Prognostic Significance of Blood Glucose Levels and Alterations Among Patients with Aluminium Phosphide Poisoning

Shock and modified shock indices in predicting poisoning severity and outcomes in acute aluminum phosphide poisoned patients

Background

Severe refractory hypotension and cardiogenic shock are the main contributors to death in acute aluminum phosphide (ALP) poisoning. Shock index (SI) and modified shock index (MSI) are easily obtained parameters that reflect shock at an early stage.

Aim

This study aimed to evaluate the role of SI and MSI in the prediction of the severity and outcomes of acute ALP poisoned patients.

Patients and methods

This cross sectional study was conducted on patients admitted to Tanta University Poison Control Centre with acute ALP poisoning from April 2022 to March 2023. Socio-demographics and toxicological data were taken, findings of clinical examination and laboratory investigations were recoded, SI was calculated by dividing heart rate over systolic blood pressure, and MSI was obtained by dividing heart rate over mean arterial pressure. Poisoning severity was assessed using poisoning severity score (PSS). Patients were divided into groups according to intensive care unit (ICU) admission and mortality.

Results

The study enrolled 94 patients. The median values of SI and MSI were significantly higher in ICU-admitted patients and non-survivors rather than their comparable groups. Significant positive correlations were observed between each of SI and MSI and PSS. At cut-off >1.14, SI conveyed fair performance to predict ICU admission and mortality (AUC = 0.710 and 0.739, respectively). Similarly, MSI had fair performance to predict ICU admission (AUC = 0.731) and mortality (AUC = 0.744) at cut-off >1.47 and >1.5, respectively.

Conclusion

Both SI and MSI could be considered simple bedside adjuncts to predict ICU admission and mortality in acute ALP poisoning.

OUP accepted manuscript

Introduction

We recently derived a simplified 3-point PGI score (representing blood pH < 7.25, Glasgow coma scale [GCS] score < 13, and impaired systolic blood pressure [SBP] < 90 mm Hg), which accurately predicted in-hospital case fatality ratio (CFR) in acute aluminum phosphide poisoning. The present study aimed to validate the PGI score and compare it with Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score, Sequential Organ Failure Assessment score (SOFA), and Simplified Acute Physiology Score (SAPS) II scores.

Patients and Methods

We performed a prospective cohort study in adult patients with aluminum phosphide ingestion admitted in PGIMER, Chandigarh (India), from April 2013 to August 2014. A univariant analysis detected the association of various baseline variables with CFR. Correlation of the PGI score with SOFA, SAPS-II, and APACHE-II scores was performed using Spearman's correlation (r_s , range -1 to +1) and scatter plots.

Results

Seventy-six patients were enrolled (mean age, 28.3 years; 41 males). CFR was 60.5%. PGI score variables-pH, GCS, and impaired SBP predicted CFR (P-value <0.001). Among patients with a total PGI score of 3 or 2, 100% died, compared with 50% in score 1 and 10.7% in score 0. Baseline PGI, SOFA, SAPS-II, and APACHE-II scores predicted CFR (P-value <0.001). There was a positive correlation between the PGI score and SOFA score (r_s , 0.855), SAPS-II score (r_s , 0.861), and APACHE-II score (r_s , 0.883). The P-value for all r_s values was <0.001.

Conclusion

The PGI score is a validated toxidrome-specific and simplified risk-stratification tool. Validation in other populations is warranted to confirm its routine use.

Unexpected survival after deliberate phosphine gas poisoning: An Australian experience of extracorporeal membrane oxygenation rescue in this setting

Phosphine poisoning is responsible for hundreds of thousands of deaths per year in countries where access to this pesticide is unrestricted. Metal phosphides release phosphine gas on contact with moisture, and ingestion of these tablets most often results in death despite intensive support. A 36-year-old woman presented to a regional hospital after ingesting multiple aluminium phosphide pesticide tablets and rapidly developed severe cardiogenic shock. In this case, serendipitous access to an untested Extracorporeal Membrane Oxygenation (ECMO) service of a regional hospital effected a successful rescue and prevented the predicted death. We discuss the toxicology, management and the evidence for and against using ECMO in this acute poisoning.

Management of Acute Aluminum Phosphide Poisoning: Has Anything Changed?

Due to its easy availability, rapid and severe toxicity, and no specific antidote, aluminum phosphide has emerged as a lethal toxin, commonly used for suicidal intent in agricultural communities. Despite various advances in medicine, this compound's toxicity is poorly understood, and it still has a very high case fatality rate with no definitive treatment options available. This review aims to understand the mechanism of toxicity, clinical toxidrome of acute aluminum phosphide poisoning, and the available therapeutic options, including recent advances. A literature review was performed searching PubMed, EMBASE Ovid, and Cochrane Library, using the following search items: ("aluminum phosphide poisoning" OR "aluminum phosphide poisoning toxicity" OR "aluminum phosphide ingestion") AND ("management" OR "therapy" OR "treatment"). Selected articles were discussed amongst all the authors to shape this review. High case fatality rate and lack of any specific antidote are persisting challenges. Therapeutic measures need to be implemented from all fronts - reducing easy access to the poison, developing less toxic alternatives for use as a pesticide, and more studies directed at developing an effective reversal agent for phosphine. The advent of promising agents like glucose-insulin-potassium infusion and lipid emulsion is a new ray of hope in the complete recovery in this fatal poisoning. The need of the hour is to find an agent that rapidly and effectively reverses aluminum phosphide's toxic effects. Large multicenter controlled trials are required to establish the role of glucose-insulin-potassium and lipid emulsion.

Trimetazedine with hyperinsulinimea-euoglycemia, N-acetyl cysteine, and vitamin C: A new approach concept for management of aluminum phosphide poisoning

Aluminum phosphide (AlP) is commonly used as a powerful suicidal tool. The exact mechanism of acute toxicity has not been well defined despite high mortality rates as well as its supportive treatment including rapid decontamination and institution of resuscitative measures. The current study aimed to investigate a new combination therapy using trimetazidine, N-acetyl cysteine, vitamin C, and hyperinsulinemia-euglycemia to manage acute AlP poisoning. Acute AlP-induced cardiotoxicity, hemodynamic changes, and hepatotoxicity were evaluated using electrocardiogram, creatinine kinase MB iso-enzyme, troponin-1, blood pressure, random blood glucose level, liver function tests, and histopathological changes in both the heart and liver in a rabbit model of AlP poisoning. The results showed that the new regimen therapy ameliorates the toxic effect of AlP with significant improvement in survival, cardiovascular and hemodynamic parameters in addition to histopathological changes. These results highlight the strong cardioprotective, antioxidant, hepatoprotective effects of the new combined therapy along with correction of hemodynamic changes and hyperglycemia as a potential target in the management of acute AlP poisoning.

Importance of pesticides for lethal poisoning in India during 1999 to 2018: a systematic review

BACKGROUND

Poisoning is a major problem in India. However, there is little systematic information on the key poisons responsible for most deaths by geographical area and over time. We aimed to review the literature to identify the poison classes causing the greatest number of deaths in India over the last 20 years.

METHODS

We performed a systematic literature review in Medline, Embase and Google Scholar (1999-2018), and Indian online medical journals, to find papers that reported deaths from all forms of poisoning in India, with last search 20 April 2020. We included epidemiological studies, observational studies, randomised trials, interventional studies, and case series published from 1999 to 2018 that showed the number of deaths and autopsy studies indicating the specific poisons or poison classes. Studies providing the case fatality for specific poisons or classes, which enabled calculation of the number of deaths, were also included. We excluded deaths due to animal bites and stings, ethanol or methanol poisoning, and gas inhalation as well as papers reporting a single death (case study of single patient). We grouped the papers into 5-year intervals and identified the two most common poison classes in each paper. We used descriptive statistics to summarise the findings over time based on the causative poison and the location of the study.

RESULTS

We identified 186 papers reporting 16,659 poisoning deaths between 1999 and 2018. The number of publications per 5-year interval showed no clear trend over the period (48, 38, 67, and 36 for consecutive periods). Half of the deaths (n = 8338, 50.0%) were reported during the first 5 years of the study (1999-2003), the number of deaths declining thereafter (to n = 1714 in 2014-2018). Deaths due to pesticide poisoning (94.5%) were dominant across the study period compared to other classes of poison [hair dye paraphenylenediamine poisoning (2.6%), medicine overdose (1.4%) or plant poisoning (1.0%)]. Among the pesticides, aluminium phosphide was the most important lethal poison during the first 10 years before declining markedly; organophosphorus insecticides were important throughout the period, becoming dominant in the last decade as aluminium phosphide cases declined. Unfortunately, few papers identified the specific organophosphorus insecticide responsible for deaths.

CONCLUSION

Use of the published literature to better understand the epidemiology of lethal poisoning in India has clear limitations, including secular variation in publishing practices and interest in poisoning. Unfortunately, there are no long-term detailed, combination hospital and community studies from India to provide this information. In their absence, our review indicates that pesticides are the most important poison in India, with organophosphorus insecticides replacing aluminium phosphide as the key lethal poison after government regulatory changes in 2001 reduced the latter's lethality. Plant and hair dye poisoning and medicines overdose caused few deaths. Aluminium phosphide deaths mostly occurred in northern Indian states, whereas deaths from organophosphorus insecticide poisoning occurred throughout India. Paraquat poisoning has become a clinical problem in the last 10 years. Lethal pesticide poisoning remains alarmingly common, emphasising the need for additional regulatory interventions to curtail the burden of pesticide poisoning deaths in India. More detailed reporting about the specific pesticide involved in lethal poisoning will be helpful to guide regulatory decisions.

Comment on Lionte et al. Association of Multiple Glycemic Parameters at Hospital Admission with Mortality and Short-Term Outcomes in Acutely Poisoned Patients. Diagnostics 2021, 11, 361

We have read with great interest the article by Lionte et al., "Association of multiple glycemic parameters at hospital admission with mortality and short-term outcomes in acutely poisoned patients", recently published in your journal [...].

A Simple Tool Predicts Mortality in Aluminum Phosphide Self-poisoning

Incorporating the toxidrome-specific prognostic systems into the daily emergency department practice might become a standard of care in low- and middle-income countries. The PGI score is appealing because it is quick and easy, it accurately identifies high-risk patients at in-hospital mortality, and it shows promise in predicting those at low risk. Although further validation of the PGI score is required in more extensive studies, it can help direct appropriate resources to those most likely to benefit and stratify patients for testing novel clinical interventions. How to cite this article: Pannu AK, Bhalla A. A Simple Tool Predicts Mortality in Aluminum Phosphide Self-poisoning. Indian J Crit Care Med 2020;24(9):755-756.

Sudden unresponsive patient with normal vital signs: what is going on?

PURPOSE OF REVIEW

To summarize the differential diagnosis and diagnostic approach of sudden unresponsiveness with normal vital signs in various settings, including the ICU.

RECENT FINDINGS

Sudden unresponsiveness may be either transient or persistent, and may result from primary brain diseases or nonstructural systemic conditions. Life-threatening causes should always be discriminated from those more benign. Regional epidemiology, for example regarding intoxications, and evolving therapeutic management, for example for ischemic stroke, should always be taken into account for optimal opportunity for rapid diagnosis and best management.

SUMMARY

Sudden unresponsiveness with normal vital signs should trigger immediate and focused diagnostic evaluation to find or exclude those conditions requiring urgent, and possibly life-saving, management.

Suicide by pesticide poisoning in India: a review of pesticide regulations and their impact on suicide trends

BACKGROUND

Pesticide self-poisoning is a common means of suicide in India. Banning highly hazardous pesticides from agricultural use has been successful in reducing total suicide numbers in several South Asian countries without affecting agricultural output. Here, we describe national and state-level regulation of highly hazardous pesticides and explore how they might relate to suicide rates across India.

METHODS

Information on pesticide regulation was collated from agriculture departments of the central government and all 29 state governments (excluding union territories). National and state-level data on suicides from 1995 to 2015 were obtained from the National Crime Records Bureau (NCRB). We used joinpoint analysis and negative binomial regression to investigate the trends in suicide rates nationally and in Kerala, in view of the robust measures Kerala has taken to restrict a number of HHPs, to identify any effect on suicides.

RESULTS

As of October 2019, 318 pesticides were registered for use in India, of which 18 were extremely (Class Ia) or highly (Class Ib) hazardous according to World Health Organization toxicity criteria. Despite many highly hazardous pesticides still being available, several bans have been implemented during the period studied. In our quantitative analyses we focused on the permanent bans in Kerala in 2005 (of endosulfan) and 2011 (of 14 other pesticides); and nationally in 2011 (of endosulfan). NCRB data indicate that pesticides were used in 441,918 reported suicides in India from 1995 to 2015, 90.3% of which occurred in 11 of the 29 states. There was statistical evidence of lower than expected rates of pesticide suicides (rate ratio [RR] 0.52, 95% CI 0.49-0.54) and total suicides nationally by 2014 (0.90, 0.87-0.93) after the 2011 endosulfan ban. In Kerala, there was a lower than expected rate of pesticide suicides (0.45, 0.42-0.49), but no change to the already decreasing trend in total suicides (1.02, 1.00-1.05) after the 2011 ban of 14 pesticides. The 2005 ban on endosulfan showed a similar effect - lower than expected pesticide suicides (0.79, 0.64-0.99), but no change to the decreasing trend of total suicides (0.97, 0.93-1.02) in 2010. There was no evidence of a decline in agricultural outputs following the bans.

CONCLUSION

Highly hazardous pesticides continue to be used in India and pesticide suicide remains a serious public health problem. However, some pesticide bans do appear to have impacted previous trends in the rates of both pesticide suicides and all suicides. Comprehensive national bans of highly hazardous pesticides could lead to a reduction in suicides across India, in addition to reduced occupational poisoning, with minimal effects on agricultural yield.

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.