What is the emergency management for a patient who has ingested aluminium phosphide?

Emergency Management of Aluminum Phosphide Poisoning

All patients with aluminum phosphide ingestion require immediate ICU admission with aggressive supportive care, as there is no specific antidote and ingestion of as little as 150-500 mg can be fatal. 1

Immediate Safety and Decontamination

Healthcare Worker Protection

• All personnel must wear full-face gas masks and butyl rubber gloves before any patient contact, as ordinary surgical masks and latex gloves do not protect against phosphine vapor 2
• Remove contaminated clothing outside the hospital immediately to prevent indoor vapor generation 2
• Ensure treatment areas are well-ventilated; healthcare workers have required atropine, pralidoxime, and intubation after exposure in poorly ventilated spaces 3, 2
• Irrigate exposed skin copiously with water 2

Gastrointestinal Decontamination

• Activated charcoal can be considered, though its ability to adsorb phosphine gas is uncertain 1
• Gastric lavage is mentioned in literature but potassium permanganate solution (traditionally recommended) may not be universally available 4

Airway and Respiratory Management

Oxygen Therapy

• Administer 100% oxygen immediately via high-flow mask or endotracheal tube to all suspected cases 2
• Continue high-flow oxygen until metabolic acidosis resolves and respiratory symptoms improve 2

Mechanical Ventilation

• Intubate early for respiratory failure, altered mental status, or hemodynamic instability 4, 5, 6
• Use low tidal-volume ventilation (≤6 mL/kg ideal body weight) with moderate PEEP to reduce ventilator-induced lung injury 2
• Target normoventilation with PaCO₂ of 5.0-5.5 kPa; avoid hyperventilation as it worsens tissue perfusion and increases mortality 2
• CPAP may be considered only for conscious, cooperative patients without contraindications (full stomach, bowel paralysis, thoraco-abdominal trauma) 1, 2

Cardiovascular Support

Hemodynamic Management

• Aggressive fluid resuscitation with crystalloid solutions is essential 1, 5
• Initiate vasopressor support (norepinephrine) early for refractory hypotension 5, 6
• Continuous cardiac monitoring is mandatory; patients develop shock and circulatory failure within hours 4, 6

Arrhythmia Management

• Calcium gluconate (100-200 mg/kg/dose) via slow infusion with ECG monitoring for life-threatening arrhythmias 1
• Do not administer sodium bicarbonate and calcium through the same IV line 1
• Magnesium sulfate is well-documented for reducing cardiac arrhythmias, though dosing protocols vary 4, 7
• Lidocaine can be used for ventricular arrhythmias 7
• Avoid succinylcholine or mivacurium for intubation if cholinesterase inhibition is suspected 1

Metabolic Management

Acidosis Correction

• Sodium bicarbonate (1-2 mEq/kg IV push) for severe metabolic acidosis 1
• Arterial blood gas monitoring is essential as severe metabolic acidosis develops rapidly 5, 6

Hyperkalemia Management

• Calcium gluconate for cardiac membrane stabilization in life-threatening arrhythmias from hyperkalemia 1

Multi-Organ Failure Management

Renal Support

• Monitor for acute kidney injury with serial creatinine measurements 6, 7
• Continuous renal replacement therapy (CRRT) or hemodialysis may be required for severe metabolic acidosis and AKI 7
• Ensure adequate hydration and urine alkalinization if myoglobinuria develops from rhabdomyolysis 1

Rhabdomyolysis Monitoring

• Monitor serum creatine kinase and potassium levels to detect rhabdomyolysis 1, 2
• Observe for delayed neuromuscular weakness appearing up to 4 days after exposure, potentially requiring prolonged ventilatory support 2

Hepatic Injury

• Monitor liver function tests (AST, ALT) as hepatic injury is common 6

Aluminum Toxicity Management (If Applicable)

Serum Aluminum Monitoring

• Measure serum aluminum levels if aluminum toxicity is suspected, particularly in dialysis patients 1

Deferoxamine (DFO) Therapy

• For serum aluminum 60-200 μg/L: administer DFO at 5 mg/kg with careful monitoring 1
• For serum aluminum >200 μg/L: DO NOT administer DFO due to high risk of acute neurotoxicity; instead perform intensive daily hemodialysis with high-flux membranes for 4-6 weeks 1, 8
• Use high-flux dialysis membranes for more effective clearance of aluminum-DFO complexes 1
• Do not administer intravenous iron if DFO is given to limit feroxamine formation 1
• DFO therapy can precipitate fatal mucormycosis (91% mortality in dialysis patients); use reduced dosing and expanded intervals to minimize risk 1

Adjunctive Therapies

N-Acetylcysteine

• N-acetylcysteine has been used in supportive care protocols 5

Extracorporeal Support

• Veno-arterial ECMO should be considered for refractory cardiogenic shock and can be lifesaving 7
• Prompt referral to a tertiary care center with ECMO and CRRT capability is recommended for severe cases 7

Critical Pitfalls to Avoid

• Never initiate patient care without proper PPE; secondary exposure has caused severe illness requiring ICU admission in healthcare workers 3, 2
• Do not use aluminum hydroxide as a phosphate binder for more than 1-2 days to avoid cumulative aluminum toxicity 1
• Avoid physical restraints without adequate sedation as this worsens outcomes 1
• Hyperbaric oxygen therapy has no role in aluminum phosphide poisoning (it is indicated for carbon monoxide, not phosphine toxicity) 8
• Do not delay intensive supportive care; rapid decontamination and immediate resuscitation are the only effective treatments 9, 6

Prognosis

Mortality from aluminum phosphide poisoning is extremely high (30-77%) due to rapid progression to multiorgan failure, cardiovascular collapse, and the absence of a specific antidote 4, 6, 7. Survival depends entirely on the speed and aggressiveness of supportive care, with successful outcomes reported even after severe cardiotoxicity and multiorgan failure when intensive interventions including ECMO and CRRT are employed 4, 7.