Acute Aluminum Phosphide Poisoning Research Articles

Prognostic value of PGI score compared to poison severity score (PSS) and simplified acute physiology score (SAPS) II as predictors of mortality and other adverse outcomes in acute poisoning with aluminum phosphide

Aluminum phosphide (AlP) poisoning is a life-threatening emergency prevalent in the Middle East region including Egypt. Early prediction of prognosis is critical for initiating the utmost intensive interventions. Though many scoring systems were studied for predicting the prognosis of AlP poisoning, these scores received wide criticism. Complexity and reliability were the main concerns. Therefore, this retrospective cross-sectional study aimed to evaluate the performance of the recently introduced PGI score as a predictor of case fatality, the need for mechanical ventilation and vasopressor therapy in acute AlP poisoning. Moreover, it compares the performance of PGI with the known poison severity score (PSS), and the simplified acute physiology score (SAPS) II. Among 144 exposed patients, we reported a mortality rate of 61.1%. Non-survivors exhibited significantly higher PGI, PSS, and SAPS II than survivors. Though the PGI, PSS, and SAPS II proved their significance as predictors of mortality and, the need for MV and vasopressors, the PGI score showed a significantly higher area under the curve (AUC) as a predictor of MV (AUC = 0.848) compared to PSS (AUC = 0.731) and SAPS II (AUC = 0.749). Additively, PGI of 2 or more was a significant predictor of mortality (AUC = 0.831, sensitivity = 65.9%, and specificity = 89.3 %) and MV (p < 0.001), while PGI of 1 or more was another predictor of vasopressor need (AUC = 0.881, sensitivity = 89.0% and specificity = 79.4%). Given the PGI score's high AUCs across all outcomes, coupled with its balanced sensitivity and specificity, the PGI score could be a simple, and robust tool replacing the PSS and SAPS II for predicting mortality, clinical decision-making including the need for MV and vasopressor therapy in acute AlP exposure. Adopting the PGI score seems substantially useful in managing acute AlP poisoning, notably in resource-restricted countries.

Effective Management of Acute Aluminum Phosphide Poisoning in Pregnancy: A Case Study of Dual Therapy Efficacy and Collaborative Care

Effective Management of Acute Aluminum Phosphide Poisoning in Pregnancy: A Case Study of Dual Therapy Efficacy and Collaborative Care

The possible therapeutic role of intravenous lipid emulsion in acute aluminium phosphide poisoning: a randomized controlled clinical trial.

Aluminum phosphide (ALP) is a highly toxic rodenticide and the mortality rates caused by it have been demonstrated up to 70-100% in various studies. Unfortunately, there is no specific antidote to manage its toxic effects. This study aimed to assess the biochemical and clinical efficacy and safety of intravenous lipid emulsion as an adjuvant therapy in acute aluminum phosphide poisoning. Sixty-four cases with acute ALP poisoning were stratified according to severity by the Poison Severity Score into severe and moderate groups (32 patients each). Patients were then randomly allocated into either receiving intravenous lipid emulsion in addition to the conventional treatment or receiving the conventional treatment only by using block randomization. Treatment by ILE resulted in a significant improvement in the survival time, the mean arterial blood pressure, arterial blood gases, and a significant reduction in serum lactate levels. The need for intubation and mechanical ventilation was insignificantly lower in the intervention groups compared to control groups. However, the reduction in mortality rate in the patients of intervention groups compared with control groups was found to be non-significant. Intravenous lipid emulsion use in acute ALP poisoning significantly prolonged the survival time, improved the metabolic acidosis, decreased the serum lactate levels and increased the mean arterial blood pressure and hospital stay in the intervention groups. And insignificantly decreased the mortality rate, need of intubation and mechanical ventilation, and the total dose of vasopressors.

The adjuvant effect of oil-based gastric lavage on the outcome of acute Aluminum phosphide poisoning: a systematic review and meta-analysis.

Aluminum Phosphide (AlP) poisoning constituted the most common cause of poisoning death in some low- and middle-income countries (LMICs). This study aimed to evaluate the safety and efficacy of oil-based gastric lavage (GL) compared with standard therapy for the treatment of AlP poisoning. Materials and methods. This systematic review complied with "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) Protocols. A comprehensive search was carried out, identifying randomized controlled trials (RCTs), including anyone presenting within 6h of exposure to AlP, and the administration of GL with oils, including liquid paraffin or coconut oil. We identified 7 RCTs. The evidence from 4 RCTs indicates that GL with paraffin oil is an effective treatment for acute AlP poisoning, decreasing the mortality rate (RR=0.62; 95% CI=0.48 to 0.81; participants=226; I 2=10%; low-quality evidence). We estimate the Number Needed to Treat of 4. Likewise, this intervention reduces the need for intubation and mechanical ventilation (RR=0.62; 95% CI=0.40 to 0.79; I2=0%; low-quality evidence). Regarding GL with coconut oil, the evidence from 4 RCTs, indicates a slight reduction in mortality (RR=0.82; 95% CI=0.69 to 0.98; participants=112; I2=0%; very low-quality evidence). Limited evidence suggests that GL with paraffin oil is effective in reducing the mortality rate. Likewise, limited evidence showed in favor of paraffin oil concerning the need for intubation and mechanical ventilation. Very limited evidence suggests that GL with coconut oil could reduce mortality. Both interventions would have a benign safety profile.

Shock and modified shock indices in predicting poisoning severity and outcomes in acute aluminum phosphide poisoned patients.

Severe refractory hypotension and cardiogenic shock are the main contributors to death in acute aluminum phosphide (ALP) poisoning. Shock index (SI) and modified shock index (MSI) are easily obtained parameters that reflect shock at an early stage. This study aimed to evaluate the role of SI and MSI in the prediction of the severity and outcomes of acute ALP poisoned patients. This cross sectional study was conducted on patients admitted to Tanta University Poison Control Centre with acute ALP poisoning from April 2022 to March 2023. Socio-demographics and toxicological data were taken, findings of clinical examination and laboratory investigations were recoded, SI was calculated by dividing heart rate over systolic blood pressure, and MSI was obtained by dividing heart rate over mean arterial pressure. Poisoning severity was assessed using poisoning severity score (PSS). Patients were divided into groups according to intensive care unit (ICU) admission and mortality. The study enrolled 94 patients. The median values of SI and MSI were significantly higher in ICU-admitted patients and non-survivors rather than their comparable groups. Significant positive correlations were observed between each of SI and MSI and PSS. At cut-off >1.14, SI conveyed fair performance to predict ICU admission and mortality (AUC=0.710 and 0.739, respectively). Similarly, MSI had fair performance to predict ICU admission (AUC=0.731) and mortality (AUC=0.744) at cut-off >1.47 and >1.5, respectively. Both SI and MSI could be considered simple bedside adjuncts to predict ICU admission and mortality in acute ALP poisoning.

Insulin-euglycemia therapy in acute aluminum phosphide poisoning: a randomized clinical trial

Introduction: Aluminum phosphide is a pesticide that is used in developing countries. Aluminum phosphide poisoning has a high mortality rate and there is no known antidote. This study aimed to evaluate the safety and efficacy of insulin-euglycemia therapy in the management of patients with acute aluminum phosphide poisoning. Methods: This trial was prospectively registered in the Pan African Clinical Trials Registry (PACTR202008534546951). A total of 108 patients were randomly allocated to two groups. The intervention group received insulin-euglycemia therapy in addition to standard treatment (norepinephrine and supportive care); the control group received standard treatment plus placebo. The main outcome measures were survival, blood pressure, and laboratory investigations. Results: The two groups had similar baseline parameters. Insulin-euglycemia therapy was associated with a significant reduction in mortality compared with that in the control group (64.8 percent and 96.3 percent, respectively; P value <0.001). Patients randomized to insulin-euglycemia also required lower doses of vasopressors (median was 7 mg versus 26 mg in control group; P value 0.006) and fewer patients needed intubation (61.1 percent versus 81.5 percent in the control group; P value 0.019). Insulin-euglycemia therapy significantly improved blood pressure (systolic, diastolic, and mean arterial pressure) (median at 6h post-admission was 80 mmHg, 55 mmHg and 65 mmHg compared with 20 mmHg, 10 mmHg and 13 mmHg in the control group respectively; P value <0.001) and bicarbonate and lactate concentrations. Conclusion: Insulin-euglycemia therapy appears to be a safe and effective treatment option for patients with aluminum phosphide poisoning. Vasopressor only therapy was associated with very poor outcomes in acute aluminum phosphide poisoning.

Efficacy of intravenous N acetylcysteine as an adjuvant therapy in the treatment of acute aluminum phosphide Poisoning: a systematic review and meta-analysis

BackgroundAluminum phosphide toxicity is a serious problem in many countries. Unfortunately, there is no specific antidote. N-acetylcysteine has been used in some studies as adjuvant therapy depending on to its antioxidant properties. We hypothesized that IV N-acetylcysteine is effective in reducing mortality rate compared to supportive treatment alone.MethodsWe searched in PubMed, Scopus, Web of Science, and Cochrane Library databases. We only included randomized controlled trials that assessed the efficacy of IV N-acetylcysteine and supportive treatment versus supportive treatment alone in acute aluminum phosphide poisoning. Four investigators independently screened the studies’ results and designed the data extraction sheet. The primary and secondary outcomes were mortality and the need for mechanical ventilation rates. Random effects estimators with weights were used to result in the pooled risk ratios.ResultsWe included four randomized controlled trials with 177 patients. 91 patients were distributed in N-acetylcysteine group and 86 patients in the control group. Mortality rates in N-acetylcysteine group and in the control group were 43.95% 66.27% respectively. There was a statistically significant reduction in mortality rate after leave out test (pooled risk ratio, 0.5; 95% confidence interval, 0.32–0.77). Regarding the need for mechanical ventilation, it was measured only in three RCTs. It was assessed in 67 patients in N-acetylcysteine group and 60 patients in the control group. 24 patients were ventilated in N-acetylcysteine group (35.8%) and 29 patients in the control group (48.3%). But it was statistically nonsignificant (pooled risk ratio, 0.71; 95% confidence interval, 0.48–1.04).ConclusionOur meta-analysis revealed that IV N-acetylcysteine may be effective in reducing mortality of severe aluminum phosphide poisoning cases.Trial registrationRegistration number in Prospero CRD42022375344 on 25 NOVEMBER 2022, retrospectively registered.

Physicians' perspectives on different therapeutic approaches for aluminum phosphide poisoning and their relevant outcomes.

Aluminum phosphide is a highly toxic pesticide that results in high mortality. To date, there is neither a definitive antidote nor a unified protocol for managing acute aluminum phosphide poisoning. This cross-sectional questionnaire-based study aims to explore different management approaches and rely on the expertise of Egyptian medical professionals to enhance the prognosis for acute aluminum phosphide poisoning. A self-administered questionnaire was formulated and electronically distributed according to published literature and experience of senior physicians. Responses were received from 151 physicians from 10 governorates. Management modalities were variable among respondents. Noradrenaline was used by 90.7% of respondents with no fixed-dose regimen. In all, 84.1% of participants utilized oil in gastrointestinal decontamination; paraffin oil was the most used solution. Overall, 92.1, 61.6, 46.4, and 34.4% of participants used sodium bicarbonate, proton pump inhibitors, IV magnesium sulfate, and antioxidants, respectively. Regarding the frequency of acute aluminum phosphide poisoning, 47% of participants managed these cases daily or a few times a week. Participants' responses denoted a poor prognosis of acute aluminum phosphide poisoning, and high percentages attributed the prognosis to exposure factors rather than treatment modalities. Statistical analysis revealed that using oil in gastrointestinal decontamination improved the outcome by 4.62-fold. Clinical toxicologists were more likely to rescue≥30% of the cases about 3-fold (2.97) than other specialties. Clinical toxicologists used oil in gastrointestinal decontamination, magnesium sulfate, and antioxidant therapy and calculated base deficit before administration of sodium bicarbonate by 7.70-, 5.30-, 3.26-, and 2.08-fold than other specialties.

N-acetylcysteine Use in Treatment of Acute Aluminium Phosphide Poisoning: Systematic Review and Meta-Analysis

N-acetylcysteine Use in Treatment of Acute Aluminium Phosphide Poisoning: Systematic Review and Meta-Analysis

Cardioprotective role of the coenzyme Q10 and coconut oil in acute aluminum phosphide poisoning: a randomized controlled clinical trial.

Aluminum phosphide (ALP)-induced cardiotoxicity is a major cause of high mortality rates. As there is no specific antidote, restoring cardiac hemodynamics is the cornerstone for saving patients. Based on oxidative stress theory in acute ALP poisoning, we examined the cardioprotective role of coconut oil and Coenzyme Q10 (COQ10) in ALP poisoning, focusing on their antioxidant capacity. This study was a randomized, controlled, single-blind, phase II clinical trial conducted at Tanta Poison Control Center over 1 year. Eighty-four ALP poisoned patients received supportive treatment and were randomly allocated to three equal groups. Gastric lavage was performed using sodium bicarbonate 8.4% with saline in group I. Alternatively, group II received 50ml coconut oil, and group III initially received 600mg CoQ10 dissolved in 50ml coconut oil; and repeated 12hours later. In addition to patient characteristics, clinical, laboratory, electrocardiography (ECG), and total antioxidant capacity (TAC) data were recorded and repeated 12hours later. Patient outcomes were evaluated. There was no significant difference among groups considering patient characteristics, initial cardiotoxicity severity, vital, laboratory data, ECG changes, and TAC. However, 12hours post-admissions, group III was significantly improved in all clinical, laboratory, and ECG parameters than comparable groups. Significant correlations were observed between elevated TAC in groups II and III with hemodynamic, serum troponin, and ECG variables. Accordingly, the need for intubation, mechanical ventilation, and the total vasopressor dose was significantly decreased in group III compared with other groups. Therefore, coconut oil and COQ10 are promising cardioprotective adjuvant therapy ameliorating the ALP-induced cardiotoxicity.

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.

Prognostic significance of poison-related factors and consumption patterns in acute aluminum phosphide poisoning.

The prognosis of acute aluminum phosphide poisoning is usually based on toxidrome features, with little focus on poison-related factors. We aimed to study the prognostic significance of poison-related factors, consumption patterns, and time delays to treatment. We performed a prospective cohort study in an academic hospital in North India in patients aged ≥ 13 with aluminum phosphide poisoning from July 2019 to December 2020. During data collection, a particular emphasis was made on the poison formulation, the ingested dose, the reconstitution of poison, vomiting, and time intervals to initiate various treatments. The primary outcome was inhospital mortality. Fifty-eight patients were enrolled (median age, 32 years; 37 males). The mean dose of the ingested poison was 6.56 (±5.42) g. The predominant formulation of poison was pellet (n = 41), followed by powder (n = 16). Twenty patients performed reconstitution of poison before consumption, and 13 stirred the poison while reconstituting. All patients but three developed vomiting after consumption. Inhospital mortality (n = 23, 39%) was significantly high with a higher ingested dose (P < 0.001), nonstirred reconstitution before consumption (P = 0.042), fewer vomiting episodes (P = 0.010), a delay in detection of the victim by someone (P = 0.001), and delayed initiation of intravenous fluids (P = 0.043). The secondary outcomes (shock and requirement of vasopressor or ventilation) remained unaffected by the stirring in the reconstitution group. Poison-related factors and time intervals determine early risk stratification at admission in aluminum phosphide poisoning.

Fresh-Packed RBC Infusion Diminishes Acute AlP Poisoned-Patients' Mortality Rate: A Clinical Trial

Accidental or intentional poisoning with Aluminum phosphide (AlP) is associated with severe complications such as metabolic acidosis, cardiac failure, and death. Previous animal experiments demonstrated that fresh-packed RBC is protective in an experimental model of AlP poisoning. The aim of this study was to assess the effect of fresh-packed RBC on survival in patients admitted to a referral hospital due to AlP poisoning in a randomized clinical trial. Eighty-two patients were admitted to Clinical Toxicology Unit at Baharloo Hospital due to acute AlP poisoning after approval by the Iranian Registry of Clinical Trials (registration reference: IRCT20180428039443N1). All patients received standard treatment, and forty-one of them received fresh-packed RBC. There was no significant difference between groups in the underlying characteristics, including vital signs and laboratory investigations. But interestingly, the mortality rate was meaningfully decreased (difference: 31.7%, 95% CI: 0.10-0.52) in patients receiving fresh-packed RBC (10 deaths/31 survived; 24.4% mortality) in comparison to standard treatment patients (23 deaths/18 survived; 56.1% mortality). Furthermore, fresh-packed RBC substantially improved the GCS, systolic/diastolic blood pressure, ST changes, and pH 12- and- 24 hours after admission. This study showed that fresh-packed RBC infusion alongside standard supportive treatment leads to a decrease in mortality rate; also, it provided evidence for a protective role of fresh-packed RBC in the management of patients with acute AlP poisoning.

Prognostic significance of poison-related factors and consumption patterns in acute aluminum phosphide poisoning

OBJECTIVES: The prognosis of acute aluminum phosphide poisoning is usually based on toxidrome features, with little focus on poison-related factors. We aimed to study the prognostic significance of poison-related factors, consumption patterns, and time delays to treatment. METHODS: We performed a prospective cohort study in an academic hospital in North India in patients aged ≥ 13 with aluminum phosphide poisoning from July 2019 to December 2020. During data collection, a particular emphasis was made on the poison formulation, the ingested dose, the reconstitution of poison, vomiting, and time intervals to initiate various treatments. The primary outcome was inhospital mortality. RESULTS: Fifty-eight patients were enrolled (median age, 32 years; 37 males). The mean dose of the ingested poison was 6.56 (±5.42) g. The predominant formulation of poison was pellet (n = 41), followed by powder (n = 16). Twenty patients performed reconstitution of poison before consumption, and 13 stirred the poison while reconstituting. All patients but three developed vomiting after consumption. Inhospital mortality (n = 23, 39%) was significantly high with a higher ingested dose (P < 0.001), nonstirred reconstitution before consumption (P = 0.042), fewer vomiting episodes (P = 0.010), a delay in detection of the victim by someone (P = 0.001), and delayed initiation of intravenous fluids (P = 0.043). The secondary outcomes (shock and requirement of vasopressor or ventilation) remained unaffected by the stirring in the reconstitution group. CONCLUSIONS: Poison-related factors and time intervals determine early risk stratification at admission in aluminum phosphide poisoning.

Comparison between Gastric Lavage with Paraffin Oil versus Coconut Oil in Acute Aluminum Phosphide Poisoning: A Randomized Controlled Clinical Trial

Comparison between Gastric Lavage with Paraffin Oil versus Coconut Oil in Acute Aluminum Phosphide Poisoning: A Randomized Controlled Clinical Trial

PGI Score as a Predictor of Cardiotoxicity and Mortality in Patients with Acute Aluminum Phosphide Poisoning

PGI Score as a Predictor of Cardiotoxicity and Mortality in Patients with Acute Aluminum Phosphide Poisoning

Acute Aluminium Phosphide Poisoning in East Delta, Egypt: a Growing Public Health Problem Over the Last Five Years

Acute Aluminium Phosphide Poisoning in East Delta, Egypt: a Growing Public Health Problem Over the Last Five Years

Prognostic Significance of Acid Base Disturbances among Patients with Acute Aluminum Phosphide Poisoning

Prognostic Significance of Acid Base Disturbances among Patients with Acute Aluminum Phosphide Poisoning

Cardiovascular manifestations of acute aluminium phosphide poisoning and their impact on survival

Background: Aluminium phosphide (AlP) is a common suicidal poison with a high mortality rate due to its cardiovascular impact and lack of antidote. The aim of the study was to describe the electrocardiographic changes and other cardio-vascular manifestations in acute AlP poisoning and evaluate its impact on survival outcomes.Methods: A prospective cross-sectional study was conducted in a tertiary care hospital including patients who presented with acute AlP ingestion in any form. Patients’ vitals and ECG at the time of admission were taken and outcomes of survival were identified. A descriptive study of echocardiography was also done. The clinical parameters were correlated with the survival outcomes.Results: Fifty patients were included with 30 males and 20 females. The consumption of AlP in tablet form caused more hemodynamic compromise (hypotension and high anion gap metabolic acidosis) as compared to the powder form. ECG changes were seen in 42% of the cases, the most common finding was prolonged QTc interval (26%). The mortality was 30%. Hypotension, bradycardia, and QRS widening were found to be significant predictors of mortality (p&lt;0.05). Echocardiography was performed for 10 patients, of which, one had right ventricular dysfunction and two had left ventricular dysfunction.Conclusions: AlP tablets are more lethal and hemodynamically compromising than AlP powder. Hypotension, bradycardia, and QRS widening are significant predictors of mortality. Direct cardiotoxicity leads to ECG changes, of which, QTc prolongation is the most common.

PGI score: prospective validation and correlation with SOFA, SAPS-II, and APACHE-II scores for predicting outcomes in acute aluminum phosphide poisoning.

We recently derived a simplified 3-point PGI score (representing blood pH<7.25, Glasgow coma scale [GCS] score<13, and impaired systolic blood pressure [SBP]<90mm Hg), which accurately predicted in-hospital case fatality ratio (CFR) in acute aluminum phosphide poisoning. The present study aimed to validate the PGI score and compare it with Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score, Sequential Organ Failure Assessment score (SOFA), and Simplified Acute Physiology Score (SAPS) II scores. We performed a prospective cohort study in adult patients with aluminum phosphide ingestion admitted in PGIMER, Chandigarh (India), from April 2013 to August 2014. A univariant analysis detected the association of various baseline variables with CFR. Correlation of the PGI score with SOFA, SAPS-II, and APACHE-II scores was performed using Spearman's correlation (rs , range -1 to +1) and scatter plots. Seventy-six patients were enrolled (mean age, 28.3years; 41 males). CFR was 60.5%. PGI score variables-pH, GCS, and impaired SBP predicted CFR (P-value <0.001). Among patients with a total PGI score of 3 or 2, 100% died, compared with 50% in score 1 and 10.7% in score 0. Baseline PGI, SOFA, SAPS-II, and APACHE-II scores predicted CFR (P-value <0.001). There was a positive correlation between the PGI score and SOFA score (rs , 0.855), SAPS-II score (rs , 0.861), and APACHE-II score (rs , 0.883). The P-value for all rs values was <0.001. The PGI score is a validated toxidrome-specific and simplified risk-stratification tool. Validation in other populations is warranted to confirm its routine use.