Serie de casos de intoxicación fatal por ingesta intencional de fosfuro de aluminio: case reports with fatal evolution / Aluminium phosphide poisonings: case reports with fatal evolution

El fosfuro de aluminio (AlP) es un plaguicida fumigante de bajo costo, cuyo único uso permitido es el control de plagas en granos almacenados. En contacto con la humedad del aire libera gas fosfina (PH3), altamente tóxico, inflamable y explosivo, pero que se disipa rápidamente. En todas las presentaciones, 3 g de la formulación genera 1 g de gas fosfina. La exposición a 1000 ppm durante 30 minutos es fatal. Presentamos una serie de casos de intoxicación severa por ingesta intencional de fosfuro de aluminio, con desenlace fatal, con el objetivo de asesorar e informar sobre los mecanismos de intoxicación y el manejo adecuado del paciente intoxicado.

Aluminium phosphide (AlP) is a fumigant pesticide inexpensive; whose only permitted use is for stored grain pest control. On contact with moisty air, it releases phosphine gas (PH3), highly toxic, flammable and explosive, but that quickly dissipates. For all presentations, a 3 g formulation generates 1 g of phosphine gas. Exposure to 1000 ppm for 30 minutes is lethal. We present a series of cases of severe poisoning with AlP, in order to advise and inform on the mechanisms of toxicity and proper management of the poisoned patient.

Aluminium Phosphide Poisoning.

Aluminium phosphide poisoning is a major cause of morbidity and mortality in northwest and central India. It liberates lethal phosphine gas when it comes in contact either with atmospheric moisture or with hydrochloric acid in the stomach. The mechanism of toxicity includes cellular hypoxia due to the effect on mitochondria, inhibition of cytochrome C oxidase and formation of highly reactive hydroxyl radicals. In India, most of the patients who come with Celphos poisoning succumb to its toxicity because of the considerable time gap between the ingestion of the poison and the initiation of proper treatment. This has led to widely prevalent scepticism among physicians while managing cases of Celphos poisoning. Due to no known specific antidote, management remains primarily supportive care. In most of the studies, poor prognostic factors were presence of acidosis and shock. The overall outcome improved in the last decade due to better and advanced intensive care management.

"Wheat pill [aluminum phosphide] poisoning"; commonly ignored dilemma. A comprehensive clinical review

The number of deaths due to wheat pill poisoning is enormous and despite aggressive management only a few patients survive the fatal effects of the wheat pill poison. Despite the growing number of patients appearing in the emergency departments with this easily available poison in the market, very little effort has been put forth to study the subject scientifically and to prevent the ongoing loss of precious lives. This is a narrative review of the wheat pill poisoning, highlighting the important steps in diagnosis and management. Data sources include Pubmed, Scopus, Medline [1996 to date], Cochrane library and Google scholar. We included all clinical trials, systematic reviews and ongoing cohort studies. Wheat pill [Aluminum Phosphide] poisoning is a lethal toxin and its effective treatment requires prompt diagnosis and early, time-efficient management. Early transfer to a healthcare facility, good resuscitation, diagnosis, monitoring, gastric lavage and supportive therapy are the hallmarks of management and may result in improved outcomes. The governmental and legislative authorities must take appropriate steps towards limiting its availability at the grass-roots level. Aluminum Phosphide poisoning must be a part of the medical students' curriculum and long-term, well-designed comprehensive research studies are required to discover new modalities of treatment

Acute anterolateral myocardial infarction due to aluminum phosphide poisoning

Aluminum phosphide [AlP] is a highly effective rodenticide which is used as a suicide poison. Herein, a 24-year-old man who'd intentionally ingested about 1 liter of alcohol and one tablet of AlP is reported. Acute myocardial infarction due to AlP poisoning has been occurred secondary to AIP poisoning. Cardiovascular complications are poor prognostic factors in AlP poisoning

The study of aluminium phosphide poisoning in a Tertiary Care Hospital - Amritsar.

Trend of poisoning had been constantly changing throughout the world, as the advent of new agents, has always replaced the older one due to their innumerable merits and demerits. Similarly in India, the pattern of ingested poisons has also changed. A number of chemical substances which are developed to save the agricultural product from rodents and pests are in fact themselves proving to be disastrous for mankind. Recently in the last two decades aluminium phosphide [Alphos] used as pesticide, rodenticide, fumigant for storage of food grains has created havoc with the human lives differently i.e. suicidal, accidental and very rarely homicidal poisoning agent. Alphos, a solid fumigant used for storage of food grains, freely accessible in the market is commonly used suicidal agent with high mortality rate as no antidote or specific treatment is available. The present study of 50 cases of aluminium phosphide poisoning showed male dominance, common in sikhs and educated persons. Heart is the first organ to be affected. Shock was present in majority of cases. Sufficient time was available for recording dying declaration.

Forensic view on aluminium phosphide poisoning.

In India, acute aluminium phosphide poisoning (AAlPP) is a serious health care problem. This study aimed to determine the characteristics of AAlPP and the predictors of mortality at the time of patients' admission. We studied consecutive admissions of patients with AAlPP admitted to the intensive care unit (ICU). We noted 38 parameters at admission to the hospital and the ICU and compared survivor and non-survivor groups. A total of 54 patients were enrolled comprising 10 females and 44 males and the mean ingested dose of poison was 0.75 ± 0.745 grams. The mortality from AAlPP was 59.3%. We found the following factors to be associated with an increased risk of mortality: a serum creatinine concentration of more than 1.0 mg % (P = 0.01), pH value less than 7.2 (P = 0.014), serum bicarbonate value less than 15 mmol/L (P = 0.048), need for mechanical ventilation (P = 0.045), need for vasoactive drugs like dobutamine (P = 0.027) and nor adrenaline (P = 0.048) AAlPP causes high mortality primarily due to early haemodynamic failure and multi-organ dysfunction.

Aluminum phosphide poisoning known as rice tablet: A common toxicity in North Iran.

Background: Aluminum phosphide (ALP) is a highly effective insecticide and rodenticide used frequently to protect stored grain. Acute poisoning with this compound is common in some countries including India and Iran, and is a serious health problem. Aim: The objective of this study was to survey ALP poisoning locally known as "Rice Tablet" and the outcome in a referral poisoning hospital in Mazandaran province, northern part of Iran. Materials and Methods: The study was a cross-sectional study from March 2007 to February 2008. Records of all patients admitted and hospitalized to a referral teaching hospital during the 2 year period were collected. Information including gender, age, cause of toxicity, amount of AIP consumed, route of exposure, time between exposure and hospital admission, signs and symptoms of toxicity at admission, therapeutic intervention, laboratory tests, and outcome were extracted from the patients' notes. Patients who died and survived were compared using appropriate statistical tests. Results: During the two-year period, 102 patients, 46 men and 56 women with mean (±SD) age 28.5 ± 12.4 year were admitted with ALP poisoning. The most common signs and symptoms at admission were nausea (79.4%), vomiting (76.5%), and abdominal pain (31.4%). 41.1% of the patients showed metabolic acidosis. Suicidal intention was the most common cause of poisoning (97%) leading to 19 (18.6%) deaths. Compared with the patients who survived, those who died had taken higher amount of ALP tablet (2.2 ± 2.4 vs. 1.4 ± 1.0, P < 0.05), had poor liver function test (P < 0.0001) and severe metabolic acidosis (pH: 7.17 ± 0.19 vs. 7.33 ± 0.08, P < 0.0001). Conclusion: ALP poisoning is a common toxicity in Iran causing high morality. This is a serious health problem in agricultural region where ALP is readily available. Withdrawal of ALP tablet from the market and introduction of safer products as rodenticides and insecticides is recommended.

Esophagobronchial fistula - a rare complication of aluminum phosphide poisoning

Aluminum phosphide is a systemic lethal poison. Fistulous communication between esophagus and airway tract [esophagorespiratory fistula] has rarely been reported in the survivors of aluminum phosphide poisoning. We report a case of benign esophagobronchial fistula secondary to aluminum phosphide poisoning, which to best of our knowledge has not been reported in the medical literature

A simplified acute physiology score in the prediction of acute aluminum phosphide poisoning outcome.

Background : Aluminum phosphide (AlP) is used as a fumigant. It produces phosphine gas, which is a mitochondrial poison. Unfortunately, there is no known antidote for AlP intoxication, and also, there are few data about its prognostic factors. AIMS: The aim of this study was to determine the impact of the Simplified Acute Physiology Score II (SAPS II ) in the prediction of outcome in patients with acute AlP poisoning requiring admission to the Intensive Care Unit (ICU). Materials and Methods : This was a prospective study in patients with acute AlP poisoning, admitted to the ICU over a period of 12 months. The demographic data were collected and SAPSII was recorded. The patients were divided into survival and non-survival groups due to outcome. Statistical Analysis : The data were expressed as mean ± SD for continuous or discrete variables and as frequency and percentage for categorical variables. The results were compared between the two groups using SPSS software. Results : During the study period, 39 subjects were admitted to the ICU with acute AlP poisoning. All 39 patients required endotracheal intubation and mechanical ventilation in addition to gastric decontamination with sodium bicarbonate, permanganate potassium, and activated charcoal, therapy with MgSO 4 and calcium gluconate and adequate hydration. Among these patients, 26 (66.7%) died. SAPSII was significantly higher in the non-survival group than in the survival group (11.88 ± 4.22 vs. 4.31 ± 2.06, respectively) (P < 0.001). Conclusion : SAPSII calculated within the first 24 hours was recognized as a good prognostic indicator among patients with acute AlP poisoning requiring ICU admission.

Aluminium phosphide poisoning: management and prevention.

Death by Aluminium phosphide (AIP) and organo-phosphide poisoning are the commonest forms of poisoning in India. Aluminium phosphide is used as rodenticide and pesticide in grain storage facilities. It produces phosphine gas, which results in mitochondrial poisoning. There is no known antidote for AIP poisoning. The effects of AIP poisoning, mediated by phosphine and mechanism of action have not been established.The information related to this poisoning is available in the literature and substantiated by practical experience. Liberated phosphine cannot be detoxified but Magnesium sulphate has been reported to be effective. Another remedy can be rapid absorption by coconut oil which might be helpful. Treatment consists of gastric lavage with potassium permanganate solution, oral administration of charcoal and sorbitol suspension, intravenous administration of sodium bicarbonate, magnesium sulphate and calcium gluconate, and oral administration of sodium bicarbonate and coconut oil. Use of coconut oil for treatment in this poisoning is suggested, although clinical trials and scientific approval is still awaited. Every suggestion, news regarding new modality of treatment for this poisoning needs to be shared in the interest of saving precious human lives. It is with this aim the present paper is written.

Trends of poisoning in Faridkot region of Punjab- A retrospective study of one year.

Since immemorial times, poisonous substances have been reported to be adversely affecting human life, both in terms of morbidity and mortality. Evolution in fields like agriculture, industry etc has made wide and easy availability of various poisonous substances. The present study is a retrospective study of one year which is related to poisoning cases that were admitted in the emergency department of G.G. S. Medical College, Faridkot from 1st January 1996 to 31st December 1996. The analysis of the data revealed that out of 78 patients admitted in the hospital, 31 patients died. The maxi-mum incidence was seen in the age group of 21-30 years with males outnumbering the females. The commonest poison used was organophosphorus group of compounds.

Prognostic factors of acute aluminum phosphide poisoning.

Background : In Morocco, acute aluminum phosphide poisoning (AAlPP) is a serious health care problem. It results in high mortality rate despite the progress of critical care. Aims : The present paper aims at determining the characteristics of AAlPP and evaluating its severity factors. Setting and design: We studied consecutive patients of AAlPP admitted to the medical intensive care unit (ICU) (Ibn Sina Hospital, Rabat, Morocco) between January 1992 and December 2007. Materials and Methods : Around 50 parameters were collected, and a comparison was made between survivor and nonsurvivor groups. Statistical Analysis : Data were analyzed using Fisher exact test, Mann-Whitney U test and Cox regression model. Results : Forty-nine patients were enrolled: 31 females and 18 males; their average age was 26± 11 years. The ingested dose of aluminum phosphide was 1.2± 0.7 g. Self-poisoning was observed in 47 cases, and the median of delay before admission to the hospital was 5.3 hours (range, 2.9-10 hours). Glasgow coma scale was 14± 2. Shock was reported in 42.6% of the patients. pH was 7.1± 0.4, and bicarbonate concentration was 16.3± 8.8 mmol/L. Electrocardiogram abnormalities were noted in 28 (57%) cases. The mortality rate was 49% (24 cases). The prognostic factors were APACHE II (P= 0.01), low Glasgow coma scale (P= 0.022), shock (P= 0.0003), electrocardiogram abnormalities (P= 0.015), acute renal failure (P= 0.026), low prothrombin rate (P= 0.020), hyperleukocytosis (P= 0.004), use of vasoactive drugs (P< 0.001), use of mechanical ventilation (P= 0.003). Multivariate analysis by logistic regression revealed that mortality in AAlPP correlated with shock (RR = 3.82; 95% CI= 1.12-13.38; P= 0.036) and altered consciousness (RR= 3.26; 95% CI= 1.18-8.99; P= 0.022). Conclusion : AAlPP is responsible for a high mortality, which is primarily due to hemodynamic failure.

Corrosive-like strictures caused by ingestion of aluminium phosphide.

Aluminium phosphide ingestion is a major cause of poisoning-related mortality in tropical countries. Local oesophageal complications due to aluminium phosphide have been reported to occur rarely. We describe 3 patients who survived the intake of aluminium phosphide tablets and developed oesophageal strictures.

Aluminium phosphide-induced esophageal stricture.

We report a 24-year-old woman and a 58-year-old man who developed short-segment esophageal strictures in the upper and mid esophagus two weeks after ingestion of aluminium phosphide tablets. They responded well to endoscopic dilatation.

Current trend of poisoning--a hospital profile.

A one-year study was carried out among the poisoning cases admitted in the emergency wing of Guru Nanak Dev Hospital attached to Government Medical College, Amritsar during the period from 10-5-1997 to 9-5-1998. Out of 10,664 admitt emergencies, 3.19% were poisoning cases. Male to female ratio was nearly 3:1. Majority (45.59%) of the victims were in the age group of 21-30 years, 69.12% were married and 51.47% belonged to urban area. At the time of admission 61.47% cases were conscious, 26.17% were partially conscious and 12.36% were unconscious. Majority (76.47%) of the victims committed suicide, in 20.88% cases manner of death was accident and homicide was reported in 1.76% cases. Commones poison was aluminium phosphide (38.23%) followed by organophosphorus compounds (17.64%). The study observed increasing trend of suicide by aluminium phosphide and organophosphorus compounds, whereas other poisons for committing suicide were less commonly used.

Benign esophageal stricture following aluminium phosphide poisoning.

Aluminium phosphide is often implicated in accidental and suicidal poisoning in India. Ingestion of even half a fresh tablet invariably results in death, whereas exposed tablets are usually considered harmless. We report two cases of short-segment esophageal strictures that occurred following ingestion of exposed tablet of aluminium phosphide. Both cases could be successfully managed by endoscopic dilatation.

Histopathological changes in cases of aluminium phosphide poisoning.

Of a total of 205 poisoning deaths in our hospital in 2003, 83 cases were due to Aluminium phosphide poisoning and were further analyzed. Most vulnerable age group was 21-40 years and M:F ratio was 2:1. On naked eye examination, almost all the vital organs were found to be congested. On microscopic study, the liver showed central venous congestion, degeneration, haemorrhage, sinusoidal dilation, bile stasis, centrilobular necrosis, Kupffer cell hyperplasia, infiltration by mononuclear cells and fatty change. Microscopy of the lungs revealed alveolar thickening, oedema, dilated capillaries, collapsed alveoli and haemorrhage. In the kidney, changes were degeneration, infiltration, tubular dilation and cloudy swelling. Changes in the brain included congestion and coagulative necrosis and in the stomach, congestion and haemorrhage. Easy availability of this cheap and highly toxic substance was responsible for the sudden spurt of poisoning with aluminium phosphide.

Successful management of hypokalaemia related conduction disturbances in acute aluminium phosphide poisoning.

A case of acute aluminium phosphide poisoning is described, who presented in shock secondary to electrolyte related cardiac rhythm disturbance and the judicious correction of the same could save his life without any consequence.