Insulin in aluminum phosphide poisoning: A systematic review of the current literature.

BACKGROUND: Aluminum phosphide (AlP) is a commonly used fumigant in agriculture and grain preservation because of its high potency and low cost. Due to the absence of a specific antidote and promising treatment modality, poisoning with this substance is deadly. Amid multiple studies in different parts of the world, each exploring options like lavage, inotropes, antioxidants, etc, we conducted a systematic review to find the possible role of exogenous insulin in treating symptomatic cases of AlP poisoning. METHODS: Experimental studies released before February 15, 2024, that reported the use of exogenous insulin were systematically reviewed following the Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The search was done on PubMed Central, Cochrane Library, and Google Scholar. RESULTS: After applying the inclusion and exclusion criteria, we finalized a few scientific papers for the review. Studying data from 4 scientific papers (3 quasi-experimental studies and 1 randomized controlled trial), we could postulate the significant improvement in survivability after the inclusion of exogenous insulin in the treatment of poisoned cases of AlP. Studies showed divergent results for the blood pressure, blood gases, and need for mechanical ventilation. Hypoglycemia, hyperglycemia, and hypokalemia were the reported adverse effects of this therapy. CONCLUSION: Our review found that the use of exogenous insulin in AlP poisoning reduced mortality rates, which was consistent across all studies. With available knowledge, its inclusion as a part of therapy might be beneficial in AlP poisoning, but to put it forward confidently, we still need high-quality randomized control trials. It is indeed a subject of interest for future research.

Assessment of the role of N-terminal pro-B-type natriuretic peptide as a predictive biomarker of mortality in acute aluminum phosphide poisoning.

BACKGROUND: In Egypt, aluminum phosphide (ALP) is a known lethal poison due to its cardiotoxicity. This study aimed to evaluate the predictive ability of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for mortality in ALP-poisoned patients. METHODS: This prospective study was conducted on patients with ALP poisoning admitted to the Poison Control Center Ain Shams University Hospitals between July and December 2022. Upon admission, all patients were followed up and had their levels of NT-proBNP, troponin I (cTnI), and creatine kinase myocardial band (CK-MB) analyzed. RESULTS: Thirty patients were enrolled in the study and were divided into survivors and non-survivors. The initial NT-proBNP levels were significantly higher among non-survivors in contrast to the initial cTnI and CK-MB levels. The study identified that the best cutoff point of NT-proBNP for predicting mortality was ≥72 pg/ml, with AUC (0.869). CONCLUSION: It can be concluded that NT-proBNP can serve as an early predictor of mortality in ALP poisoning.

The role of miRNA-21 and hypoxia inducible factor-1 in predicting post mortem interval in cardiac muscles of aluminum phosphide deaths.

BACKGROUND: The assessment of the postmortem interval (PMI) represents one of the major challenges in forensic pathology. Because of their stability, microRNAs, or miRNAs, are anticipated to be helpful in forensic research. OBJECTIVE: To see if estimation of PMI is possible using miRNA-21 and Hypoxia-inducible factor-1α (HIF-1α) expression levels in the heart samples from aluminum phosphide toxicity (Alpt). METHODS: This was a cross sectional study on 60 post-mortem samples (heart tissues) collected at different intervals during forensic autopsies. The two groups were allocated equally according to the cause of death into Group I (non-toxicated deaths, n = 30): Deaths caused by other than toxicity, and Group II (toxicated deaths, n = 30): Deaths due to Alpt. MDA (Malondialdehyde) and GSH (Glutathione), were measured in heart tissues using ELIZA. MiRNA- 21and HIF-1α expression levels were measured in heart tissues at different PMI using RT-Q PCR. ROC curve for detection of toxicated deaths using miRNA-21 and HIF was carried out. RESULTS: miRNA-21 and HIF-1α expression levels in Alp deaths were up regulated while GSH was downregulated with statistically significant difference. There was positive correlation between miRNA-21, HIF-1α and MDA with PMI while there was negative correlation between GSH and PMI in Alp deaths. In prediction of post mortem interval in Alp deaths miRNA-21 sensitivity and specificity were (75.9 %, 51.7 %, respectively) while HIF-1α sensitivity and specificity were 100 %. CONCLUSION: PMI can be calculated using the degree to which particular miRNA-21 and HIF-1α are expressed in the heart tissue. The combination of miRNA-21 with HIF-1α in post mortem estimation is precious indicators.

Metal phosphide poisoning in a disaster-stricken area. Can early hemodialysis improve outcomes?

BACKGROUND: Phosphide metal poisoning results in tens of thousands of fatalities per year worldwide. The mortality in critically ill patients often exceeds 50%. The available treatment is supportive and there is no antidote. Dialysis is recommended to treat advanced complications but has not been prescribed early in the process. In this study we report our experience in using dialysis in the early hours of presentation of the patients and suggest it can favorably improve the prognosis. We also draw attention to the risk of suicide under conditions of chronic conflict such as those in northwestern Syria, and to the lack of necessary mental health support for patients after suicide attempts. METHODS: Retrospective review of records of patients poisoned with aluminum phosphide and admitted to critical care facilities in northwestern Syria between July 2022 and June 2023. RESULTS: During the observation period 16 cases were encountered. Suicide was the reason of the poisoning in 15 patients, the median patient age was 18 years and over two thirds of the patients were female. Early dialysis was used in 11 patients who were critically ill and their mortality rate was 18%. CONCLUSIONS: Phosphide metal poisoning is common in the disasters stricken area of northwestern Syria. Most cases are suicidal and impact young females. Early dialytic interventions may favorably impact the outcomes.

Poisoning cases and their management in Amhara National Regional State, Ethiopia: Hospital-based prospective study.

BACKGROUND: Poisoning is a significant public health problem globally. Ethiopia is a low-income country undergoing technological and social change that may increase access to drugs and chemicals, potentially increasing the incidence of poisoning. This study describes the epidemiology of hospital admissions due to poisoning in a region of Ethiopia. METHODS: An institution based prospective observational study was employed, as a study design, in selected hospitals of the region from January to December 2018. RESULTS: Of 442 poisoning cases, 78 (17.6%) died. Almost all poisoning cases were intentional self-poisonings. The most frequent poisonings were organophosphate compounds, 145 (32.8%), and metal phosphides (majorly aluminum phosphide), 115 (26.0%). The ingested poison was most frequently accessed from the patients' homes, 243 (55.0%), followed by purchases from local shops, 159 (36%). The median duration of admission was 24 hours. Of all the cases, 23 (5.2%) were admitted to intensive care units (ICU) requiring mechanical ventilation. Most of the cases admitted to the ICU were aluminum phosphide-poisoned patients. The majority of deaths (43 of 78) were due to metal phosphides. From the multivariate logistic regression analysis, altered level of consciousness on hospital arrival, metal phosphide poisoning, and no laboratory result as a part of the diagnosis process or investigation of the extent of toxicity were found to be significantly associated with the likelihood of poor treatment outcome. CONCLUSION: The majority of the poisoning cases were females. The most common reasons for the intent of self-poisoning were dispute-related, mainly family disharmonies, followed by psychiatric conditions. The poisoning agents were mostly obtained from households. Organophosphate compounds and metal phosphides were the first and the second most frequently encountered poisoning agents, respectively, and it was noted that the later ones were responsible for most of the fatal cases. Of the pharmacologic interventions, atropine was the only agent regarded as an antidote. The most commonly employed agent for supportive treatment was cimetidine followed by maintenance fluids, while gastric lavage was the only GI decontamination method used among others. The fatality rate of poisoning in this study was found to be much higher than in other similar studies. Impaired consciousness upon hospital arrival, metal phosphide poisoning, and no involvement of laboratory investigation were found to significantly associate with the likelihood of death. Generally, the results dictate the need for the design and implementation of strategies to create awareness, prevent, and manage poisoning incidences in the community.

Evaluation of the protective effect of coenzyme Q10 on hepatotoxicity caused by acute phosphine poisoning.

Background: Aluminum phosphide (AlP) poisoning is prevalent in numerous countries, resulting in high mortality rates. Phosphine gas, the primary agent responsible for AlP poisoning, exerts detrimental effects on various organs, notably the heart, liver and kidneys. Numerous studies have documented the advantageous impact of Coenzyme Q10 (CoQ10) in mitigating hepatic injuries. The objective of this investigation is to explore the potential protective efficacy of CoQ10 against hepatic toxicity arising from AlP poisoning. Method: The study encompassed distinct groups receiving almond oil, normal saline, exclusive CoQ10 (at a dosage of 100 mg/kg), AlP at 12 mg/kg; LD50 (lethal dose for 50%), and four groups subjected to AlP along with CoQ10 administration (post-AlP gavage). CoQ10 was administered at 10, 50, and 100 mg/kg doses via Intraparietal (ip) injections. After 24 h, liver tissue specimens were scrutinized for mitochondrial complex activities, oxidative stress parameters, and apoptosis as well as biomarkers such as aspartate transaminase (AST) and alanine transaminase (ALT). Results: AlP induced a significant decrease in the activity of mitochondrial complexes I and IV, as well as a reduction in catalase activity, Ferric Reducing Antioxidant Power (FRAP), and Thiol levels. Additionally, AlP significantly elevated oxidative stress levels, indicated by elevated reactive oxygen species (ROS) production, and resulted in the increment of hepatic biomarkers such as AST and ALT. Administration of CoQ10 led to a substantial improvement in the aforementioned biochemical markers. Furthermore, phosphine exposure resulted in a significant reduction in viable hepatocytes and an increase in apoptosis. Co-treatment with CoQ10 exhibited a dose-dependent reversal of these observed alterations. Conclusion: CoQ10 preserved mitochondrial function, consequently mitigating oxidative damage. This preventive action impeded the progression of heart cells toward apoptosis.

Gastrointestinal decontamination using oil-based solutions in patients with acute aluminum phosphide poisoning: a systematic review and meta-analysis.

Some studies suggested that gastrointestinal (GIT) decontamination with oil may improve the prognosis of patients who ingested aluminum phosphide (AlP). The aim of this study is to compare the efficacy and safety of gastric lavage with oil-based solutions to any method of gastric decontamination not using oils in patients presenting with acute AlP poisoning. The literature was searched for English-published randomized controlled trials (RCTs) from inception to 16 September 2023. The searched electronic databases included MEDLINE/PubMed, Cochrane Library, Web of Science, Egyptian Knowledge Bank, Scopus, and Google Scholar. Data were extracted and pooled by calculating the risk ratio (RR) for categorical outcomes and standardized mean difference (SMD) for numerical outcomes, with 95% confidence intervals (CI). Seven RCTs were included. Paraffin oil was significantly associated with a lower risk of mortality (RR = 0.59 [95% CI: 0.45, 0.76], p < .001), intubation (RR = 0.59 [95% CI: 0.46, 0.76], p < .001) and vasopressor need (RR = 0.71 [95% CI: 0.56, 0.91], p = .006). Survival time was significantly prolonged with paraffin oil (SMD = 0.72 [95% CI: 0.32, 1.13], p < .001). Coconut oil was significantly associated with prolonged survival time (SMD = 0.83 [95% CI: 0.06, 1.59], p = .03) as well as decreased risk of requiring intubation (RR = 0.78 [95% CI: 0.62, 0.99], p = .04). Oil-based GIT decontamination using paraffin oil showed benefits over conventional lavage regarding the incidence of in-hospital mortality and endotracheal intubation, and survival time. Coconut oil showed some benefits in terms of the intubation incidence and survival time. Decontamination using paraffin oil is recommended. Future clinical trials are warranted with larger sample sizes and focusing on cost-benefit and safety.

[Clinical characteristics and follow-up analysis of 12 patients of acute phosphine poisoning].

Objective: To investigate the clinical characteristics of patients with acute phosphine poisoning, and to follow up and evaluate the prognosis of patients. Methods: In May 2022, 12 patients with phosphine poisoning by respiratory inhalation in Beijing Chao-Yang Hospital of Capital Medical University were analyzed. The patients were treated with symptomatic support therapy. Three months later, patients were re-evaluated the symptoms of poisoning, pulmonary function and magnetic resonance imaging (MRI) of the brain to understand the prognosis of the phosphine poisoning. Results: The main symptoms of 12 patients were respiratory and central nervous system symptoms with hypoxia. The symptoms of poisoning improved after treatment. Follow-up found that the patients had different degrees of residual symptoms. Pulmonary function showed increased airway resistance. Airway challenge test was positive in some patients. MRI of the head of some patients showed small ischemic focus in bilateral frontal lobes. Conclusion: Acute phosphine poisoning may cause persistent damage to the respiratory system and central system, and residual symptoms after 3 months.

[Cardiogenic shock due to phosphine poisoning]. / Cardiogene shock door intoxicatie met fosfinegas.

BACKGROUND: Toxic inhalations form a rare cause of poisoning in the Netherlands. The initial symptoms of toxic inhalations may appear similar to acute viral infections. In the maritime sector aluminum or zinc phosphide is used to overcome rodent infestations during transportation. CASE DESCRIPTION: Here we discuss two patients intoxicated with gaseous phosphide used as fumigant in the transport of grains. The exposure to phosphide gas resulted in respiratory and gastrointestinal tract symptoms. Upon admission one of the patients deteriorated resulting in respiratory insufficiency, multi-organ failure and cardiogenic shock. CONCLUSION: Phosphide gas poisoning forms a rare cause for transient acute heart and multiorgan failure largely due to mitochondria dysfunction. In the case of unexplained incapacitation of multiple patients and/or pets toxic inhalations should differentially diagnostically be considered.

Trimetazedine with hyperinsulinimea-euoglycemia, N-acetyl cysteine, and vitamin C: A new approach concept for management of aluminum phosphide poisoning.

Aluminum phosphide (AlP) is commonly used as a powerful suicidal tool. The exact mechanism of acute toxicity has not been well defined despite high mortality rates as well as its supportive treatment including rapid decontamination and institution of resuscitative measures. The current study aimed to investigate a new combination therapy using trimetazidine, N-acetyl cysteine, vitamin C, and hyperinsulinemia-euglycemia to manage acute AlP poisoning. Acute AlP-induced cardiotoxicity, hemodynamic changes, and hepatotoxicity were evaluated using electrocardiogram, creatinine kinase MB iso-enzyme, troponin-1, blood pressure, random blood glucose level, liver function tests, and histopathological changes in both the heart and liver in a rabbit model of AlP poisoning. The results showed that the new regimen therapy ameliorates the toxic effect of AlP with significant improvement in survival, cardiovascular and hemodynamic parameters in addition to histopathological changes. These results highlight the strong cardioprotective, antioxidant, hepatoprotective effects of the new combined therapy along with correction of hemodynamic changes and hyperglycemia as a potential target in the management of acute AlP poisoning.

Validation of Corrected and Dispersed QT as Predictors of Adverse Outcomes in Acute Cardiotoxicities.

Acute cardiovascular poisoning is a major cause of adverse outcomes in poisoning emergencies. The prognostic validity of corrected QT (QTc) and dispersed QT (QTd) in these outcomes is still limited. The present study aimed to determine the risk factors of mortality, adverse cardiovascular events (ACVE), and intensive care unit (ICU) admission in patients with acute cardiovascular toxicities and assess the validity of QTc and QTd intervals in predicting these outcomes. This study was conducted on adult patients admitted to Tanta University Poison Control Center with a history of acute cardiotoxic drugs or toxins exposure. The demographic and toxicological data of patients were recorded. Clinical examination, routine laboratory investigations, ECG grading, and measurement of QTc and QTd were performed. The patients were grouped according to their adverse outcomes. Among the included patients, 51 (31.48%) patients died, 61 (37.65%) patients had ACVE, and 68 (41.98%) patients required ICU admission. The most common cause of poisoning is aluminum phosphide, followed by cholinesterase inhibitors. QTd and QTdc showed no significant difference among outcome groups. The best cut-off values of QTc to predict mortality, ACVE, and ICU admission were > 491.1 ms, > 497.9 ms, and ≥ 491.9 ms, respectively. The derived cut-off QTc values were independent predictors for all adverse outcomes after adjusting for poison type, serum HCO3, and pulse. The highest odds ratios for all adverse outcomes were observed in aluminum phosphide poisoning and low HCO3 < 18 mmol/L. Thus, serum HCO3 and QTc interval should be monitored for acute cardiotoxicities, especially in aluminum phosphide and cholinesterase inhibitors poisoning.

Acute occupational phosphine intoxications in the maritime shipping sector: a scoping review.

The aim is to assess the prevalence and knowledge on acute occupational exposure to phosphine in the shipping industry. We followed PRISMA guidelines for scoping review. We searched in 4 databases without language and date restrictions for scientific articles in peer-reviewed and gray literature. We found 13 peer-reviewed articles and 63 articles in gray literature. These covered 56 incidents from 1963 to 2019 for a total of 254 victims and 22 fatalities. There is an increase in the number of reported cases over the last 20 years. Neurologic and gastrointestinal symptoms are predominant, and hospitalization is needed in 80% of cases. Our review underlined the principal risk as gas exposure through leaks between holds and the ventilation system. Further studies on the knowledge and the prevention in order to improve good practices onboard, prevent the risk of fire explosion, and a global reporting system of new cases are recommended.

Antidotal effect of dihydroxyacetone against phosphine poisoning in mice.

Phosphine (PH3 ) is widely used as an insecticide and rodenticide. On the contrary, many cases of PH3 poisoning have been reported worldwide. Unfortunately, there is no specific antidote against PH3 toxicity. Disruption of mitochondrial function and energy metabolism is a well-known mechanism of PH3 cytotoxicity. Dihydroxyacetone (DHA) is an adenosine triphosphate supplying agent which significantly improves mitochondrial function. The current study was designed to evaluate DHA's effect on inhalational PH3 poisoning in an animal model. DHA was injected into BALB/c mice before and/or after the start of the PH3 inhalation. The cytochrome c oxidase activity was assessed in the animals' brain, heart, and liver exposed to PH3 (for 15, 30, and 60 min, with and without the antidote). The LC50 of PH3 was calculated to be 18.02 (15.42-20.55) ppm over 2 h of exposure. Pretreatment of DHA (1 or 2 g/kg) increased the LC50 of PH3 by about 1.6- or 3-fold, respectively. Posttreatment with DHA (2 g/kg) increased the LC50 of PH3 by about 1.4-fold. PH3 inhibited the activity of cytochrome c oxidase in the assessed organs. It was found that DHA treatment restored mitochondrial cytochrome c oxidase activity. These findings suggested that DHA could be an effective antidote for PH3 poisoning.

Cardiopulmonary effects of phosphine poisoning: A preliminary evaluation of milrinone.

Exposure to phosphine (PH3) presents with a host of diverse, non-specific symptoms that span multiple organ systems and is characterized by a high mortality rate. While a comprehensive mechanism for PH3 poisoning remains inconclusive, prior studies have implicated cardiac failure and circulatory compromise as potential pathways central to PH3-induced mortality. In this study, milrinone (MLR), a phosphodiesterase-3 inhibitor used to treat cardiac failure, was investigated as a potential countermeasure for PH3 poisoning. Lethality, physiological responses, and behavioral changes were evaluated in telemetrized female rats pretreated with water (sham) or one of three doses of MLR (40, 200, or 600 µg/kg) and exposed to PH3 (660 ppm for 25-40 min; 16,500-26,400 ppm × min). Animals receiving prophylactic administration of 600 µg/kg of MLR had nominally improved survivability compared to sham animals, although median lethal concentration-time and time of death did not differ substantially between treatment groups. Changes in respiration and behavior induced by PH3 appeared largely unaffected by MLR pretreatment, regardless of dose. Conversely, MLR pretreatment alleviated some aspects of PH3-induced cardiac function impairment, with slight dose-dependent effects observed for cardiac contractility, mean arterial pressure, and QRS duration. Together, these results illustrate the importance of circulatory compromise in PH3 poisoning and highlight the potential viability of MLR as a potential countermeasure option or part of a countermeasure regimen when administered prophylactically at 600 µg/kg.

Acute occupational phosphine intoxications in the maritime shipping sector: Belgian and French reported cases.

BACKGROUND: During ship transport of organic cargo e.g. soybeans in bulk or textiles in containers, there is a risk of pests damaging the cargo during transport as well as of unwanted global spread of organisms. Consequently, fumigation of the shipped goods is recommended. While aiming to protect the cargo from being damaged by pests during the transport time, fumigation constitutes a risk to the health of seafarers and port workers and even fatal cases are seen. Phosphine gas is increasingly applied for fumigation. Based on former experiences this article aims to describe the risk and to provide recommendations for prevention. MATERIALS AND METHODS: All reports of acute occupational exposures to phosphine in the maritime shipping industry to the Belgian Poison Centre were analysed and compared to reports in a study by ANSES (Agence nationale de sécurité sanitaire de l'alimentation, de l'environnement et du travail), which collected data from the French Poison Centres. Data were registered and analysed between the 1st of January 1999 and the 31 of December 2018. RESULTS: The reported incidents have so far been rather few but seem to have increased over the last years. Symptoms are gastro-intestinal, neurologic and respiratory and often seem "vague" and non-specific and are often difficult to recognise for first responders. In the cases where the aetiology of the incident is known, there often seems to be a lack of clear information about the risk and options for mitigation in workplaces and among the workers. Twelve publications of case reports were included from the literature review that showed the same patterns as found in the registered incident reports. CONCLUSIONS: There seems to be an increase in incidents of acute poisoning from phosphine worldwide. This increase could be linked to the phasing out of methyl bromide in the Montreal Protocol but may also have other explanations. Strict precautions are needed when using phosphine for fumigation of ship cargoes and containers. Since symptoms are often vague, first-responders need to pay attention to the possible occurrence of acute phosphine intoxication as it may be life threatening. Phosphine intoxication remains a diagnosis nor to underestimate not to miss. Further monitoring and research is needed. Preventive actions are mandatory. It is essential to implement in a strict way the existing legislation of an in-transit fumigation with phosphine. Training of the crew and good communication between the different actors during an in-transit fumigation (ship-owner, captain, fumigator, crew, longshoremen) is the key of a good prevention of accidents.

Complicated central catheterization in atypical celphos poisoning simulating throttling homicide: Review of neck resuscitation artefacts.

Therapeutic artefacts are a challenge for forensic pathologists for correct interpretation at autopsy. A 23-year-old female was found unconscious at home and immediately admitted to an emergency of a tertiary care hospital where resuscitative measures were taken. However, she died after 4 h of hospitalization. The injuries (abrasions, subcutaneous bruising and haemorrhage in the deep structures of the neck) discovered at autopsy simulated the findings of throttling and aroused the suspicion of homicide. Later, enquiry revealed that it happened due to mal-positioned central line in the carotid artery during internal jugular vein access to provide fluid as the patient was in shock due to aluminium phosphide (Celphos)poisoning. The bleeding diatheses in Celphos poisoning might have precipitated the extensive neck haemorrhage in this case.

Three Years Analysis Of Poisoning Cases Of Forensic Medicine Toxicological Laboratory, Khyber Medical College, Peshawar.

BACKGROUND: Poison is defined as any substance which harms, endangers or even kills a person irrespective of the quality or quantity. Pakistan is a developing country and farming is the major occupation of the majority of the population. Due to the easy availability and increased use of pesticides, the accidental and suicidal poisoning is very common. The objective of the study is to find out the most common poison used by the people in the general population and its frequency in our setup. METHODS: The present cross-sectional study with retrospective data collection was undertaken in the Department of Forensic Medicine, Khyber Medical College (KMC) Peshawar to determine the frequency of different poisons detected in various samples brought to the toxicological laboratory. A three-year data (1stJanuary 2014 to 31 December 2016) was retrieved from Forensic Laboratory of KMC, Peshawar. Different methods were used for the detection of poisons. All the cases coming from Khyber Pakhtunkhwa province were included whereas; cases from other provinces were excluded. RESULTS: The study revealed that poisoning was more common among females and the most common age group affected was 21-25 years. The incidence of positive cases was more in Peshawar district followed by Swat district. The common poison detected was phosphine (wheat pill). CONCLUSIONS: Female and young people from Peshawar and Swat are more prone to Aluminum Phosphide (wheat pill) poison. It is a dangerous and lethal poison, so healthcare workers at emergency department ought to be prepared for such cases. Furthermore, its routine use as a domestic pesticide has to be strictly prohibited by creating awareness among the public.

Successful treatment of aluminium phosphide poisoning by dihydroxyacetone: A two-case report study.

WHAT IS KNOWN AND OBJECTIVE: Aluminium phosphide (AlP) is an agricultural fumigant which produces phosphine gas in the presence of moisture. Phosphine inhibits oxidative phosphorylation and causes cell death by inhibiting cytochrome C oxidase. Clinical manifestations of AlP poisoning are refractory hypotension, tachycardia, low oxygen saturation and severe metabolic acidosis. CASE SUMMARY: Two cases received dihydroxyacetone (DHA) in addition to routine management of AlP poisoning. Administration of DHA (7 gr in 50 mL sodium bicarbonate, gavage) 2 times at a 1-hour interval improved the clinical signs. WHAT IS NEW AND CONCLUSION: This is the first case report to highlight the safe and successful treatment of AlP poisoning with DHA. However, more clinical studies are recommended to determine the precise mechanism of DHA action.

Sudden Cardiac Arrest in an Asymptomatic Zinc Phosphide-Poisoned Patient: A Case Report.

Zinc phosphide is a gray to black powder mainly used as a rodenticide. In contact with gastric fluid, it releases phosphine which is the main toxic material of this compound. Phosphine interferes with oxidative respiratory cycle of the cells, but is generally expected to manifest its toxicity with prodromal signs and symptoms including abdominal pain, nausea and vomiting, metabolic acidosis, and increased liver function tests. A 64-year-old man was referred to our center with the history of ingestion of three full table spoons of zinc phosphide powder with only a mild GI discomfort. Abdominal X-ray revealed radiopaque material in epigastric and abdominal right upper quadrant. Despite treatment with polyethylene glycol and completely normal vital signs and lab tests, he experienced sudden cardiac arrest 19 h after admission. Autopsy showed clues of focal myopathy and fibrosis with evidences of ischemia and congestion in cardiac tissue, pulmonary edema, shrunken bilateral kidneys, and nutmeg yellow liver. Toxicology panel confirmed the presence of phosphine and zinc phosphide in the gastric fluid. The patient deteriorated suddenly despite being completely symptom-free during the hours preceding cardiovascular arrest. Since the cardiopulmonary injury is the most rampant cause of early death, checking of the cardiac enzymes and cardiac monitoring could be beneficial for early detection and efficient management of these patients.