A Peculiar Case of Phosphine Toxicity

Abstract

SESSION TITLE: Occupational and Environmental Lung Diseases SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Phosphine gas is a colorless, flammable and highly toxic gas. Despite aggressive measures, phosphine gas toxicity has a very high mortality rate due to cardiopulmonary failure. We present an unusual case of aluminum phosphide toxicity who was the sole survivor in her family. CASE PRESENTATION: A 45-year-old woman with no medical problems presented to emergency room (ER) with acute onset of nausea, vomiting, diarrhea and dyspnea. Four children also presented with similar symptoms. Family was discharged with diagnosis of acute gastroenteritis. Because of worsening respiratory distress, family again presented to ER. Diagnosis of phosphine toxicity (PT) was made based on history. Husband sprayed Aluminum Phosphide (AP) rodenticide underneath the trailer about 2 weeks ago. Then he attempted to wash out the substance with water, which resulted in creation of phosphine gas. All four children passed away in the ER from severe cardiogenic shock and acute hypoxic respiratory failure from pulmonary edema. She was intubated due to worsening multi-organ failure. Bedside ultrasound showed significantly reduced ejection fraction. Patient was started on vasopressors and inotropes. Patient was taken to cath lab for emergent Impella ventricular support device. Arrangements were made to transfer patient to a tertiary care center for extracorporeal membrane oxygenation (ECMO). Patient was supported with ECMO until patient stabilized. She was discharged home in stable condition without any organ injury. She was the sole survivor of the family due to aggressive management of cardiorespiratory failure. DISCUSSION: Metallic phosphides (zinc and aluminum phosphide) are used worldwide as rodenticides and pesticides. They are banned in US so toxicity is rare here. Acute respiratory failure can occur due to pulmonary edema. Mortality often occurs from severe cardiac toxicity which leads to cardiac arrhythmias or refractory shock and cardiac failure. The cornerstone of treatment is supportive measures, which include oxygen and possible intubation for respiratory support; IVF, vasopressors for hypotension and shock. However, aggressive treatment by emergent Impella and ECMO support was necessary. CONCLUSIONS: PT is a fairly rare occurrence but remains to be a public health threat. Its high mortality rate and when the gas dissipates into the air can affect a large population. Supportive measures are the mainstay of treatment. More research needs to be conducted in order to expand knowledge of the treatment. It is strongly recommended to transfer these patients to ECMO supporting centers as they deteriorate rapidly and are unresponsive to ACLS protocol when the cardiovascular system collapses. Reference #1: Gupta S, Ahlawat SK. Aluminum phosphide poisoning--a review. J Toxicol Clin Toxicol 1995; 33:19. DISCLOSURE: The following authors have nothing to disclose: Totini Chatterjee, Omar Salh, Thien Vo, Manish Patel No Product/Research Disclosure Information