carbon monoxide poisoning 5
• Do not use aluminum hydroxide as a phosphate binder for more than 1-2 days if dialysis is required, to avoid cumulative aluminum toxicity 1
• Be aware that spontaneous ignition can rarely occur in aluminum phosphide poisoning cases 7

The key to survival is rapid decontamination and immediate initiation of aggressive supportive measures, as the mortality remains extremely high despite all interventions 4. Success depends on early presentation, immediate ICU care, and meticulous management of cardiovascular collapse and metabolic derangements 3, 2.