What is the emergency management of an adult with acute calcium phosphide (Celphos) poisoning presenting with nausea, vomiting, abdominal pain, dyspnea, cough, chest tightness, hypotension, tachycardia, altered mental status, and metabolic acidosis?

Emergency Management of Acute Calcium Phosphide (Celphos) Poisoning

Immediately initiate aggressive gastric decontamination with coconut oil and sodium bicarbonate lavage, establish invasive monitoring, correct severe metabolic acidosis with full-dose intravenous sodium bicarbonate, and provide aggressive hemodynamic support with vasopressors and intravenous magnesium sulfate. 1, 2, 3

Immediate Gastrointestinal Decontamination

• Perform extensive gastric lavage with a mixture of coconut oil and sodium bicarbonate solution as soon as possible to prevent further phosphine gas release and absorption 1, 2
• Administer activated charcoal (1 g/kg) via nasogastric tube if the patient presents within 1-2 hours of ingestion, though evidence for benefit is limited 2
• Alternative lavage with potassium permanganate (1:10,000 solution) can oxidize phosphine gas if available, though coconut oil-bicarbonate mixture is equally effective 2
• Never induce vomiting, as this provides no benefit and may worsen complications through aspiration 2

Aggressive Correction of Metabolic Acidosis

• Administer full correction of severe metabolic acidosis with intravenous sodium bicarbonate, not the traditional half-correction approach 3
• Full correction of acidosis improved survival from 30.36% to 57.5% compared to half-correction in one study 3
• Repeated boluses of sodium bicarbonate are necessary to cope with the severity and rapidity of acidosis development 3
• Monitor arterial blood gas frequently (every 1-2 hours initially) to guide ongoing bicarbonate therapy 3

Cardiovascular Support and Hemodynamic Management

• Establish invasive monitoring with arterial line and central venous access for all patients with aluminum phosphide poisoning 1, 4
• Initiate vasopressor therapy immediately for hypotension: norepinephrine is the preferred first-line agent, with dopamine as an alternative 4, 2
• Administer intravenous magnesium sulfate as specific therapy to reduce cardiac arrhythmias and improve outcomes, though optimal dosing is not standardized 5, 2
• Consider digoxin for refractory cardiogenic shock, as it may provide inotropic support 2
• For refractory cardiogenic shock unresponsive to vasopressors and inotropes, consider intra-aortic balloon pump if available 2

Respiratory Management

• Provide supplemental oxygen to maintain adequate tissue oxygenation in all patients 4
• Intubate and mechanically ventilate for respiratory distress, loss of consciousness, or airway protection 4
• Monitor for acute respiratory distress syndrome (ARDS) development, which is common in aluminum phosphide poisoning 4, 2

Cardiac Arrhythmia Management

• Continuous cardiac telemetry monitoring is mandatory, as arrhythmias are a leading cause of death 4, 5, 2
• Obtain serial electrocardiograms to detect ST-segment changes, conduction abnormalities, and arrhythmias 5
• Trimetazidine may be useful to stop ventricular ectopic beats and bigeminy while preserving oxidative metabolism 2
• If cardiac arrest occurs, initiate immediate cardiopulmonary resuscitation; survival after cardiac arrest has been reported with aggressive management 4

Renal Support and Extracorporeal Therapy

• Consider hemodialysis for severe poisoning with refractory metabolic acidosis or multi-organ failure 4
• Hemodialysis contributed to successful outcomes in case reports of aluminum phosphide poisoning with cardiac arrest 4
• Monitor renal function closely, as kidneys are a primary target organ for phosphine toxicity 2

Specific Adjunctive Therapies

• Administer oral coconut oil (30-60 mL) as specific therapy to potentially bind phosphine and reduce absorption 1, 2
• Coconut oil can be given both as part of gastric lavage solution and orally after lavage 1, 2
• Monitor serum magnesium levels and maintain in high-normal range with supplementation 5, 2

Laboratory Monitoring

• Serial arterial blood gas analysis to assess metabolic acidosis and guide bicarbonate therapy 3
• Cardiac troponin levels to detect myocardial injury, which is common and may present as acute myocardial infarction pattern 5
• Complete blood count, renal function, liver function, and electrolytes every 6-12 hours 4, 5
• Silver nitrate paper test on gastric aspirate can confirm phosphine gas presence 2

Critical Pitfalls to Avoid

• Do not use only half-correction of metabolic acidosis; full correction significantly improves survival 3
• Do not delay gastric lavage; early decontamination with coconut oil-bicarbonate mixture is associated with better outcomes 1
• Do not underestimate the severity; aluminum phosphide has extremely high mortality (often >60-70%) and requires ICU-level care for all patients 1, 2
• Do not discontinue monitoring prematurely; effects can be prolonged and delayed deterioration may occur over 24-48 hours 1, 5
• There is no specific antidote for aluminum phosphide poisoning; aggressive supportive care is the only proven intervention 4, 2

Expected ICU Course

• Mean ICU stay is approximately 5-6 days for survivors 1
• Cardiovascular manifestations (shock, arrhythmias) are the most common presenting features (58% of patients) 1
• Multi-organ dysfunction occurs in approximately 18% of cases 1
• Even with optimal management, mortality remains high at 40-60%, though aggressive protocols have achieved survival rates up to 42-57.5% 1, 3