Management of Acute Aluminum Phosphide Poisoning: Has Anything Changed?

Gastrointestinal decontamination using oil-based solutions in patients with acute aluminum phosphide poisoning: a systematic review and meta-analysis

Some studies suggested that gastrointestinal (GIT) decontamination with oil may improve the prognosis of patients who ingested aluminum phosphide (AlP). The aim of this study is to compare the efficacy and safety of gastric lavage with oil-based solutions to any method of gastric decontamination not using oils in patients presenting with acute AlP poisoning. The literature was searched for English-published randomized controlled trials (RCTs) from inception to 16 September 2023. The searched electronic databases included MEDLINE/PubMed, Cochrane Library, Web of Science, Egyptian Knowledge Bank, Scopus, and Google Scholar. Data were extracted and pooled by calculating the risk ratio (RR) for categorical outcomes and standardized mean difference (SMD) for numerical outcomes, with 95% confidence intervals (CI). Seven RCTs were included. Paraffin oil was significantly associated with a lower risk of mortality (RR = 0.59 [95% CI: 0.45, 0.76], p < .001), intubation (RR = 0.59 [95% CI: 0.46, 0.76], p < .001) and vasopressor need (RR = 0.71 [95% CI: 0.56, 0.91], p = .006). Survival time was significantly prolonged with paraffin oil (SMD = 0.72 [95% CI: 0.32, 1.13], p < .001). Coconut oil was significantly associated with prolonged survival time (SMD = 0.83 [95% CI: 0.06, 1.59], p = .03) as well as decreased risk of requiring intubation (RR = 0.78 [95% CI: 0.62, 0.99], p = .04). Oil-based GIT decontamination using paraffin oil showed benefits over conventional lavage regarding the incidence of in-hospital mortality and endotracheal intubation, and survival time. Coconut oil showed some benefits in terms of the intubation incidence and survival time. Decontamination using paraffin oil is recommended. Future clinical trials are warranted with larger sample sizes and focusing on cost-benefit and safety.

The adjuvant effect of oil-based gastric lavage on the outcome of acute Aluminum phosphide poisoning: a systematic review and meta-analysis

Introduction

Aluminum Phosphide (AlP) poisoning constituted the most common cause of poisoning death in some low- and middle-income countries (LMICs). This study aimed to evaluate the safety and efficacy of oil-based gastric lavage (GL) compared with standard therapy for the treatment of AlP poisoning. Materials and methods. This systematic review complied with "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) Protocols. A comprehensive search was carried out, identifying randomized controlled trials (RCTs), including anyone presenting within 6 h of exposure to AlP, and the administration of GL with oils, including liquid paraffin or coconut oil.

Results

We identified 7 RCTs. The evidence from 4 RCTs indicates that GL with paraffin oil is an effective treatment for acute AlP poisoning, decreasing the mortality rate (RR = 0.62; 95% CI = 0.48 to 0.81; participants = 226; I 2 = 10%; low-quality evidence). We estimate the Number Needed to Treat of 4. Likewise, this intervention reduces the need for intubation and mechanical ventilation (RR = 0.62; 95% CI = 0.40 to 0.79; I2 = 0%; low-quality evidence). Regarding GL with coconut oil, the evidence from 4 RCTs, indicates a slight reduction in mortality (RR = 0.82; 95% CI = 0.69 to 0.98; participants = 112; I2 = 0%; very low-quality evidence).

Conclusions

Limited evidence suggests that GL with paraffin oil is effective in reducing the mortality rate. Likewise, limited evidence showed in favor of paraffin oil concerning the need for intubation and mechanical ventilation. Very limited evidence suggests that GL with coconut oil could reduce mortality. Both interventions would have a benign safety profile.

Zinc Phosphide Poisoning: From A to Z

Zinc phosphide is a rodenticide that is used in agricultural, urban and industrial environments in México. After ingestion, it reacts with hydrochloric acid, hydrolyzing into phosphine. It causes cellular hypoxia via mitochondrial toxicity, resulting in multiple organ dysfunction and death. There is no antidote or specific treatment for zinc phosphide toxicity. We present the case of a 45-year-old female who ingested zinc phosphide with suicidal intent. On arrival at the emergency department, she had multisystemic disorders. Supportive care, decontamination and antidotal therapy were initiated. Subsequently, she evolved to clinical improvement with a resolution of the biochemical abnormalities of tissue hypoperfusion. She was discharged on day 7 without complications. In this review, we provide updated therapeutic options and discuss their specific pathophysiological basis.

Case Report: Acute Intoxication from Phosphine Inhalation

Aluminum phosphide is a highly effective insecticide for fumigation in granaries and is often used in rural grain storage. However, people's awareness of its toxicity is not strong. A case of acute inhalation toxicity of phosphine caused by the use of aluminum phosphide to fumigate a granary is reported here. The case presented with aspiration pneumonia and acute left heart failure. The patient was cured using comprehensive life support treatment, including respiratory support, antiarrhythmic treatment, and blood pressure maintenance with vasoactive drugs. There is no specific antidote for phosphine poisoning at present, and the comprehensive application of restricted fluid resuscitation, high-dose glucocorticoid shock, vasoactive drugs and bedside hemofiltration is significant in improving the prognosis of patients. It is also important to remind people to pay attention to their own protection in the process of using aluminum phosphide.

Prognostic significance of poison-related factors and consumption patterns in acute aluminum phosphide poisoning

OBJECTIVES

The prognosis of acute aluminum phosphide poisoning is usually based on toxidrome features, with little focus on poison-related factors. We aimed to study the prognostic significance of poison-related factors, consumption patterns, and time delays to treatment.

METHODS

We performed a prospective cohort study in an academic hospital in North India in patients aged ≥ 13 with aluminum phosphide poisoning from July 2019 to December 2020. During data collection, a particular emphasis was made on the poison formulation, the ingested dose, the reconstitution of poison, vomiting, and time intervals to initiate various treatments. The primary outcome was inhospital mortality.

RESULTS

Fifty-eight patients were enrolled (median age, 32 years; 37 males). The mean dose of the ingested poison was 6.56 (±5.42) g. The predominant formulation of poison was pellet (n = 41), followed by powder (n = 16). Twenty patients performed reconstitution of poison before consumption, and 13 stirred the poison while reconstituting. All patients but three developed vomiting after consumption. Inhospital mortality (n = 23, 39%) was significantly high with a higher ingested dose (P < 0.001), nonstirred reconstitution before consumption (P = 0.042), fewer vomiting episodes (P = 0.010), a delay in detection of the victim by someone (P = 0.001), and delayed initiation of intravenous fluids (P = 0.043). The secondary outcomes (shock and requirement of vasopressor or ventilation) remained unaffected by the stirring in the reconstitution group.

CONCLUSIONS

Poison-related factors and time intervals determine early risk stratification at admission in aluminum phosphide poisoning.

Toxicoepidemiology of Phosphide Poisoning in the Central Part of Iran

Objective

Aluminum phosphide (ALP) and zinc phosphide (ZnP) are toxic agrochemical pesticides, which are commonly used as an agent of self-harm in developing countries. Because of high toxicity of phosphides, we evaluated toxico-epidemiology ALP and ZnP poisoning in with respect to outcome.

Methods

We performed a cross-sectional study with retrospective chart review including the records for patients admitted due to phosphide poisoning (ALP, ZnP) in a poisoning referral center in Khorshid Hospital, affiliated with Isfahan University of Medial Sciences, Isfahan, Iran. Demographic characteristics, clinical manifestations, outcome (survived or death), and length of hospital stay for the patients were recorded in a data collecting form. Binary backward stepwise logistic regression was used for outcome prediction.

Findings

Sixty patients were evaluated in the study. The mean age of patients was 27.61. Thirty-nine patients were men. 96.7% of the patients ingested it intentionally. Most of the patients on admission were conscious (66.7%). Abnormality of EKG was noted in 8.3%. The mortality in ALP and ZnP poisoning was 39.2% and 22.2%, respectively. Serum bicarbonate and base excess in the venous blood gas analysis, systolic blood pressure, and serum sodium level were significantly different between patients with ALP and ZnP poisoning on admission time (P < 0.05). On admission, systolic blood pressure was an important predictive factor for mortality (odds ratio 4.87; 95% confidence interval: 1.5-15.45; P = 0.007).

Conclusion

The rate of mortality in phosphide poisoning is high. Knowing predictive factors for mortality help physicians for selecting patients in intensive care unit admission and aggressive treatment.

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.