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      Clinical Profile and Treatment Outcome of Aluminum Phosphide Poisoning in Felege Hiwot Referral Hospital, Northwest Ethiopia: A Retrospective Study

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          Abstract

          Background

          Aluminum phosphide (AlP) is an effective fumigant and rodenticide which is a commonly used agent for self-poisoning in parts of Ethiopia. AlP poisoning results in serious manifestations involving many vital organs and it has high mortality. Despite its high incidence and mortality, studies on AlP poisoning in Ethiopia are lacking. Our objective was to study the clinical profile and treatment outcome of AlP poisoning in Felege Hiwot Referral Hospital (FHRH), a major referral hospital in Ethiopia.

          Methods

          It is a retrospective study conducted over all consecutive AlP poisoning cases who presented to the emergency department (ED) of the hospital from March 2018 to August 2020. A questionnaire was used to collect data from patient medical records. All data were analyzed using SPSS 25.

          Results

          A total of 125 patients were studied. Females were 57.6% and males were 42.4%. Age of patients ranged from 12 to 60 with mean age 28.5 years. The average number of AlP tablets taken was 1.2 (3.6 gm) and the average time of arrival to hospital after AlP ingestion was 4.8 hours. Nausea and vomiting were the commonest presenting features seen in 74.4% of the cases followed by hypotension which was seen in half of the cases. A wide range of laboratory findings and complications were also observed. Cases of AlP poisoning with hypotension were managed in the ICU with dopamine infusion, magnesium sulphate, hydrocortisone, and calcium gluconate in addition to gastric lavage and fluid administration. Those cases without hypotension were managed with gastric lavage and maintenance fluid only. Overall mortality from AlP poisoning was 31.2%.

          Conclusion

          With a treatment protocol used in FHRH, mortality from AlP poisoning was 31.2%. Using this protocol in resource limited settings might give opportunities to reduce mortality from AlP poisoning.

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          Most cited references53

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          Aluminium and zinc phosphide poisoning.

          Aluminium and zinc phosphides are highly effective insecticides and rodenticides and are used widely to protect grain in stores and during its transportation. Acute poisoning with these compounds may be direct due to ingestion of the salts or indirect from accidental inhalation of phosphine generated during their approved use. Both forms of poisoning are mediated by phosphine which has been thought to be toxic because it inhibits cytochrome c oxidase. While phosphine does inhibit cytochrome C oxidase in vitro, the inhibition is much less in vivo. It has been shown recently in nematodes that phosphine rapidly perturbs mitochondrial morphology, inhibits oxidative respiration by 70%, and causes a severe drop in mitochondrial membrane potential. This failure of cellular respiration is likely to be due to a mechanism other than inhibition of cytochrome C oxidase. In addition, phosphine and hydrogen peroxide can interact to form the highly reactive hydroxyl radical and phosphine also inhibits catalase and peroxidase; both mechanisms result in hydroxyl radical associated damage such as lipid peroxidation. The major lethal consequence of phosphide ingestion, profound circulatory collapse, is secondary to factors including direct effects on cardiac myocytes, fluid loss, and adrenal gland damage. In addition, phosphine and phosphides have corrosive actions. There is usually only a short interval between ingestion of phosphides and the appearance of systemic toxicity. Phosphine-induced impairment of myocardial contractility and fluid loss leads to circulatory failure, and critically, pulmonary edema supervenes, though whether this is a cardiogenic or non-cardiogenic is not always clear. Metabolic acidosis, or mixed metabolic acidosis and respiratory alkalosis, and acute renal failure are frequent. Other features include disseminated intravascular coagulation, hepatic necrosis and renal failure. There is conflicting evidence on the occurrence of magnesium disturbances. There is no antidote to phosphine or metal phosphide poisoning and many patients die despite intensive care. Supportive measures are all that can be offered and should be implemented as required.
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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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              An update on toxicology of aluminum phosphide

              Aluminum phosphide (AlP) is a cheap solid fumigant and a highly toxic pesticide which is commonly used for grain preservation. In Iran it is known as the “rice tablet”. AlP has currently aroused interest with increasing number of cases in the past four decades due to increased use in agricultural and non-agricultural purposesand also its easy availability in the markets has increased its misuse to commit suicide. Upon contact with moisture in the environment, AlP undergoes a chemical reaction yielding phosphine gas, which is the active pesticidal component. Phosphine inhibits cellular oxygen utilization and can induce lipid peroxidation. It was reported that AlP has a mortality rate more than 50% of intoxication cases. Poisoning with AlP has usually occurred in attempts to suicide. It is a more common case in adults rather than teen agers. In some eastern countries it is a very common agent with rapid action for suicide. Up to date, there is no effective antidote or treatment for its intoxication. Also, some experimental results suggest that magnesium sulfate, N-acetyl cysteine (NAC), glutathione, vitamin C and E, beta-carotenes, coconut oil and melatonin may play an important role in reducing the oxidative outcomes of phosphine. This article reviews the experimental and clinical features of AlP intoxication and tries to suggest a way to encounter its poisoning.
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                Author and article information

                Journal
                Open Access Emerg Med
                Open Access Emerg Med
                oaem
                oaem
                Open Access Emergency Medicine : OAEM
                Dove
                1179-1500
                16 June 2021
                2021
                : 13
                : 239-248
                Affiliations
                [1 ]Private Practice , Addis Ababa, Ethiopia
                [2 ]Felege Hiwot Referral Hospital , Bahir Dar, Ethiopia
                [3 ]Amhara Public health Institute , Bahir Dar, Ethiopia
                Author notes
                Correspondence: Dereje Endeshaw Bogale Email dereje1073@yahoo.com
                Article
                313181
                10.2147/OAEM.S313181
                8216064
                34163261
                aaaf0a60-52f4-4af0-ac30-74c331c12eff
                © 2021 Bogale et al.

                This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. For permission for commercial use of this work, please see paragraphs 4.2 and 5 of our Terms ( https://www.dovepress.com/terms.php).

                History
                : 28 March 2021
                : 25 May 2021
                Page count
                Figures: 0, Tables: 0, References: 53, Pages: 10
                Categories
                Original Research

                aluminum phosphide,poisoning,magnesium sulphate,protocol,hypotension

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