Yellow Phosphorous Research Articles

Profile and Outcome of Patients Presenting to the Emergency Department with Yellow Phosphorus Poisoning

ABSTRACT Background: Yellow phosphorus-containing rodenticide poisoning as a means of deliberate self-harm is being widely encountered in South India. Hence, a comprehensive study delineating its profile and patient outcome is required to implement measures to control the persistent threat. Materials and Methods: This is a single-center, retrospective observational study of all patients presenting to the emergency department with a history of consumption of yellow phosphorus rodenticide poisoning between 2014 and 2020. Institutional review board approval was obtained before commencement. Results: During the study period, 164 patients who presented with consumption of yellow phosphorous were included in the analysis. The mean age with standard deviation of patients was 27.5 (10.6) years, with a female preponderance (87/164: 53.1%). N-acetyl cysteine (NAC) was administered in 87.2% (143/164), and its administration within 48 h of poison consumption showed a significant correlation with good outcomes (72.3% vs. 50%; OR: 0.38; 95% CI: 0.18–0.80; P-value = 0.012). Altered sensorium, hypoxemia, transaminitis, hyperbilirubinemia, and hypoalbuminemia had significant correlations with bad outcomes. The in-hospital mortality rate was 9.7% (16/164), and 21.4% (35/164) of the patients left against medical advice. Conclusion: Yellow phosphorous poisoning is associated with significant mortality. NAC given within 48 h of patient presentation had a significant correlation with good outcomes.

Assessing the clinical efficacy of low-volume therapeutic plasma exchange in achieving recovery from acute liver failure induced by yellow phosphorous poisoning.

Acute liver failure (ALF) following yellow phosphorous (YP) ingestion is similar to acetaminophen-induced ALF and it has become a public concern in our region. This study assessed low volume therapeutic plasma exchange (LV-TPE) efficacy in improving the transplant free survival in YP poisoning. Adult patients with toxicology reports of YP and ALF requiring critical care were included in the study. LV-TPE was planned for three consecutive days and three more if required. Performed 1.3 to 1.5 plasma volume replacing with 0.9% normal saline, 5% human albumin solution, and fresh frozen plasma based on ASFA 2019 criteria. MELD score, laboratory parameters, LV-TPE details were captured. The study end point was clinical outcome of the patients. Among 36 patients, 19 underwent LV-TPE and 17 opted out of LV-TPE and they were included as a control arm. The MELD score was 32.64 ± 8.05 and 37.83 ± 9.37 in both groups. There were 13 survivors in LV-TPE group leading to a 68.42% reduction in mortality. The coagulation and biochemical parameters showed a significant percentage change after LV-TPE. Refractory shock, delay in initiating procedure and acidosis were independent predictors of mortality. A well-timed LV-TPE improves the survival of patients with ALF due to YP poisoning.

A cross-sectional study of the clinical profile of children admitted with yellow phosphorous poisoning in a tertiary care hospital

Background: Yellow phosphorous (YP) is a protoplasmic poison that is mainly used as a rodenticide. Aims and Objectives: The aim of the study is to describe the clinical profile of YP poisoning in children in a tertiary care hospital. Materials and Methods: This is a cross-sectional study done in a tertiary care hospital in Tamil Nadu. A convenience sample of all the cases admitted during the year 2022 was done. Demographic and clinical data were collected and analyzed. Results: The male: female ratio was 1.16:1 (n=13). The mean age of the children was 4.0769±1.373 years. About 84.61% of the children reported to the hospital within 6 h. On admission, fever (30.76%), vomiting (30.76%), abdominal pain (30.76%), bleeding (15.38%), and altered sensorium (15.38%) were the common symptoms. All the children ingested YP accidentally. Leukocytosis was observed in about 30.76%. The mean peak serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were 516.9231±685.976 IU/L and 161.9231±215.107 IU/L, respectively. There were no alterations in the Electrocardiographic tracings, levels of serum electrolytes, blood glucose, and serum creatinine in children with YP poisoning. Significant differences were observed between children who survived and children who died in the levels of mean peak AST, mean peak ALT, INR, and in the presence of encephalopathy and bleeding manifestations. Conclusion: YP is an uncommon but lethal poison in children. Creating awareness among parents about the dangers of YP and nationwide prohibition of the sale of YP will be an important step in eliminating deaths in children who are accidental victims.

Novel radiological technique to recognize acute liver failure caused by yellow phosphorous containing rodenticides.

Yellow phosphorous rodenticide (YPR) poisoning is the commonest cause for acute liver failure (ALF) in southern and western India. Due to medicolegal issues, history of YPR ingestion may not be available. As early recognition of YPR poisoning is important and there are no specific biochemical assays, other early predictors to identify this entity is necessary. We evaluated the diagnostic role of plain computed tomography (CT) in identifying YPR-induced ALF. All patients admitted to the liver unit with a diagnosis of ALF underwent a plain CT scan abdomen. Demographic details, clinical history, laboratory parameters, liver attenuation index (LAI) calculated on CT scan, treatment details, need for liver transplantation and clinical outcome were analyzed. Parameters for YPR-induced ALF (ALF-YPR) and other causes (ALF-OTH) were compared. Ability of LAI to distinguish ALF-YPR and ALF-OTH was analyzed using receiver operating characteristic (ROC) curve analysis. Twenty-four patients (15 female [62.5%]) were included in the study. Thirteen patients (54%) had YPR poisoning, while the rest formed the ALF-OTH group (11,46%). ALF-YPR patients had higher transaminase levels, lower peak serum bilirubin levels. ALF-YPR livers had significantly lower LAI as compared to ALF-OTH (- 30 vs. - 8, p = 0.001). On ROC curve analysis, an LAI greater than - 18 ruled out YPR as the cause for ALF with 91% sensitivity and 85% specificity. On regression analysis, LAI was the only independent factor predicting ALF-YPR (odds ratio - 0.86, [0.76, 0.96] p = 0.008). Our data shows that LAI on plain abdominal CT scan can be used to quickly recognize ALF-YPR in unclear cases so that necessary treatment protocol can be activated, or patient transfer arranged. Our analysis shows that an LAI greater than - 18 can reliably rule out YPR ingestion as the cause for ALF.

CLINICAL PROFILE OF PATIENTS WITH RODENTICIDE POISONING IN A TERTIARY CARE CENTER

Background: Poisoning is one of the leading cause for admission in emergency department and rodenticides are one of the major poisons used. It is highly toxic substance where morbidity and mortality are signicant. After Methods: obtaining informed consent 100 patients admitted with rodenticide poisoning in Department of General Medicine, Siddhartha medical college is enrolled into the study after fullling inclusion and exclusion criteria, data is collected and appropriate treatment is given. Out of 100 Results: patients included in the study, 55patients (55%) consumed zinc phosphide. 27patients(27%) consumed warfarin derivatives. 18patients(18%) consumed yellow phosphorous. Female preponderance(54%) was seen in this study. Poisoning is more common below 29years of age. Total of 77patients(77%) recovered without complications, most common symptom is vomiting and complication is acute hepatitis(23%). Conclusion: This study shows Yellow phosphorous has the worst outcome. Zinc phosphide is the most common poison consumed and low mortality is seen in zinc phosphide and warfarin compounds

Role of Therapeutic Plasmapheresis(PLEX) in Acute Liver Failure Due to Rodenticide Yellow Phosphorous(YP) Paste Poisoning: A Single Tertiary Centre Experience

Background: Rodenticide paste containing Yellow phosphorous(YP)poisoning is very common in South India,. The incidence of hepatotoxicity and acute liver failure(ALF) is around 40%. Although therapeutic plasmapheresis(PLEX)has been established as a grade 1 recommendation in ALF, there are few such studies in this context. Our objective: was to study the efficacy of PLEXs in ALF due to YP poisoning and to evaluate the predictive factors in determining its success. Methods: A total of 53 patients underwent plasmapheresis for ALF due to YP poisoning, over two years (December 2018-December 2020). Demographic data and biochemical parameters were recorded before and after. Overall total and liver transplant(LT)- free survival was analyzed. Results: Of all patients, (67%) completely recovered, while 6% worsened, and was transferred to transplant units,with some undergoing LT ,while 13% were discharged against medical advice, and the rest expired(14%). The study showed mean significant improvement in Total Leukocyte Count (Before and after plasmapheresis Total leucocyte count(TLC) Mean±Std were 4638±2820 ; 6130±2274 P=<0.003*), total bilirubin (Before and after plasmapheresis total bilirubin mean±Std were 3.7± 3; 2.2±1.9, P=0.003*), SGOT (Before and after plasmapheresis SGOT mean±Std were 252±136; 48±33, P=0.01∗), and international normalized ratio (Before and after plasmapheresis INR mean±Std were 2.1± 1.4 ;1.8 ± 1.1, P=0.024*) (P < 0.05) . A significant association was noted between success of treatment on time taken to reach the treatment facility and the quantity of toxin consumed. It was also noted that leukopenia, due to toxin-induced myelosuppression was a major independent predictor of mortality and and, preceded hepatic manifestations like transaminitis and coagulopathy. Early initiation of PLEX in such patients, was found to have significant survival benefits. Conclusion: Therapeutic PLEX appears to be a novel intervention providing survival benefit in patients with ALF due to YP poisoning and appears a feasible nontransplant treatment option especially in a resource-constrained setting,

Fatal case of ratol poisoning

Ratol is a commonly used rodenticide containing yellow phosphorous. It is commonly used to control pest in grain storage and household. Easy availability, high fatality and inexpensive nature are the predominant reasons for it being commonly employed for suicidal purposes. Here a case is presented where a 30-year-old female consumed Ratol and died after 6 days of hospitalization. History, clinical features, autopsy findings were suggestive of Ratol poisoning but viscera report was negative. Histopathology of uterus was suggestive of early pregnancy. Legal and medical issues related to the case are discussed.

Acute Liver Failure: Indian Perspective.

Acute Liver Failure: Indian Perspective.

Current Trends of Poisoning in Tertiary Care Hospitals Located in a Rural Area of Salem, Tamil Nadu, India

Time wise epidemiological studies are important to find out the trends of poisoning in each region. Thepresent study was conducted by collecting data regarding age, sex, marital status, religion, occupation, typeand manner of poisoning of cases which got admitted and treated over a period of 3 years to know the currentpattern of poisoning in tertiary care hospitals located in a rural area of Salem, Tamil Nadu.Total number cases studied were 170 cases, Among them 60cases (35.3%) belonged to 21-30yrs, maleswere 86 cases (50.6%) and females 84 cases (49.4%), both the sex were almost equally distributed, 103cases(60.6%) were married, 151cases(88.8%) came from rural area, 160 cases (94.1%) were suicidaland all belonged to Hindu religion. Occupation-wise 56 cases (32.9%) were house wives, students 51cases (31.8%), followed by farmers, laborers and others. Coming to the type of poisons, maximum wereorganophosphorous compounds 38 cases (22.4%), followed by Paraquat, 3% yellow phosphorous, oleanderseeds and others.

A retrospective study of clinical profile and outcome of patients with rodenticide poisoning in tertiary care teaching hospital, Mandya Karnataka, India

Background: Poisoning is the major health problem in developing countries like India. Rodenticides are one of the commonest substances used for poisoning in India. Rodenticides are the substances used to kill rats. They differs from chemical composition and toxicity profile. Prognosis mainly depends on chemical content of poison.Methods: This retrospective record-based study was conducted between October 2018 to September 2019 at MIMS tertiary care teaching hospital, Mandya, Karnataka, India. Data regarding age, sex, marital status, occupation, socioeconomic status, type of poison, route of exposure, clinical presentation, complications and outcome of poisoning and associated comorbid conditions were collected from the hospital records and documented in the pre-structured proforma. Descriptive analysis was carried out by the mean and standard deviation for quantitative variables, frequency and proportion for categorical variables.Results: Out of 126 study subjects, 77 (61.11%) were female, 49 (38.89%) were male. Most common age group was 21 to 30 years (45.23%), followed by 31 to 40 years (26.19%) group. Most common poison was zinc phosphide (52.39%), followed by yellow phosphorous (30.16%). Mode of poisoning was suicidal (94.4%) followed by accidental (5.6%).Most common symptom at presentation was nausea, vomiting (62.6%) followed by pain abdomen (52.4%).Most common complication was hepatitis 34 (26.98%) patients, followed by hepatic encephalopathy in 6 (4.76%) and cardiogenic shock in 6 (4.76%) patients. Total mortality was 8 (6.3%).Conclusions: Among rodenticides zinc phosphide was most common consumed poison in present study. Yellow phosphorous was most toxic poison and Aluminium phosphide was most lethal poison. Even though there is no specific antidote, early symptomatic treatment is the key in reducing the mortality.

Shrinkage properties and microstructure of high volume ultrafine phosphorous slag blended cement mortars with superabsorbent polymer

Phosphorous slag (PS) is a special industrial solid waste generated during the production of yellow phosphorous. In present study, the effect of high volume ultrafine phosphorous slag (UPS) and superabsorbent polymer (SAP) on the shrinkage properties, compressive strength, hydration products and pore structure were investigated. Results indicated that compressive strength can be obviously improved by UPS, no matter at early or late ages. Specimens blended with UPS presented higher total shrinkage and autogenous shrinkage than that with raw PS. Incorporating SAP helps mitigate the high shrinkage of UPS blended system, especially for autogenous shrinkage. MIP, XRD and TG characterization showed that UPS could refine pore structure, and consume more Ca(OH)2 as early as 3 days.

A study on outcome of rodenticide poisoning patients admitted to a tertiary care teaching hospital in relation to the chemical content of that poison

Background: Poisoning is the major health problem in India. Rodenticides are the commonest poisoning in Asian countries like India. Rodenticides are the substance used to kill rats. Prognosis mainly depends on chemical content of poison.Methods: This retrospective record-based study was conducted between January 2017 to December 2017 at government hospital department of general medicine, MIMS, Mandya, Bangalore, Karnataka, India. Data regarding age, sex, marital status, occupation, type of poison, route of exposure, and outcome of poisoning and associated co-morbid conditions were collected from the hospital records and documented in the pre-structured proforma. Descriptive analysis was carried out by the mean and standard deviation for quantitative variables, frequency and proportion for categorical variables.Results: Out of 56 patients 33 (59%) were female 23 (41%) were male. Most common age group was 20 to 30 years, followed by 31 to 40 years group. Most common poison was yellow phosphorous (41%), followed by aluminium phosphide (29%). Most common complication was hepatitis (20%),followed by cardiogenic shock (9%).Total mortality was 3 (5%).Conclusions: Among rodenticides yellow phosphorous was most common consumed poison in present study. Aluminium phosphorus was most lethal poison. Even though there is no specific antidote, early symptomatic treatment is the key in reducing the mortality.

45. Liver Transplant in Acute Liver Failure – Looking Back

Background and Aims: Acute liver failure (ALF) although relatively uncommon, tends to affect young individuals and is the leading cause for emergency liver transplantation (LT) the world over. We carried out this study to look at the disease spectrum and to identify the possible predictors of poor outcomes after LT. Methods: We analyzed retrospectively data of 70 cases (median age 24yrs, M:F 1:2) of LT performed for ALF at our institution from April 2007 to April 2017 (out of total of 560 (12%)). Results: The etiology was identified in 53 cases [HAV (n = 15), HBV(n = 5), HEV (n = 1), ATT induced n= (6), Acute Wilson's (n = 3), Autoimmune (n = 5) and Yellow Phosphorous (YP), rodenticide poisoning (n = 16)] and remaining 17 cases were of indeterminate etiology. Etiology differed between adults (>12 years, n = 61) and children (n = 9). Whilst the most common etiology in adults were indeterminate followed by HAV and YP poisoning, equal incidence of indeterminate, acute Wilson's and ATT induced liver failure were seen among children. Upon meeting King's College criteria, 69 had live donor LT (55 Right lobe grafts, 3 left lobe grafts, 4 lefts lateral segment grafts and 5 cases were APOLT) and 1 deceased donor LT. Post-operative morbidity seen were bile leak (23%), sepsis (17.3%), ACR (14.4%), AKI (13%), graft dysfunction (5%), HAT (2.8%) and PVT (1.4%). Overall mortality was 36% (50% in the pediatric and 34% in adults), vast majority of which (92%) occurred within 30 days of transplant. The major cause of mortality was sepsis with MODS. Risk factors for mortality on univariate analysis included donor age >35yrs, pre-transplant renal dysfunction, Grade 4 encephalopathy and hepatitis A, YP poisoning and seronegative etiology. However, on multivariate analysis, only grade IV HE was a significant risk factor for post-transplant mortality. Over a median follow up of 6.17yrs, 60.2% of perioperative survivors are leading a normal life. Most of these mortalities (81.2%) occurred in the immediate post-operative period (within 30 days). Conclusions: LT for ALF carry high mortality (36%) in those presenting with Grade 4 encephalopathy. Nevertheless, if they survive the perioperative period, long term survival is excellent. The authors have none to declare.

A retrospective study of clinical profile and outcome of patients with rodenticide poisoning in a tertiary care hospital

Background: In developing countries, the substances most commonly used for self-poisoning are agricultural pesticides including rodenticides. Authors aimed to assess the clinical status and outcomes of patients with rodenticide poisoning in a tertiary care hospital.Methods: This retrospective record-based study was carried over three years. Apart from demographic details, information regarding the time of ingestion, nature and amount of the compound. Other details included clinical features, complications, treatment and outcome of the patient. Descriptive analysis was carried out by the mean and standard deviation for quantitative variables, frequency and proportion for categorical variables.Results: Of the 120 study subjects, 85 (93.40%) participants self-harmed, 2 (2.20%) were homicidal, and 4 (4.40%) had accidentally consumed the rodenticide. About 52 (32.70%) participants had vomiting, 34 (21.38%) had giddiness, 32 (20.13%) participants had abdominal pain. On the whole, 85 (73.28%) participants recovered, 23 (19.83%) participants had absconded, 6 (5.17%) participants had referred and 2 (1.72%) of them expired.Conclusions: Phosphorous compounds, particularly yellow phosphorous are the most lethal rodenticides followed by Coumadin. Symptomatic management of the patients at the earliest possible time is the mainstay, as there are no specific antidotes for any of the compounds.

Rodenticide poisoning: Literature review and management

Rodenticide is a broad term, and there are a wide variety of such compounds depending on the geographical region and availability. These compounds differ in their chemical composition, mechanism of action, toxic doses, and lethal effects. Coumarins, aluminum phosphide, zinc phosphide, and yellow phosphorous are the most easily available and commonly used rodenticides for deliberate self-harm. Aluminum phosphide poisoning is rapidly fatal, whereas yellow phosphorous poisoning too is associated with a high mortality within 1–2 weeks of consumption.

Histopathological Profile In Fatal Yellow Phosphorous Poisoning.

Yellow phosphorous (YP) is the toxic form of elemental phosphorous and the chief constituent of firecrackers and rodenticides. In India, the rodenticide paste is frequently used for the suicidal purpose. This study is an autopsy-based observational study which describes the histopathological features of heart, lungs, liver, and kidney of fatal cases of YP poisoning. The most common autopsy features in the viscera were congestion and petechial hemorrhage. The liver histopathology findings were microvesicular steatosis (68%), hepatic necrosis (62%), macrovesicular steatosis (50%), inflammatory cells (46%), sinusoidal congestion (40%), cholestasis (32%), and toxic hepatitis (18%). Hepatic necrosis ranged from being focal to centrizonal in distribution. Congestion was the most common feature observed in the lungs and the kidney. This is the largest autopsy-based study on YP poisoning till date. The histopathological features of liver were consistent with YP poisoning whereas the findings of heart, lungs, and kidney were nonspecific in nature.

9. Predictors of prognosis in yelllow phosphorous poisoning

Background and Aims: We aim to analyse the predictors of prognosis in yellow phosphorus poisoning. Methods: We analysed 25 cases of Rat Killer paste poisoning (Yellow Phosphorous) presented to our emergency department between November 2017 to March 2018. Results: The mean age of presentation is between 18 and 25 years. Among the 25, 20 patients developed toxic hepatitis. Acute Liver Failure developed in 10 patients. Among the 25 patients,10 (40%) patients survived. The predictors of survival from our analysis include time of presentation after consumption,early treatment with N-Acetyl cysteine,amount of poison consumed, longer duration of development of jaundice after consumption of poison,early therapeutic plasma exchange and the absence of cardiac toxicity. Conclusions: More awareness about early treatment with N-Acetyl cysteine is needed to improve the prognosis in case of Yellow Phosphorous poisoning. The author has none to declare.

Rodenticide poisoning in children: A study of clinical profile and electrocardiographic changes

Objectives: To study the clinical profile and electrocardiographic (ECG) changes in rodenticide poisoning in children. Methods: Patients admitted with a history of ingestion of rat poison between October 2014 and October 2016 were included in the study. Clinical history was taken in detail, and stomach wash samples were sent for toxicological analysis. Continuous ECG monitoring was done in all cases. Investigations to assess organ functions and coagulation profile were done at admission and repeated as indicated. Results: There were 17 cases of rodenticide poisoning. Zinc phosphide was the rodenticide identified in 50% of cases, bromodiolone in 30%, and yellow phosphorous in 20% cases. Only 23% presented within 1 h of ingestion and only 12% received stomach wash from referring hospital. Out of the 17 cases, 12 cases (70%) were symptomatic, of which 42% hadminor symptoms such as vomiting and abdominal pain and 58% had major symptoms including dysrhythmias, shock, coagulation abnormality, hepatic failure, and seizures. ECG changes were observed in 7 cases (42%), and coagulopathy was seen in 2 (12%) cases of which one had hepatic failure. The mean time of onset of ECG changes was 19.7 h (range 9-36 h). The overall mortality rate was 17.6%. Cardiac arrhythmia was the most common cause of death (66%). Conclusion: Zinc phosphide has been detected as the most common chemical being used as domestic rodenticide. Transient rate abnormalities, metabolic acidosis, fever, and leukocytosis are early markers of toxicity and they should be looked for in all cases. General public, medical, and aramedicalpersonnel should be made aware of the toxic nature of rodenticides.

Persistent Left Ventricular Dysfunction in a Teenager with Yellow Phosphorous Poisoning

Yellow phosphorous is a chemical compound used widely as a rodenticide and in fireworks. Due to its easy availability in India, consumption with suicidal intention is common. Liver is the organ most commonly involved. Though cardio-toxicity manifesting as hypotension, tachycardia, arrhythmias and transient electrocardiogram changes is well known, a persistent left ventricular dysfunction is yet to be reported. We report a case of persistent left ventricular dysfunction as a long term sequelae in a teenager with intentional consumption of this compound.

Advanced purification and comprehensive utilization of yellow phosphorous off gas

Yellow phosphorous is an important raw material in the chemical industry. However, during the production of yellow phosphorous, high concentrations of carbon monoxide and other impurities are released. Without appropriate purification and removal, this off gas has potential to cause severe pollution problems once released. Purified yellow phosphorous off gas can be beneficially reused as a raw material in chemical production for synthesis of high value-added chemical reagents. In this paper, the significance of purification and reutilization of yellow phosphorous off gas are explored. The principles, processes, and main characteristics of the technologies for purification and reuse of yellow phosphorus off gas (including technical measurements of impurity reduction, relevant engineering cases, and public acceptance of the technologies) are summarized. In view of the existing problems and scientific development requirements, this paper proposes several recommendations for green production based on the concept of recycle economics. We conclude that advanced purification and comprehensive reutilization can be an effective solution for heavy pollution resulting from yellow phosphorous off gassing.