Emergency Management of Aluminum Phosphide (Celphos) Poisoning
Aluminum phosphide poisoning requires immediate intensive care admission and aggressive supportive care, as there is no specific antidote and mortality remains extremely high despite all interventions. 1, 2
Immediate Scene Safety and Stabilization
Ensure adequate ventilation of the treatment area before patient contact; phosphine gas poses severe risk to healthcare workers, and secondary exposure has caused life-threatening illness in providers without full-face gas masks and butyl-rubber gloves. 1
Contact the Poison Help hotline (1-800-222-1222 in the United States) immediately for case-specific guidance. 1
Secure the airway early as the foundational step; do not delay intubation while attempting decontamination procedures. 1
Avoid succinylcholine or mivacurium for intubation if cholinesterase inhibition is suspected. 1
Gastrointestinal Decontamination
Perform extensive gastric lavage with a mixture of coconut oil and sodium bicarbonate solution; this approach has been associated with 42% survival in one case series. 3
Do not administer activated charcoal unless specifically advised by poison control; current evidence shows no clear benefit and potential for harm. 1
Do not induce vomiting or give syrup of ipecac, as these provide no clinical advantage and may delay definitive care. 1
The evidence for gastric lavage with coconut oil and sodium bicarbonate comes from a single-center study showing improved survival 3, though this conflicts with general toxicology principles that question the utility of gastric lavage. Given the absence of any proven antidote and the extremely high mortality, this intervention may be reasonable in the first hour after ingestion.
Cardiovascular Support
Shock and Arrhythmia Management
Administer calcium gluconate 100-200 mg/kg as a slow IV infusion with continuous ECG monitoring for life-threatening arrhythmias to stabilize cardiac membranes. 1
Do not infuse sodium bicarbonate and calcium through the same IV line to avoid precipitation. 1
Use norepinephrine infusion for refractory hypotension when standard fluid resuscitation fails. 4, 5
The profound circulatory collapse in aluminum phosphide poisoning results from direct myocardial toxicity, fluid loss, and adrenal damage 2. Cardiogenic shock occurs in approximately 85% of patients and is the primary cause of death 6.
Metabolic Acidosis
Give sodium bicarbonate 1-2 mEq/kg IV push for severe metabolic acidosis, which occurs in over 80% of patients. 1, 6
Monitor arterial blood gases, lactate, and electrolytes serially to detect early derangements. 1
Aluminum Toxicity Management
Measure serum aluminum concentrations in suspected severe toxicity. 1
For serum aluminum 60-200 µg/L: administer deferoxamine 5 mg/kg IV with careful monitoring and use high-flux dialysis membranes to enhance clearance. 1
For serum aluminum >200 µg/L: avoid deferoxamine due to risk of acute neurotoxicity; instead perform intensive high-flux hemodialysis daily for 4-6 weeks until levels fall. 1
Do not give intravenous iron concurrently with deferoxamine to prevent formation of feroxamine complexes. 1
Recognize that deferoxamine therapy can precipitate fatal mucormycosis; use reduced dosing (5 mg/kg) and extend intervals between doses. 1
Additional Supportive Measures
Administer intravenous magnesium sulfate for hemodynamic support, though evidence for magnesium disturbances in aluminum phosphide poisoning is conflicting. 2, 4
Provide N-acetylcysteine infusion as an antioxidant, given that phosphine generates hydroxyl radicals causing lipid peroxidation. 2, 5
Treat life-threatening hyperkalemia with calcium gluconate for cardiac membrane stabilization. 1
Monitor for rhabdomyolysis with serial creatine kinase and potassium measurements; provide adequate hydration and urine alkalinization if myoglobinuria develops. 1
Critical Monitoring Requirements
Maintain continuous cardiac monitoring for arrhythmias and conduction disturbances, which occur in over 80% of patients. 6
Perform serial ECG monitoring, as abnormalities develop rapidly and predict mortality. 6
Monitor for pulmonary edema (both cardiogenic and non-cardiogenic), disseminated intravascular coagulation, hepatic necrosis, and acute renal failure. 2
Common Pitfalls to Avoid
Do not assume ingestion of only aluminum phosphide; mixed toxic ingestions are common and require broader toxicological assessment. 1
Do not rely on the absence of symptoms to rule out severe injury; systemic toxicity usually appears within a short interval after ingestion. 2
Do not use physical restraints without adequate sedation, as this worsens outcomes. 1
Do not delay hospital presentation; 65% of patients in one series had delayed arrival, which significantly impacts survival. 6
The pathophysiology involves phosphine gas rapidly perturbing mitochondrial morphology, inhibiting oxidative respiration by 70%, and causing severe drops in mitochondrial membrane potential 2. Despite intensive supportive care, mortality remains extremely high, with survival rates of only 42% even with aggressive multimodal treatment 3.