What is the appropriate immediate management for acute aluminum phosphide (Celphos) poisoning?

Treatment of Aluminum Phosphide (Celphos) Poisoning

Immediate Life-Saving Actions

All aluminum phosphide exposures require immediate ICU-level care because ingestion of as little as 150-500 mg can be fatal, and aggressive supportive management is the only proven intervention since no specific antidote exists. 1

Scene Safety and Initial Stabilization

• Ensure proper ventilation of treatment areas before initiating patient care because phosphine gas released from aluminum phosphide is highly toxic to healthcare workers; secondary exposure has caused severe illness requiring ICU admission in providers who did not use full-face gas masks and butyl rubber gloves. 1
• Activate emergency medical services immediately if the patient exhibits altered mental status, seizures, difficulty breathing, or vomiting. 2
• Contact the Poison Help hotline (1-800-222-1222 in the United States) without delay for case-specific guidance. 2

Airway and Respiratory Management

• Secure the airway early and provide respiratory support as the foundational step in poisoning management. 1
• Consider continuous positive airway pressure (CPAP) ventilation for patients with adequate consciousness and without contraindications. 1
• Avoid succinylcholine or mivacurium for intubation if cholinesterase inhibition is suspected. 1

Gastrointestinal Decontamination

Activated charcoal can be considered for gastrointestinal decontamination in patients with aluminum phosphide ingestion, although its ability to adsorb phosphine gas is uncertain. 1 However, do not administer activated charcoal unless advised by poison control center, as there is no evidence it is effective as a first aid component and it may cause harm. 2

One study reported using extensive gastric lavage with a mixture of coconut oil and sodium bicarbonate solution, achieving a 42% survival rate, though this represents low-quality evidence from a single center. 3

Do not induce vomiting or administer syrup of ipecac because there is no clinically relevant advantage and it may cause intractable emesis and delayed care. 2

Cardiovascular Support

Shock and Arrhythmia Management

• Monitor continuously for refractory hypotension, cardiac failure, and life-threatening arrhythmias which develop within hours and are the major cause of mortality. 4, 5
• Administer calcium gluconate (100-200 mg/kg/dose) via slow infusion with ECG monitoring for life-threatening arrhythmias to achieve cardiac membrane stabilization. 1
• Provide standard vasopressor support (norepinephrine infusion) for refractory hypotension. 5
• Do not administer sodium bicarbonate and calcium through the same IV line. 1

Metabolic Acidosis Management

• Administer sodium bicarbonate (1-2 mEq/kg IV push) for severe metabolic acidosis. 1
• Monitor arterial blood gas, lactate, and electrolytes to detect early metabolic derangements. 4, 5

Renal Support and Aluminum Toxicity Management

Indications for Renal Replacement Therapy

Consider early initiation of continuous renal replacement therapy (CRRT) along with other resuscitative measures, as emerging evidence shows successful outcomes with this intervention. 6

Aluminum Level-Based Management

Measure serum aluminum levels if aluminum toxicity is suspected, particularly in severe cases. 1

• For serum aluminum levels between 60-200 μg/L: Administer deferoxamine (DFO) at 5 mg/kg intravenously with careful monitoring; use high-flux dialysis membranes to enhance clearance of aluminum-DFO complexes. 1

• For serum aluminum levels >200 μg/L: Do not administer deferoxamine due to high risk of precipitating acute aluminum neurotoxicity; instead, perform intensive high-flux hemodialysis daily for 4-6 weeks until levels decline. 1

• Do not administer intravenous iron if DFO is given to limit formation of feroxamine. 1

• Recognize that DFO therapy can precipitate fatal mucormycosis with 91% mortality in dialysis patients; use reduced dosing (5 mg/kg) and expanded intervals between treatments to minimize risk. 1

Hyperkalemia Management

Treat hyperkalemia with calcium gluconate for cardiac membrane stabilization in life-threatening arrhythmias. 1

Multi-Organ Failure Monitoring

• Watch for and treat rhabdomyolysis with adequate hydration and urine alkalinization if myoglobinuria develops. 1
• Monitor serum creatinine kinase and potassium to detect rhabdomyolysis early. 1
• Assess hepatic function because aluminum phosphide may cause liver injury. 4
• Monitor for hemolytic anemia, especially in individuals with G6PD deficiency. 4

Adjunctive Therapies (Emerging Evidence)

Consider membrane stabilizers and cardioprotective agents including magnesium sulfate, trimetazidine, N-acetyl cysteine, thiamine, vitamin C, and hydrocortisone, as emerging evidence suggests potential benefit in decreasing fatal outcomes. 4, 7, 5 The use of magnesium sulfate to reduce cardiac arrhythmias is well documented, though there is no uniformity in dose or frequency worldwide. 7

Critical Pitfalls to Avoid

• Avoid physical restraints without adequate sedation as this can worsen outcomes. 1
• Do not delay airway management while attempting decontamination procedures. 1
• Do not assume the patient ingested only aluminum phosphide—mixed ingestions are common and require broader toxicological assessment. 1
• Recognize that clinical symptoms do not reliably predict the depth of injury; a silent presentation may still harbor life-threatening damage. 1