Investigating the outcomes of aluminum phosphide poisoning in khorshid referral hospital, Isfahan, Iran: A retrospective study

Insulin in aluminum phosphide poisoning: A systematic review of the current literature

BACKGROUND

Aluminum phosphide (AlP) is a commonly used fumigant in agriculture and grain preservation because of its high potency and low cost. Due to the absence of a specific antidote and promising treatment modality, poisoning with this substance is deadly. Amid multiple studies in different parts of the world, each exploring options like lavage, inotropes, antioxidants, etc, we conducted a systematic review to find the possible role of exogenous insulin in treating symptomatic cases of AlP poisoning.

METHODS

Experimental studies released before February 15, 2024, that reported the use of exogenous insulin were systematically reviewed following the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The search was done on PubMed Central, Cochrane Library, and Google Scholar.

RESULTS

After applying the inclusion and exclusion criteria, we finalized a few scientific papers for the review. Studying data from 4 scientific papers (3 quasi-experimental studies and 1 randomized controlled trial), we could postulate the significant improvement in survivability after the inclusion of exogenous insulin in the treatment of poisoned cases of AlP. Studies showed divergent results for the blood pressure, blood gases, and need for mechanical ventilation. Hypoglycemia, hyperglycemia, and hypokalemia were the reported adverse effects of this therapy.

CONCLUSION

Our review found that the use of exogenous insulin in AlP poisoning reduced mortality rates, which was consistent across all studies. With available knowledge, its inclusion as a part of therapy might be beneficial in AlP poisoning, but to put it forward confidently, we still need high-quality randomized control trials. It is indeed a subject of interest for future research.

Clinico-epidemiological evaluation of pharmaceutical/non-pharmaceutical poisoning in a referral poisoning emergency in the Central part of Iran

The pattern of poisoning varies in different societies. In this study, we investigated the clinical-epidemiological features and outcomes of poisoned patients based on the substances involved, whether pharmaceutical or non- pharmaceutical toxins. This cross-sectional study involved a retrospective chart review of all poisoned patients who presented to the poisoning emergency hospital in the center of Iran between January 2015 and December 2019. We collected data on socio-demographics, the nature of the poisoning, and the outcomes. Backward stepwise binary regression analysis was conducted to predict the mortality. Throughout the study period, 5777 patients with acute poisoning met the inclusion criteria. Of these, 3524 cases (61%) were attributed to pharmaceutical, and 2253 cases (39%) were due to non-pharmaceutical poisoning. The majority of pharmaceutical poisonings (82.9%) were intentional, whereas non-pharmaceutical poisonings accounted for 46.2% of intentional exposures (P < 0.001). Patients with non-pharmaceutical poisoning were predominantly men, older in age, and had a history of addiction compared to those with pharmaceutical poisoning (P < 0.001). In binary logistic regression analysis, patients poisoned by non-pharmaceutical substances had a significantly higher risk of mortality [Odds ratio, 3.14; (95% CI 1.39-7.10); P = 0.006] compared to those poisoned by pharmaceutical substances (P < 0.001). The pattern of poisoning differs in terms of age and gender when comparing pharmaceutical to non-pharmaceutical poisoning. Patients poisoned by non-pharmaceutical may have a worse outcome compared to those poisoned by pharmaceutical substances.

The therapeutic effect of a novel parenteral formulation of dihydroxyacetone in aluminum phosphide-intoxicated patients

Background and objectives

Aluminum phosphide (AlP), known as "rice tablet," is widely used as an effective pesticide. However, AlP poisoning is a common cause of mortality in many countries, such as Iran. Unfortunately, there is no specific antidote for AlP toxicity to date. AlP releases phosphine gas when it is exposed to moisture or acid. Phosphine is a potent mitochondrial toxin that could significantly inhibit cellular energy metabolism. AlP poisoning is an emergency condition that needs instant and effective intervention. Dihydroxyacetone (DHA) is a simple saccharide used for several pharmacological as well as cosmetic purposes. Previously, we found that DHA could significantly prevent mitochondrial impairment induced by toxic agents such as cyanide and phosphine in various in vitro and in vivo experimental models.

Methods

Hospitalized patients (n = 111) were evaluated for eligibility criteria. Among these patients, n = 35 cases were excluded due to incomplete data (n = 11) and suspicion of poisoning with poisons other than AlP (n = 24). Meanwhile, n = 76 cases with confirmed AlP poisoning were included in the study. AlP-poisoned patients who did not receive DHA (n = 18) were used as the control group.Patients (n = 58) received at least one dose of DHA (500 ml of 5 % DHA solution w/v, i.v.) as an adjuvant therapy in addition to the routine treatment of AlP poisoning. Arterial blood gas (ABG), blood pH, bicarbonate levels, and other vital signs and biochemical measurements were monitored. Moreover, the mortality rate and hospitalization time were evaluated in DHA-treated and AlP-poisoned patients without DHA administration. Several biomarkers were assessed before (upon hospitalization) and after DHA treatment. The routine tests for AlP-poisoned patients in this study were the measurement of electrolytes (K+ and Na+), WBC, RBC, hemoglobin, INR, carbonate (HCO3), blood pH, PaCO2, and PaO2 and SGPT, SGOT, BUN, Cr.

Results

Upon patients' admission, significant decreases in blood pH (acidosis), blood PaO2, and HCO3 levels were the hallmarks of AlP poisoning. It was found that DHA significantly alleviated biomarkers of AlP poisoning and tremendously enhanced patients' survival rate (65.52 % in DHA-treated vs 33.34 % in the control group) compared to patients treated based on hospital routine AlP poisoning protocols (no DHA). No significant adverse effects were evident in DHA-treated patients in the current study.

Interpretation and conclusions

These data suggest that parenteral DHA is a novel and effective antidote against AlP poisoning to be used as an adjuvant in addition to routine supportive treatment.

Trial registration

IR.SUMS.REC.1394.102.

The therapeutic benefit of antioxidants on the outcome of acute aluminum phosphide poisoning: a systemic review and meta-analysis

This systematic review and meta-analysis pool evidence available from clinical trials to verify the effect of antioxidants on the outcome of acute aluminum phosphide (AlP) poisoning. A systematic review complied with "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) Protocols. Meta-analysis was conducted on 10 studies that fulfill eligibility criteria. Four antioxidants were implemented: N-Acetyl cysteine (NAC), L-Carnitine, Vitamin E, and Co-enzyme Q10 (Co Q10). Risk of bias, publication bias, and heterogeneity were assessed to ensure the results' reliability. Antioxidants significantly decrease mortality of acute AlP poisoning around three folds (OR = 2.684, 95% CI: 1.764-4.083; P < .001) and decrease the need for intubation and mechanical ventilation by two folds (OR = 2.391, 95% CI 1.480-3.863; P < .001) compared with control. Subgroup analysis revealed that NAC significantly decreases mortality by nearly three folds (OR = 2.752, 95% CI: 1.580-4.792; P < .001), and vitamin E significantly decreases mortality by nearly six folds (OR = 5.667, 95% CI: 1.178-27.254; P = .03) compared with control. L-Carnitine showed a borderline significance (P = .050). Co Q10 decreased the mortality compared with the control; however, the difference was not statistically significant (P = .263). This meta-analysis provides solid evidence regarding the efficacy of antioxidants in improving the outcome of acute AlP poisoning with reference to NAC. Wide confidence interval and small relative weight affect reliability regarding vitamin E efficacy. Future clinical trials and meta-analyses are recommended. To our knowledge, no previous meta-analysis was conducted to investigate the efficacy of treatment modalities for acute AlP poisoning.

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.

Acute pesticide poisoning in the central part of Iran: A 4-year cross-sectional study

Objectives

Intoxication with pesticides is a well-known public health problem. We aimed to describe the demographic and toxico-clinical characteristics and outcomes of patients with pesticide poisoning.

Methods

This retrospective cross-sectional study was performed in Khorshid Hospital affiliated with Isfahan University of Medical Sciences, Isfahan, Iran. All patients with pesticide poisoning (insecticides, herbicides, fungicides, rodenticides, and acaricides) were evaluated. The patients' demographic, toxicological, clinical, and laboratory findings from March 2016 until March 2021 were collected and analyzed.

Results

During the study period, 25,659 patients with acute poisoning were admitted, of which, 1567 (6.1% of the total poisoning) with pesticide poisoning were included. The mean ± SD age of the patients was 31.34 ± 13.7 years and 55.3% were men (male/female ratio = 1.23). In approximately 75% of the patients, poisoning occurred by suicidal attempts, while in 14.3% (n = 224), it was accidental. Insecticides caused about 51.30% of the poisonings. However, rodenticides were most commonly used in completed suicide attempts (79.9%). The frequency of previously attempted suicide, and self-harming was different among the patients with respect to the type of pesticide poisoning (p < 0.05). Previous suicidal attempts (35.3%) and self-harming (17.3%) were reported more in patients poisoned with the combination of pesticides. Half of the patients were employed. Nausea and vomiting (56.7%, n = 889) were the most common clinical manifestations; 8.3% (n = 130) of the patients died, 64 of whom had rodenticide poisoning.

Conclusion

The prevalence of pesticide poisoning was relatively low; most were insecticide poisoning. Poisoning occurred most through attempted suicide. Rodenticides and herbicides had higher mortality rates than other pesticides. Patients with previously attempted suicide and self-harming behavior may use a combination of pesticides.

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.