Could hydroxyethyl starch be a therapeutic option in management of acute aluminum phosphide toxicity?

Accidental Aluminum Phosphide Intoxication Successfully Treated with Hyperbaric Oxygen Therapy: A Case Report

The most common pesticide agents are organophosphates and phosphides, aluminum phosphide (ALP) in particular. ALP is a major cause of suicidal poisoning in many countries. In other countries, the problem of accidental, mainly occupational-related, poisoning is also real and actual. Almost two thirds of individuals in poisoning cases have died. This case report describes a case of a patient with accidental ALP intoxication. The origin of the poisoning was the fumigation of stored grain in an agricultural building adjacent to the building in which patient was temporarily housed, while both buildings were connected by an underground corridor, through which the released poison gas penetrated. The case was originally presented by the rescuers as well as healthcare professionals of the local hospital as carbon monoxide intoxication, which has a similar symptomatology as ALP intoxication. The patient was treated comprehensively, including using the HBOT method, which is very unique in the case of phosphine intoxication in human medicine, with an excellent final clinical outcome. This was the first described case of HBOT for ALP intoxication in clinical medicine, although the HBOT indication itself became a coincidence in this case. Further studies must be undertaken to demonstrate the effectiveness of HBOT in treating patients with ALP poisoning.

Pattern and predictors of death from aluminum and zinc phosphide poisoning using multi-kernel optimized relevance vector machine

The use of metal phosphides, particularly aluminum phosphide, poses a significant threat to human safety and results in high mortality rates. This study aimed to determine mortality patterns and predictive factors for acute zinc and aluminum phosphide poisoning cases that were admitted to Menoufia University Poison and Dependence Control Center from 2017 to 2021. Statistical analysis revealed that poisoning was more common among females (59.7%), aged between 10 and 20 years, and from rural regions. Most cases were students, and most poisonings were the result of suicidal intentions (78.6%). A new hybrid model named Bayesian Optimization-Relevance Vector Machine (BO-RVM) was proposed to forecast fatal poisoning. The model achieved an overall accuracy of 97%, with high positive predictive value (PPV) and negative predictive value (NPV) values of 100% and 96%, respectively. The sensitivity was 89.3%, while the specificity was 100%. The F1 score was 94.3%, indicating a good balance between precision and recall. These results suggest that the model performs well in identifying both positive and negative cases. Additionally, the BO-RVM model has a fast and accurate processing time of 379.9595 s, making it a promising tool for various applications. The study underscores the need for public health policies to restrict the availability and use of phosphides in Egypt and adopt effective treatment methods for phosphide-poisoned patients. Clinical suspicion, positive silver nitrate test for phosphine, and analysis of cholinesterase levels are useful in diagnosing metal phosphide poisoning, which can cause various symptoms.

Refractory cardiogenic shock caused by zinc phosphide toxicity

Zinc phosphide toxicity is a rare entity that presents most frequently among farmers in developing countries who use it as a rodenticide. The phosphine gas released after the ingestion inhibits cytochrome c oxidase, disrupting the mitochondrial physiology and oxidative phosphorylation and causing myocardial stunning. Here we present a case of a 20-year-old man who attempted suicide with zinc phosphide toxicity. Initially, he was hemodynamically stable with a normal ejection fraction; however, in a few hours, he deteriorated quickly and became hemodynamically unstable, with rapid deterioration of his ejection fraction to 20%. He was started on norepinephrine and then dobutamine; however, he had cardiac arrest from refractory cardiogenic shock despite resuscitative measures.

Reducing the risk of death induced by aluminum phosphide poisoning: The new therapies

Numerous people suffer from accidental or deliberate exposure to different pesticides when poisoning with aluminum phosphate (AlP) is increasing in the eastern countries. Aluminum phosphate is a conventional insecticide that quickly reacts with water or the moistures in the atmosphere and produces fatal phosphine gas, which absorbs quickly by the body. Oral consumption or inhalation of AlP leads to excessive reaction of the body such as fatigue, vomiting, fever, palpitation, vasodilatory shock, increasing blood pressure, cardiac dysfunction, pulmonary congestion, shortness of breath, and death. The garlic smell from the patient's mouth or exhale is one of the methods to recognize the positioning. Due to the lack of individual antidotes, several supportive treatments are required. The present study focused on the available and new therapies that help reduce the effect of AlP poisoning and the mortality rate. The therapies are divided into the antioxidant-related agent and the other agents. The impacts of each agent on the experimental cases are reported.

Comparative Assessment of the Effects of Hydroxyethyl Starch and Normal Saline on Severe Hypotension in Patients with Aluminum Phosphide Poisoning: A Retrospective Study

Background

Aluminum phosphide poisoning is one of the most common forms of poisoning which requires immediate and urgent treatment.

Objective

This study aimed to compare the efficiency of two solutions, including hydroxyethyl starch and normal saline, in treating hypotension in patients with aluminum phosphide poisoning.

Methods

This retrospective cohort study was conducted on 35 patients with aluminum phosphide poisoning. We reviewed the profile of 18 patients treated with hydroxyethyl starch and 17 patients treated with normal saline. Within-group and between-group differences in systolic blood pressure before and after treatment were compared using paired t-test and independent t-test, respectively.

Results

The mean ± standard deviation (SD) age of the subjects in the starch and normal saline groups was 27.06 ± 9.72 and 27.88 ± 9.08, respectively. The levels of blood pressure in the two groups were not significantly different before the treatment; the mean ± SD of systolic blood pressure in the starch and normal saline groups was 72.67 ± 14.49 and 68.59 ± 8.3, respectively (P=0.313). After the treatment, it was significantly increased to 94 ± 24.45 and 85.18 ± 19.9 in the starch group (P=0.001) and the normal saline group (P=0.004), respectively. However, there was no significant difference between the two groups (P=0.245). Only one person survived in each group.

Conclusion

According to the results of this study, although there was no significant difference between the two groups in terms of their effects on hypotension, these treatments could not prevent mortality.

Human Zinc Phosphide Exposure in Lebanon: A Case Report and Review of the Literature

Introduction

Toxicity from rodenticides such as metal phosphides is common worldwide, particularly in developing countries where consumers have access to unlabeled and uncontrolled insecticides and pesticides.

Case Report

We present the first documentation of a metal phosphide exposure in Lebanon. A middle-aged woman presented to the emergency department following the ingestion of an unknown rodenticide. Spectroscopy analysis of the sample brought by the patient was used and helped identify zinc phosphide. The patient developed mild gastrointestinal symptoms and was admitted to the intensive care unit for observation without further complications.

Review

We subsequently conducted a literature review to understand the diagnosis, pathophysiology, clinical presentation, and management of metal phosphide toxicity. Multiple searches were conducted on MEDLINE and PubMed, and articles related to the topics under discussion were included in the review. Metal phosphide is associated with significant morbidity and mortality involving all body systems. Patients presenting with metal phosphide intoxication need extensive workup including blood testing, electrocardiogram, and chest radiography. To date there is no antidote for metal phosphide toxicity, and management is mostly supportive. Many treatment modalities have been investigated to improve outcomes in patients presenting with metal phosphide toxicities.

Conclusion

Emergency physicians and toxicologists in developing countries need to consider zinc and aluminum phosphides on their differential when dealing with unlabeled rodenticide ingestion. Treatment is mostly supportive with close monitoring for sick patients. Further research is needed to better understand metal phosphide toxicity and to develop better treatment options.

The Molecular Mechanism of Aluminum Phosphide poisoning in Cardiovascular Disease: Pathophysiology and Diagnostic Approach

Nowadays, poisoning with metal phosphides, especially aluminum phosphide (ALP), is one of the main health threats in human societies. Patients suffer from significant complications due to this type of poisoning, and the heart is one of the main organs targeted by ALP. Therefore, in this study, we discussed the effect of phosphine on cardiac function. This study is based on data obtained from PubMed, between 2002 and 2020. The key keywords included "Aluminum phosphide," "Oxidative Stress," "Mitochondria," "Cardiovascular disease," and "Treatment." The results showed that ALP produced reactive oxygen species (ROS) due to mitochondrial dysfunction. ROS production leads to red blood cell hemolysis, decreased ATP production, and induction of apoptosis in cardiomyocytes, which eventually results in cardiovascular disease. Since ALP has the most significant effect on cardiomyocytes, the use of appropriate treatment strategies to restore cell function can increase patients' survival.

A study of the predictive factors of mortality in acute poisoning with aluminum phosphide with special reference to echocardiography and SOFA score

Aluminum phosphide (AlP) is considered now one of the most common causes of poisoning among agricultural pesticides. Poisoning with AlP is extremely toxic to humans with high mortality rate. The aim of this work was to evaluate the prognostic factors and outcome of acute aluminum phosphide poisoning in Alexandria Main University Hospital during a period of 6 months from 1 November 2017 until the end of April 2018, highlighting the role of SOFA score and echocardiography in predicting the mortality. The prospective study was conducted on all patients admitted with acute AlP poisoning to Alexandria Main University Hospital for those 6 months. Patients' data were collected in a special sheet and included biosocial data, medical history, poisoning history, complete medical examination, investigations, duration of hospital stay, and the outcome. All patients were assessed according to SOFA score on admission. Thirty patients were admitted during the period of the current study. Females outnumbered males in all age groups with a sex ratio of 2.75:1. The mean age of patients was 22.77 ± 12.79 years. 96.6% of patients came from rural areas. 93.3% of the cases were exposed to poisoning at home, where suicidal poisoning accounted for (86.7%) of cases. 43.3% of patients died (n = 13), and the median value of SOFA score among non-survivors was 10, versus 1 among survivors. The median value of ejection fraction among non-survivors (25%) was half its value in survivors (50%). Although there were many predictors of severity of AlP poisoning, SOFA score was the most predictive factor of mortality detected by multivariate analysis.

Effect of hydroxyethyl starch on acidosis in patients with aluminum phosphide poisoning

Background

Given the fact that various studies have reported the positive effects of hydroxyethyl starch therapy in controlling shock, this study aimed to compare the effects of hydroxyethyl starch on modifying acidosis and treating patients with aluminum phosphide poisoning.

Methods

This was a randomized clinical trial that was conducted on 60 patients with aluminum phosphide poisoning. We compared the two groups of patients treated with hydroxyethyl starch and normal saline. Base excess and serum pH of arterial blood gases (ABG) were measured before and after the treatment and compared by t-test.

Results

Results showed that arterial pH in the starch group and normal saline group increased by 0.13 and 0.18, respectively, and the difference between the two groups was not statistically significant. The difference in the base excess before and after treatment in the starch group and normal saline group was 6.41 and 5.39, respectively, and the difference between the two groups was not statistically significant. Changes in mean values of arterial pH after the intervention in comparison with before treatment were statistically significant (p<0.05).

Conclusion

Overall, the results of the present study show that starch is at least as effective as normal saline in treating acidosis in patients poisoned with aluminum phosphide and can be used instead of normal saline, and both of the two treatments could be equally effective.

Targeting of oxidative stress and inflammation through ROS/NF-kappaB pathway in phosphine-induced hepatotoxicity mitigation

AIMS

Poisoning with aluminium phosphide (AlP) commonly has a high rate of mortality and morbidities. Phosphine gas is the main cause of AlP poisoning that has deleterious effect on multi-organs especially heart, kidney, and liver. Furthermore, several studies reported that resveratrol has cytoprotective effects through its pleiotropic property. The purpose of this study was to estimate the dose-dependent role of resveratrol on phosphine induced acute hepatic toxicity in rat model.

MAIN METHODS

The rats have been exposed to LD₅₀ of AlP (12 mg/kg) by gavage, and resveratrol doses (20, 40, and 80 mg/kg) were injected 30 min after intoxication. After 24 h, the serum and liver tissue were collected for present study.

KEY FINDINGS

The results indicated that phosphine causes an alteration in oxidative stress markers including elevation of ROS, and GSH level, MPO activity, reduction in SOD, catalase and G6PD activity as well as reduction in SOD1 and catalase expression. Furthermore, phosphine significantly induced phosphorylation of IkappaB, NF-kappaB and up-regulation of TNF-α, IL-1β, IL-6, and ICAM-1 expression. Also, phosphine induces markedly reduced hepatocytes lives cell and elevated apoptosis and necrosis. Co-treatment of resveratrol in a dose-dependent manner reversed aforementioned alterations. All in all, histological analysis indicated a deleterious effect of phosphine on the liver, which is mitigated by resveratrol administration.

SIGNIFICANCE

The results of the present study suggest targeting ROS/NF-kappaB signalling pathway by resveratrol may have a significant effect on the improvement of hepatic injury induced by phosphine. It also may be a possible candidate for the treatment of phosphine-poisoning.

Aluminium phosphide poisoning with severe cardiac dysfunction and the role of digoxin

Aluminium phosphide (ALP) is a common cause of suicidal poisoning in India where it is easily available and commonly known as 'rice tablet'. In rural areas of India, it is still used to protect rice and stored grains from rodents and pests. 1 There is no specific antidote for phosphide poisoning and treatment involves meticulous supportive care. Ingestion can lead to severe cardiac suppression and cardiogenic shock. For patients poisoned with ALP who continue to have refractory shock with persistent myocardial suppression despite the use of adrenergic inotropic agents, the addition of digoxin may be beneficial. We present a case where digoxin was utilised with beneficial patient outcomes.

Therapeutic effects of oral liothyronine on aluminum phosphide poisoning as an adjuvant therapy

Background:

In aluminum phosphide (AlP) poisoning, death is mainly due to cardiovascular failure and refractory acute heart failure. There is a lot of evidence showing thyroid hormones have cardioprotective effects.

Objective:

The purpose of this study was to evaluate the effect of oral liothyronine in the treatment of AlP poisoning.

Methods:

Twenty-four patients from intensive care unit of Baharloo Hospital, Tehran, Iran, were included based on the inclusion and exclusion criteria. They were randomly divided into two parallel groups of 12 cases and 12 controls. Intervention in the case group was administration of 50 µg liothyronine via nasogastric tube after gastric lavage, in the first 6 h of poisoning. In both groups, the routine treatment of AlP poisoning was performed. Blood samples were prepared at the beginning of the study and after 12 h. Patients were followed up till discharge from the hospital or death.

Results:

The findings demonstrated that oral liothyronine was able to significantly improve systolic blood pressure, arterial blood pH, and total thiol molecules and also could decrease lipid peroxidation, increase catalase activity, and prevent further decline in total antioxidant capacity.

Conclusion:

Liothyronine administration is effective in controlling AlP poisoning and can improve patients’ outcome.

A review of aluminium phosphide poisoning and a flowchart to treat it

The use of pesticides such as aluminium phosphide (AlP) has increased in the recent years and improved the quantity and quality of agricultural products in a number of developing countries. The downside is that AlP causes severe chronic and acute health effects that have reached major proportions in countries such as India, Iran, Bangladesh, and Jordan. Nearly 300,000 people die due to pesticide poisoning in the world every year. Poisoning with AlP accounts for many of these deaths. Unfortunately, at the same time, there is no standard treatment for it. The aim of this article is to give a brief review of AlP poisoning and propose a treatment flowchart based on the knowledge gained so far. For this purpose we reviewed all articles on the management of AlP poisoning published from 2000 till now. Using a modified Delphi design, we have designed a handy flowchart that could be used as a guide for AlP poisoning management of patients in emergency centres.

Successful management of zinc phosphide poisoning

Zinc phosphide (Zn₂P₃) rodenticide, is generally misused intentionally for suicidal purpose in Iran. For many years, scientists believe that liberation of phosphine (PH₃) on contact with acidic content of the stomach is responsible for clinical presentations. However, relatively long time interval between ingestion of Zn₂P₃ and presentation of its systemic toxicity, and progression of acute liver failure could not be explained by the current opinion. Hence, an innovative theory intended that phosphonium, as an intermediate product will create and pass through the stomach, which then will reduce to produce PH₃in the luminal tract. Here, we present a case of massive Zn₂P₃ poisoning. In our case, we used repeated doses of castor oil to induce bowel movement with an aim of removing unabsorbed toxin, which was proved by radiography. Interestingly, the patient presents only mild symptoms of toxicity such as transient metabolic acidosis and hepatic dysfunction.

Thoughts on the current management of acute aluminum phosphide toxicity and proposals for therapy: An Evidence-based review

The majority of aluminum phosphide (ALP) toxicity cases are suicidal attempts. Despite advances in critical care medicine, the mortality rate of ALP remains very high. Unfortunately, knowledge on the toxicokinetics of ALP is very low. An obsolete idea was proposed that inhibition of complex IV of cytochrome C oxidase is responsible for multiorgan dysfunction. However, based on human studies, this effect might be insignificant. Thus, a novel idea proposes that the main mechanism might be vascular wall integrity disruption. The low frequency of acute toxicity and unanswered questions about the toxicokinetics and toxicodynamics has led to leaden advances of novel treatments. The aim of this review was to evaluate problems regarding current treatment protocols and propose new ideas based on updated information. For this purpose, we reviewed all available articles on the management of ALP poisoning published to date. Considering failure of conventional therapies on maintaining systolic blood pressure, correcting acid-base disturbances, and support cardiac function, the previous treatment protocols have been overruled. However, repudiate of conventional treatments in this deadly condition is not without penalties for the health-care provider. The introduction of new therapies including refuse of gastric lavage with water-soluble compounds, administration of a high molecular weight colloidal solution for fluid resuscitation and termination using sodium bicarbonate, and vasoactive agents has been prospected to improve patient survival. This protocol is in early clinical evaluation; nevertheless, it appears to improve patient's survival; hence, future randomized trials should be performed to support their effectiveness.

Aluminum phosphide poisoning: Possible role of supportive measures in the absence of specific antidote

Aluminum phosphide (ALP) poisoning is one of the major causes of suicidal deaths. Toxicity by ALP is caused by the liberation of phosphine gas, which rapidly causes cell hypoxia due to inhibition of oxidative phosphorylation, leading to circulatory failure. Treatment of ALP toxicity is mainly supportive as there is no specific antidote. We recently managed 7 cases of ALP poisoning with severe hemodynamic effects. Patients were treated with supportive measures including gastric lavage with diluted potassium permanganate, coconut oil and sodium-bicarbonate first person account should be avoided in a scientific paper. Intravenous magnesium sulfate, proper hemodynamic monitoring and vasopressors. Four out of 7 survived thus suggesting a role of such supportive measures in the absence of specific antidote for ALP poisoning.

A systematic review of aluminium phosphide poisoning

Every year, about 300,000 people die because of pesticide poisoning worldwide. The most common pesticide agents are organophosphates and phosphides, aluminium phosphide (AlP) in particular. AlP is known as a suicide poison that can easily be bought and has no effective antidote. Its toxicity results from the release of phosphine gas as the tablet gets into contact with moisture. Phosphine gas primarily affects the heart, lungs, gastrointestinal tract, and kidneys. Poisoning signs and symptoms include nausea, vomiting, restlessness, abdominal pain, palpitation, refractory shock, cardiac arrhythmias, pulmonary oedema, dyspnoea, cyanosis, and sensory alterations. Diagnosis is based on clinical suspicion, positive silver nitrate paper test to phosphine, and gastric aspirate and viscera biochemistry. Treatment includes early gastric lavage with potassium permanganate or a combination with coconut oil and sodium bicarbonate, administration of charcoal, and palliative care. Specific therapy includes intravenous magnesium sulphate and oral coconut oil. Moreover, acidosis can be treated with early intravenous administration of sodium bicarbonate, cardiogenic shock with fluid, vasopresor, and refractory cardiogenic shock with intra-aortic baloon pump or digoxin. Trimetazidine may also have a useful role in the treatment, because it can stop ventricular ectopic beats and bigeminy and preserve oxidative metabolism. This article reviews the epidemiological, toxicological, and clinical/pathological aspects of AlP poisoning and its management.