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      Successfully managed aluminum phosphide poisoning: A case report

      case-report

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          Abstract

          Introduction

          and Importance: Aluminum phosphide (ALP) is a commonly available pesticide in agricultural countries like Nepal. Upon ingestion, this releases highly toxic phosphine gas in the gastrointestinal tract when it comes in contact with humidity. This leads to refractory shock, metabolic acidosis, cardiac arrhythmia, renal failure, and hepato-biliary impairment.

          Case presentation

          We present a successfully managed case of a 17-year-old girl who ingested 6 g (2 tablets) of ALP tablets with suicidal intent. Although the mortality has been reported as 70–100% with mere ingestion of 150–500 mg of ALP, this case survived even after developing severe metabolic acidosis, acute renal failure, refractory shock, and ventricular tachycardia.

          Clinical discussion

          ALP poisoning is most often lethal. However, there is an emerging evidence of successful use of various drugs such as magnesium sulfate, trimetazidine, and other interventions such as intra-aortic balloon pump and extra corporeal membrane oxygenation in case of ALP poisoning.

          Conclusion

          Owing to the unavailability of an effective antidote of ALP to date, we emphasize early initiation of supportive management, intensive monitoring, and potential role of membrane stabilizers like magnesium sulfate, and cardio-protective agents like trimetazidine, N-Acetyl cysteine, thiamine, vitamin C, and hydrocortisone in decreasing the likelihood of fatal outcome.

          Highlights

          • Aluminum phosphide poisoning poses a major risk of mortality as it has no specific antidote.

          • Early supportive management, critical monitoring, and timely intervention of shock and arrhythmia can save a life.

          • Magnesium sulfate, trimetazidine and N-Acetyl cysteine may add additional advantages in combating the fatal outcome.

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          Most cited references20

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          CARE 2013 Explanations and Elaborations: Reporting Guidelines for Case Reports.

          Well-written and transparent case reports (1) reveal early signals of potential benefits, harms, and information on the use of resources; (2) provide information for clinical research and clinical practice guidelines (CPGs), and (3) inform medical education. High-quality case reports are more likely when authors follow reporting guidelines. During 2011-2012 a group of clinicians, researchers, and journal editors developed recommendations for the accurate reporting of information in case reports that resulted in the CARE (CAse REport) Statement and Checklist. They were presented at the 2013 International Congress on Peer Review and Biomedical Publication, have been endorsed by multiple medical journals, and translated into nine languages. This explanation and elaboration document has the objective to increase the use and dissemination of the CARE Checklist in writing and publishing case reports. Each item from the CARE Checklist is explained and accompanied by published examples. The explanations and examples in this document are designed to support the writing of high-quality case reports by authors and their critical appraisal by editors, peer reviewers, and readers. This article and the 2013 CARE Statement and Checklist, available from the CARE website [www.care-statement.org] and the EQUATOR Network, [www.equator-network.org] are resources for improving the completeness and transparency of case reports.
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            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.
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              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.
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                Author and article information

                Contributors
                Journal
                Ann Med Surg (Lond)
                Ann Med Surg (Lond)
                Annals of Medicine and Surgery
                Elsevier
                2049-0801
                17 September 2021
                October 2021
                17 September 2021
                : 70
                : 102868
                Affiliations
                [a ]Shree Birendra Hospital, Chhauni, Kathmandu, Nepal
                [b ]Department of Medicine, Resident of Internal Medicine, Shree Birendra Hospital, Chhauni, Kathmandu, Nepal
                [c ]Department of Medicine, Faculty of Internal Medicine, Shree Birendra Hospital, Chhauni, Kathmandu, Nepal
                Author notes
                []Corresponding author. drsrikknepal@ 123456gmail.com
                Article
                S2049-0801(21)00818-9 102868
                10.1016/j.amsu.2021.102868
                8463823
                34603718
                064a132a-4902-41ac-b21f-00d75d78b0e7
                © 2021 The Authors

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                : 11 August 2021
                : 14 September 2021
                : 14 September 2021
                Categories
                Case Report

                aluminum phosphide,case report,poisoning,refractory shock,suicide

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