Intra-aortic balloon pump in toxic myocarditis due to aluminum phosphide poisoning

Abstract

Introduction: Aluminum phosphide (ALP) is a pesticide that is highly toxic. It is a mitochondrial toxin that causes death by cardiac and metabolic toxicity. The most ominous effect is cardiac toxicity, which may range from minor electrocardiographic abnormalities to severe depression of cardiac contractility secondary to toxic myocarditis. There is no documented report of the use of Intra-aortic Balloon Pump (IABP) for toxic myocarditis from ALP poisoning, although it has been used effectively for toxic myocarditis due to other toxins.Case Report: We are reporting a young female who presented with ALP poisoning, in cardiogenic shock due to myocarditis. We used an IABP for cardio-circulatory support until the effects of ALP resolved. She is the only reported survivor of ALP poisoning, presenting with cardiogenic shock.Discussion: Several reports describe the use of IABP for cardiogenic shock due to toxic myocarditis. There is no report in the medical literature using IABP for cardiogenic shock caused by ALP toxin-induced myocarditis. Our patient presented with cardiocirculatory shock, necessitating the use of inotropes and mechanical ventilation. As she did not improve despite ventilation and maximal doses of inotropes, IABP was used for cardio-circulatory support until the effects of ALP resolved.

Successful treatment of cardiogenic shock with an intraaortic balloon pump following aluminium phosphide poisoning

“…Unfortunately, it was unsuccessful. A successful treatment of AlP with an IABP was first reported by Siddaiah et al (12) in 2009, in a 22-year old female who, suffering with cardiogenic shock due to AlP poisoning, was treated with an IABP until the effects of AlP resolved. There are no other reports in the literature on IABP in the treatment of AlP poisoning and the case presented here was the second successful one in this regard.…”

“…In fact, AlP is generally the most commonly used fatal intentional poison in Iran and India (3,7,8). AlP poisoning leads to multiorgan failure (9,10), but death following this poisoning is most often caused by refractory hypotension and cardiogenic shock in the form of toxic chemical myocarditis, which leads to severe left ventricular dysfunction (8,11,12). The exact mechanism of its toxicity is unclear, but the release of phosphine gas as well as cytochrome oxidase inhibition, oxidative stress, and free oxygen radicals have been suggested as the main causes of toxicity (8,13).…”

“…Refractory hypotension is generally managed by early resuscitation with fluid and vasoactive agents (norepinephrine or phenylephrine, dopamine, and dobutamine). Moreover, Vitamins C and E (3), hyperbaric oxygenation (15), N-acetyl cysteine (16), digoxin (11), and recently intra-aortic balloon pump (IABP) (12) have been used to treat toxic myocarditis due to rice tablet poisoning.…”

Chemical Reaction between Boric Acid and Phosphine Indicates Boric Acid as an Antidote for Aluminium Phosphide Poisoning

“…2,3 Many reports have proposed experimental or individual case treatments for A1P poisoning, including digoxin; N-acetylcysteine; hyperbaric oxygen; magnesium ( 25 Mg 2+ )-carrying nanoparticles; intragastric irrigation with sweet almond oil; a combination of vitamin C and methylene blue; extensive gastric lavage with coconut oil and a sodium bicarbonate solution with simultaneous aspiration; perfusion with an intraaortic balloon pump; Nω-nitro-L-arginine methyl ester; a combination of atropine and pralidoxime; and trimetazidine. [12][13][14][15][16][17][18][19][20][21] However, no specific antidote has yet been found for the routine treatment of AlP poisoning and unfortunately most people who are poisoned do not survive. [2][3][4] Recently, boric acid has been theoretically proposed as an antidote for AlP poisoning.…”

Use of continuous renal replacement therapy in acute aluminum phosphide poisoning: a novel therapy

“…The new therapeutic strategies tried in AP poisoning with varied success includes magnesium supplementation, 8 N-acetylcysteine, 9 hyperbaric oxygen, 10 IABP, 11 gastric lavage with mixture of coconut oil and bicarbonate solution, 12 almond oil 13 and digoxin. 14 However, either these strategies have not been tried in humans 9,10,13 or controlled human trials have failed to produce results consistently.…”