Una ingesta explosiva / An explosive intake

La ingesta de petardo supone un riesgo potencial para la vida del paciente si este contiene el compuesto tóxico denominado fósforo amarillo (FA). Afortunadamente, dicho material no es utilizado actualmente en nuestro país para la fabricación de productos de pirotecnia, no siendo así en otras regiones del mundo como Asia o América Latina. La ingesta de FA puede causar el fallecimiento del paciente hasta en un 20-50% de los casos por acumulación tóxica en el organismo, produciendo fundamentalmente fallo hepático y, consecuentemente, fallo multiorgánico. Los petardos en España contienen materiales no tóxicos para el organismo, por lo que su ingesta puede producir náuseas y molestias abdominales, pero no un riesgo letal para el paciente. (AU)

The ingestion of firecrackers poses a potential risk to the patient's life if they contain the toxic component called yellow phosphorus (YFP). Fortunately, this material is not currently used in our country for the manufacture of pyrotechnic products, but this is not the case in other regions of the world such as Asia or Latin America. The ingestion of YFP can cause the death of up to 20-50% of cases, by toxic accumulation in the organism, producing mainly hepatic failure and consequently multiorgan failure. Firecrackers in Spain contain non-toxic materials for the organism, so their ingestion may cause nausea and abdominal discomfort, but not a lethal risk for the patient. (AU)

Management of Yellow Phosphorus-Induced Acute Liver Failure: A Case Report and Review of Literature.

Three percent (3%) of yellow phosphorus is the active component of the rodenticide Ratol®. It is a potent hepatotoxin that leads to acute liver failure (ALF) with high mortality. There is no antidote available; the only definitive management is liver transplantation. Therapeutic plasma exchange, or plasmapheresis, appears to help these patients by removing the toxin, its metabolite, or the inflammatory mediators released in the body in response to the toxin. Here, we report a case of a 19-year-old male with an alleged history of Ratol® ingestion and ALF with acute kidney injury. He had a complete reversal of his condition with timely intervention in the form of plasmapheresis.

Investigation of the Pozzolanic Activity Improvement of Yellow Phosphorus Slag with Thermal Activation.

Yellow phosphorus slag (YPS) is a byproduct from the production of yellow phosphorus. It has potential pozzolanic activity and can be used as a supplementary cementitious material. However, the early strength of cement mortar decreases significantly with increasing YPS dosage, which restricts the utilization of YPS in cement and concrete. This study aimed to increase the pozzolanic activity of YPS ash by thermal activation. The strength method, alkali dissolution method and polymerization degree method were used to evaluate the effect of thermal activation at different temperatures on the pozzolanic activity of YPS ash. The results showed that YPS ash calcined at 800 °C helps to enhance the early strength because the fluorine in cuspidine (Ca4Si2O7F2) is insoluble, reducing the retarding effect on the mortar. The higher late strength of YPS ash calcined at 100 °C was due to the low polymerization degree of [SiO4]. The pozzolanic activity of YPS ash is positively correlated with the dissolution concentration of (Si + Al) and the compressive strength and negatively associated with the polymerization degree. This paper shows a possibility for the large-scale utilization of YPS.

Industrial-scale composting of swine manure with a novel additive-yellow phosphorus slag: Variation in maturity indicators, compost quality and phosphorus speciation.

Composting experiment of swine manure, adding with yellow phosphorus slag(YPS) at 5% (w/w), was conducted in an industrial-scale reactor covered with semi-permeable membrane. During 27 days of composting, the changes in temperature, compost quality and phosphorus(P) speciation of products were monitored. Results indicated that the temperature of compost pile was sharply increased on day 2, and the thermophilic period lasted for 15 days. The dynamics in germination index(GI), pH, nutrient contents, etc. of products were in line with conventional composting process. For P distribution, the contents of total-P and citric acid extracted-P(CAP) of products were increased during composting, while that of Olsen-P was decreased. HCl extracted inorganic P(HCl-Pi), a slowly release fraction of P, was dominated in the product, which showed an increasing trend during the composting. These results suggest that the industrial-scale composting with novel YPS additive can be accomplished, and its product contains abundant slowly released P.

Reticuloendothelial activation and phenotypic alteration of peripheral monocytes with enhanced liver recruitment drive liver injury secondary to yellow phosphorus.

BACKGROUND AND AIM: Monocytes and macrophages play a crucial role in the pathogenesis of acute liver failure (ALF). We aimed to study reticuloendothelial activation and its correlation with disease severity in commonly encountered yellow phosphorus (rodenticide)-induced hepatotoxicity patients. We also studied peripheral monocyte phenotype in a subset of patients. METHODS: Reticuloendothelial activation markers were analyzed and correlated with disease severity score in a prospectively collected database of yellow phosphorus-related hepatoxicity patients between 2018 and 2021. In a prospective cohort of these patients and age-matched healthy controls, peripheral blood monocyte phenotyping was performed. RESULTS: Reticuloendothelial activation markers were analyzed in 67 patients [Age: 23(12-64) years; median (range), men: 25, acute liver injury (ALI): 38, ALF: 29, model for end-stage liver disease (MELD) score: 28 (7-40)] of yellow phosphorus-induced hepatotoxicity. Serum ferritin (927; 10.3-34 807 ng/mL), sCD163 (4.59; 0.11-12.7 µg/mL), sCD25 (3050; 5.6-17 300 pg/mL) and plasma von Willebrand factor (423.5, 103-1106 IU/dL) were increased and showed significant correlation with liver disease severity assessed by MELD score (ρ = 0.29, ρ = 0.6, ρ = 0.56 and ρ = 0.46 respectively). Phenotyping and serum immune markers were performed in seven patients (M: 4; age: 27, 15-37 years; median, range; MELD score: 36, 21-40) and compared with eight healthy controls. Increase in classical monocytes and decrease in patrolling and intermediate monocyte subsets were observed in ALF cohort. HLA-DRlow CD163hi (immune exhaustion), CD64hi (immune complex-mediated response), and CCR2hi (liver homing) monocyte phenotype was noted. CONCLUSION: Altered peripheral monocyte phenotype with enhanced liver homing and macrophage activation, suggests important role of innate immune activation, and provides a potential therapeutic target, in yellow phosphorus-induced hepatotoxicity.

Improving Transplant-free Survival With Low-volume Plasma Exchange to Treat Children With Rodenticide Induced Hepatotoxicity.

Background: In a prior report, no patient with rodenticidal hepatotoxicity who met Kochi criteria (MELD score ≥36 or baseline INR ≥6 with hepatic encephalopathy) (PMID: 26310868) for urgent liver transplantation survived with medical management alone. Plasma exchange (PLEX) may improve survival in these patients. Objectives: We describe our experience with low-volume PLEX (PLEX-LV) in treating rodenticide ingestion induced hepatotoxicity in children. Methods: From prospectively collected database of rodenticidal hepatotoxicity patients managed as in-patient with department of Hepatology from December 2017 to August 2021, we retrospectively studied outcomes in children (≤18 years). Hepatotoxicity was categorized as acute liver injury (ALI, coagulopathy alone) or acute liver failure (ALF, coagulopathy and encephalopathy). Kochi criteria was used to assess need for urgent liver transplantation. The primary study outcome was one-month survival. Results: Of the 110 rodenticidal hepatotoxicity patients, 32 children (females: 56%; age: 16 [4.7-18] years; median, range) constituted the study patients. The study patients presented 4 (1-8) days after poison consumption (impulsive suicidal intent:31, accidental:1). Twenty children (62%) had ALI [MELD: 18 (8-36)] and 12 (38%) had ALF [MELD: 37 (24-45)].All children received standard medical care, including N-acetyl cysteine; ALF patients also received anti-cerebral edema measures. None of the patient families opted for liver transplantation. Seventeen children (ALI: 6, ALF: 11) were treated with PLEX-LV (3 [1-5] sessions, volume of plasma exchanged per session: 26 [13-38] ml/kg body weight) and peri-procedure low dose prednisolone.At 1 month, 28 of the 32 children (87.5%) were alive (4 ALF patients died). Of 10 children who met Kochi listing criteria for urgent liver transplantation, two children were ineligible for PLEX-LV (due to hemodynamic instability) and of the remaining 8 children treated by PLEX-LV, 6 (75%) survived. Conclusions: PLEX-LV shows promise as an effective non-liver transplant treatment in children with rodenticidal hepatotoxicity.

Unique granulated leucocytes in peripheral blood in yellow phosphorous poisoning: An interesting tool for monitoring therapeutic response.

Yellow phosphorus is one of the most commonly used rodenticides in India for household pest control. It is available as pastes containing 2% to 5% of yellow phosphorus. Yellow phosphorous-containing rodenticides are easily available and account for one of the most common causes of suicidal poisoning in India. We describe a case of yellow phosphorus poisoning in a 17-years-old child who recovered from hepatic encephalopathy and showed unique peripheral smear findings in the form of spurious monocytosis and hypergranulosis of these granulocytes.

Changing trends in the profile of rodenticide poisoning.

Background: Deliberate self-poisoning (DSP) is one of the leading causes of mortality and morbidity, with rodenticides being common compounds used by many victims. However, comprehensive data regarding the spectrum and outcome of rodenticide poisoning is scant. Method: This retrospective study was conducted in the Emergency Department (ED) of a large tertiary care hospital in South India between January 2017 and December 2018. All patients with deliberate consumption of rodenticides were included in the analysis. Results: During the study period, 1802 patients presented with DSP, among which 145 (8%) consumed rodenticide compounds. The mean (SD) age was 27.9 (10.7) years. Young adults (16-30 years) comprised 73% (106/145) of the study population. The majority (87%) were triaged as priority 2, while 10% were triaged as priority 1. Common rodenticide compounds consumed were yellow phosphorous (57%: 82/145), coumarins (12%: 17/145), zinc phosphide (19%: 27/145), and aluminum phosphide (1%: 1/145). A significant proportion of patients (18.6%) were under the influence of alcohol. Among the 73 males, 25 (34.2%) gave a history of co-consumption of alcohol. There was a history of previous DSP attempts in 6%. The majority (68%) of the patients were discharged alive from the hospital, and the in-hospital mortality rate was 9%. Age >30 years (adjusted OR: 2.2; 95% CI: 1.00-5.05; p value: 0.04) was an independent predictor of poor outcome. Conclusion: Rodenticide compound consumption for DSP is prevalent in young adults and is associated with significant mortality, especially with yellow phosphorous poisoning. The current trend in our country of the increasing use of highly fatal phosphorous compounds over the innocuous coumarin derivatives is a cause of grave concern.

Outcome of Plasma Exchange in Acute Liver Failure due to Yellow Phosphorus Poisoning: A Single-center Experience.

BACKGROUND: Yellow phosphorus (YP) is a protoplasmic poison that causes acute liver failure (ALF) for which liver transplantation is the definitive modality. Hereby, we present our clinical data on the role of plasma exchange (PE) in ALF due to YP poisoning when liver transplantation is not readily available. METHODS: Our study is a prospective observational type, conducted between January 2017 and January 2020, which included patients with ALF due to YP poisoning requiring PE. Clinical features, quantity of poison consumed, and laboratory data before and after PE were noted, and the outcome was documented. RESULTS: This study had 10 patients. The mean age was 30 years. The ratio of male to female being 1.5:1. The amount of YP consumed (median) was 10 gm. Six patients consumed ≤10 gm and four consumed >10 gm. The mean of total PE sessions was 3.3. Seven patients (70%) had recovery from ALF, out of which five had consumed <10 gm of YP. Among patients who recovered after consuming YP, the mean day to get admitted to the hospital was 3.6 ± 1.81 (p = 0.017) and the time to start PE was 4.86 ± 1.67 days (p = 0.033). Three patients did not recover from ALF, of whom two expired. Peak total bilirubin (mg/dL) decreased to 2.76 from 9.29 (p = 0.005), serum glutamic oxaloacetic transaminase to 53.5 from 530 (IU/L) (p = 0.005), serum glutamic pyruvic transaminase to 54.5 from 378 (IU/L) (p = 0.005), international normalized ratio to 1.08 from 2.26 (p = 0.008), prothrombin time(s) decreased to 13.3 from 25.5 (p = 0.013), and activated partial thromboplastin time(s) to 24.6 from 40.8 (p = 0.007) post-PE sessions. CONCLUSIONS: Our study revealed that the patient outcome depends on the quantity of poison consumed, duration of hospitalization, and time to start PE from the day of YP consumption. PE may be considered as a bridge to liver transplant in ALF patients. HOW TO CITE THIS ARTICLE: Angraje S, Sekar M, Mishra B, Matcha J. Outcome of Plasma Exchange in Acute Liver Failure due to Yellow Phosphorus Poisoning: A Single-center Experience. Indian J Crit Care Med 2021;25(9):1020-1025.

Rodenticide-induced acute liver failure - Uncommon presentation of commonly available poison.

Rodenticide or 'rat poison' is easily available in a predominantly agrarian economy such as India. Metal phosphides or yellow phosphorous are two common rodenticides. Acute liver failure caused by accidental or suicidal poisoning with rodenticides has been infrequently reported in literature. Liver transplantation offers the best chances of survival in severe intoxication. However, the availability of liver transplantation in resource-limited settings presents a challenge. N-acetyl cysteine has been successfully used in paracetamol poisoning. Its use in rodenticide-induced acute liver failure is not so well known. We report three cases of rodenticide-related acute liver failure, one of them being a pregnant lady. All three patients were given N-acetyl cysteine and two patients improved. It is possible that the administration of N-acetyl cysteine contributed to the improvement in these two.

Liver Transplantation Society of India Guidelines for the Management of Acute Liver Injury Secondary to Yellow Phosphorus-Containing Rodenticide Poisoning Using the Modified Delphi Technique of Consensus Development.

BACKGROUND: Acute liver failure caused by the ingestion of yellow phosphorus-containing rodenticide has been increasing in incidence over the last decade and is a common indication for emergency liver transplantation in Southern and Western India and other countries. Clear guidelines for its management are necessary, given its unpredictable course, potential for rapid deterioration and variation in clinical practice. METHODS: A modified Delphi approach was used for developing consensus guidelines under the aegis of the Liver Transplantation Society of India. A detailed review of the published literature was performed. Recommendations for three areas of clinical practice, assessment and initial management, intensive care unit (ICU) management and liver transplantation, were developed. RESULTS: The expert panel consisted of 16 clinicians, 3 nonclinical specialists and 5 senior advisory members from 11 centres. Thirty-one recommendations with regard to criteria for hospital admission and discharge, role of medical therapies, ICU management, evidence for extracorporeal therapies such as renal replacement therapy and therapeutic plasma exchange, early predictors of need for liver transplantation and perioperative care were developed based on published evidence and combined clinical experience. CONCLUSION: Development of these guidelines should help standardise care for patients with yellow phosphorus poisoning and identify areas for collaborative research.

Therapeutic Plasma Exchange with Continuous Renal Replacement Therapy for Pediatric Acute Liver Failure: A Case Series from Thailand.

AIM AND OBJECTIVE: Pediatric acute liver failure (PALF) is a life-threatening condition. Extracorporeal support has been applied for toxic metabolite clearance and serves as a bridging therapy to liver transplantation (LT) or to the regeneration of the liver, but evidence for treatment approaches is still lacking in the pediatric population. We aim to report our experience on therapeutic plasma exchange with high-volume continuous renal replacement therapy (TPE + HV-CRRT) as a promising supportive treatment for PALF. MATERIALS AND METHODS: A total of eight PALF cases aged 9 months to 14 years, weighing 10-50 kg., who were admitted to PICU King Chulalongkorn Memorial Hospital, Thailand and treated with TPE + HV-CRRT from January 2016 to September 2019 were reviewed. Patient demographic data, indications, technical aspects, and clinical outcomes were recorded. RESULTS: All patients who underwent TPE + HV-CRRT showed clinical improvement regarding serum bilirubin levels and coagulation studies after the therapy. Complications from the therapy were hemodynamic instability, symptomatic fluid overload, and bleeding from catheter sites. Among these, 6 (75%) patients survived with 4 (50%) successful LTs and 2 (25%) spontaneous recovery. Two children (25%) died while on the transplantation list. CONCLUSION: TPE + HV-CRRT can be used safely as a bridging therapy in children with PALF. As opposed to the adult population, higher volume of TPE or higher blood flow rate in pediatric patients might associate with hemodynamic instability during the procedure. HOW TO CITE THIS ARTICLE: Trepatchayakorn S, Chaijitraruch N, Chongsrisawat V, Chanakul A, Kongkiattikul L, Samransamruajkit R. Therapeutic Plasma Exchange with Continuous Renal Replacement Therapy for Pediatric Acute Liver Failure: A Case Series from Thailand. Indian J Crit Care Med 2021;25(7):812-816.

Study on Preparation and Interfacial Transition Zone Microstructure of Red Mud-Yellow Phosphorus Slag-Cement Concrete.

Open stockpiling and the continual production of industrial solid wastes such as red mud (RM) and yellow phosphorus slag (YPS) have caused serious environmental pollution issues. Additionally, concrete prepared easily and with high strength is a widely applied building material. Therefore, replacing part or all of the cement for preparing concrete with RM and YPS will greatly reduce this kind of solid waste and, thus, decrease environmental pressures. This study investigated the best ratio for the replacement of concrete with RM and YPS, testing the mechanical properties as well as the morphology, material composition, and microporous structure of the interface transition zone (ITZ). The results showed for the concrete prepared with ordinary Portland cement replaced by 10.00 wt.% RM and 18 wt.% YPS, compared to ordinary Portland cement concrete, the compressive strength of concrete with basalt aggregate and dolomite aggregate increased by 25.04% and 27.27%, respectively, when the concrete was cured with steam for 28 days. Furthermore, it had a smaller average pore diameter and crystal size in the ITZ. The aggregate and matrix were more closely intertwined. This was because RM had a low cementitious activity and mainly had a filling effect when added to concrete, while the highly active silica in YPS could react with the Ca(OH)2 crystal (CH) produced from cement hydration to form calcium silicate hydrate (CSH) gel, improving the mechanical properties and microstructure of the concrete.

Yellow phosphorus and Potash for SOX and NOX removal.

Flue gases emitted from the industries and other emission sources are considered the main atmospheric issues. The main Flue gases emitted are sulfur oxides SOX and Nitrogen oxides NOX. The study was about methods of removing SOX and NOX from emitted gases and the possibility of deriving useful byproducts. The process for removing was investigated using different absorbers, process conditions, and phosphorus allotropes. The yellow phosphorus (P4) was applied for removal accompanied by Potash. The simultaneous removal achieved higher removing efficiency for SOX than NOX. Yellow phosphorus emulsion proved to be one of the effective SOX and NOX removal techniques. Byproducts produced from SOX and NOX proved to contain the complete fertiliser Nitrogen Phosphorus Potassium NPK. The obtained results showed that several useful byproducts can be derived from SOX and NOX removal process.

Sustainable and Clean Utilization of Yellow Phosphorus Slag (YPS): Activation and Preparation of Granular Rice Fertilizer.

Yellow phosphorus slag (YPS) is a typical industrial solid waste, while it contains abundant silicon micronutrient required for the growth of rice. The key scientific problem to use the YPS as rice fertilizer is how to activate the slag efficiently during the phosphorite reduction smelting process. In this work, an alkaline rice fertilizer from the activated YPS was successfully prepared to use the micronutrients. Thermodynamic analyses of SiO2-CaO, SiO2-CaO-Al2O3, and SiO2-CaO-Al2O3-MgO systems were discussed to optimize the acidity for reduction smelting. Results showed that the reduction smelting followed by the water quenching process can realize the reduction of phosphorite and activation of YPS synchronously. Ternary acidity m(SiO2)/(m(CaO) + m(MgO)) of 0.92 is suitable for the reduction smelting and activation of the slag. After smelting, the molten YPS can be effectively activated by water quenching, and 78.28% P, 90.03% Ca, and 77.12% Si in the YPS are activated, which can be readily absorbed by the rice roots. Finally, high-strength granular rice fertilizers with a particle size of Φ2-4 mm were successfully prepared from the powdery nitrogen-phosphorus-potassium (NPK) and activated YPS mixture.

Acute Pancreatitis Complicating Liver Transplantation in a Case of Fulminant Hepatic Failure Due to Yellow Phosphorus Poisoning.

INTRODUCTION: Yellow phosphorus (YP) is a general protoplasmic poison causing hepatic, cardiac, renal, and multiorgan failure. We report an unusual case of fulminant liver failure due to ratol (YP) poisoning complicated by acute pancreatitis postoperatively after liver transplantation. CASE REPORT: A 25-yr-old man presented with alleged consumption of approximately 7 gm of Ratol paste. Serum amylase and lipase levels were 880 and 2423, respectively, and CT imaging of pancreas was normal. He developed fulminant liver failure, fulfilling King's college criteria and an living donor liver transplantation was performed. Intraoperatively fat saponification was seen at the root of mesentery. On postoperative day (POD) 13, he developed incisional wound dehiscence and he underwent laparotomy with extensive slough removal from the lateral aspect of wound. On POD 21, wound showed evidence of burst abdomen. CT abdomen revealed inflamed tail of pancreas with peripancreatic fat stranding and an exploratory laparotomy was performed again. Intraoperatively, walled-off necrotic collection was seen in the tail of the pancreas and necrosectomy was carried out. All the aforementioned re-explorations were carried out under steroid immunosuppression. He was restarted on tacrolimus on POD27. Graft function and cholestatic biochemistry improved progressively, and he was discharged and is on regular follow-up. DISCUSSION: YP is very toxic with rapid absorption and gets accumulated in liver causing acute liver failure. Acute pancreatitis in a patient after liver transplantation for fulminant liver failure owing to Ratol poisoning has not been reported in published English literature. Although clinically relevant pancreatitis is rare in ratol poisoning, despite elevated pancreatic enzymes, it is prudent to meticulously image pancreas before embarking on liver transplantation. In those with pretransplant elevation of pancreatic enzymes, it is desirable to follow up the enzyme values postoperatively.

Novel low-temperature H2S removal technology by developing yellow phosphorus and phosphate rock slurry as absorbent.

Recycling hazardous gas of H2S is one of the most important strategies to promote sustainable development. Herein, a novel method regarding purifying H2S is proposed by using yellow phosphorus and phosphate rock slurry as absorbent. The H2SO4, formed in situ by H2S conversion, can be devoted to decompose phosphate rock, and the spent absorption slurry was applied as raw material for the production of phosphorus chemical products. According to the characterization analysis, it was found that H2S was first oxidized to SO2 via O2 as well as O3 induced by P4. Subsequently, the generated SO2 dissolved rapidly in water to form H2SO4, and then reacted with the main component of phosphate rock, CaMg(CO3)2. Most notably, the active substances, such as, O3, SO4•- and OH•, produced in the reaction process, can oxidize H2S and HS- to these sulfur products. In addition, trace amounts of Fe3+ and Mn2+ that were dissolved from phosphate rock displayed a promotional effect on the formation of active substances. Consequently, as high as 85% of H2S removal efficiency can be obtained even under acidic condition and low temperature. The proposed H2S purification method offers a promising option for sulfur recovery and H2S pollution control.

O3 oxidation excited by yellow phosphorus emulsion coupling with red mud absorption for denitration.

Directing to unwieldiness NOx emitted by the industry, the removal of NOx was implemented using yellow phosphorus (P4) emulsion and red mud slurry as composite absorbent. Where yellow phosphorus is considered to stimulate formation of the ecological ozone (O3) from O2, the oxidation of insoluble NO into water-soluble NOx species by O3, and the red mud as a pH buffer can be used to maintain the pH of the absorption liquid in a range that better absorbs NOx. NO is finally converted into NO2- and NO3-, whereas the yellow phosphorus is mainly PO43-. Single-factor influencing on the efficiency of denitration include the concentration of yellow phosphorus, reaction temperature, stirring intensity, gas flow rate, O2 content, and red mud solid-liquid ratio were investigated. Response surface methodology (RSM) was used to optimize the process parameters. It was indicated that the removal rate of NOx can reach 99.3% under the optimal conditions. Moreover, the possible denitration reaction mechanism was also discussed.

Acute liver failure secondary to yellow phosphorus rodenticide poisoning: Outcomes at a center with dedicated liver intensive care and transplant unit.

Accidental or suicidal poisoning with yellow phosphorus or metal phosphides (YPMP) such as aluminum (AlP) zinc phosphide (Zn3P2) commonly cause acute liver failure (ALF) and cardiotoxicity. These are used as household, agricultural and industrial rodenticides and in production of ammunitions, firecrackers and fertilizers. In absence of a clinically available laboratory test for diagnosis or toxin measurement or an antidote, managing their poisoning is challenging even at a tertiary care center with a dedicated liver intensive care unit (LICU) and liver transplant facility. PATIENTS AND METHODS: Patients with YPMP related ALF were monitored using standardized clinical, hemodynamic, biochemical, metabolic, neurological, electrocardiography (ECG) and SOFA score and managed using uniform intensive care, treatment and transplant protocols in LICU. Socio-demographic characteristics, clinical and biochemical parameters and scores were summarized and compared between 3 groups i.e. spontaneous survivors, transplanted patients and non-survivors. Predictors of spontaneous survival and the need for liver transplant are also evaluated. RESULTS: Nineteen patients with YPMP related ALF were about 32 years old (63.2% females) and presented to us at a median of 3 (0 - 10) days after poisoning. YPMP related cardiotoxicity was rapidly progressive and fatal whereas liver transplant was therapeutic for ALF. Spontaneous survivors had lower dose ingestion (<17.5 grams), absence of cardiotoxicity, < grade 3 HE, lactate < 5.8, SOFA score < 14.5, and increase in SOFA score by < 5.5. Patients with renal failure need for CVVHDF and KCC positivity on account of PT-INR > 6.5 had higher mortality risk. Patients undergoing liver transplant and with spontaneous recovery required longer ICU and hospital stay. At median follow-up of 3.4 (2.6 - 5.5) years, all spontaneous survivors and transplanted patients are well with normal liver function. CONCLUSIONS: Early transfer to a specialized center, pre-emptive close monitoring, and intensive care and organ support with ventilation, CVVHDF, plasmapheresis and others may maximize their chances of spontaneous recovery, allow accurate prognostication and a timely liver transplant.