Letter to the Editor. A review of aluminium phosphide poisoning and a flowchart to treat it: recommendation for a revision

Abstract

I read with great interest the paper entitled "A review of aluminium phosphide poisoning and a flowchart to treat it" published in your journal by Hashemi-Domeneh et al. (1). This article has tried, and failed, to review up-to-date knowledge related to aluminium phosphide (ALP) poisoning and propose an easy-to-use management paradigm for health professionals. In addition, it has largely ignored the existing evidence of the different aspects of ALP poisoning beyond metabolism-based consequences. It has therefore failed to answer the question why the mortality rate remains high, even with such considerable advances in treatment protocols. First, the paper has undermined the significance of local thermal injuries in different settings of ALP poisoning. These complications have frequently been reported in the literature and are believed to play a substantial role in the unfavourable outcome (2). Second, the paper is not consistent with two of the three pillars of evidence-based medicine, including clinical expertise and best available evidence (3). Expert opinions and current evidence propose three readily available and feasible recommendations that should be included in the flowchart described in this paper. These are as follows: (A) Do not administer potassium permanganate in gastrointestinal (GI) decontamination. It induces an exothermic reaction that leads to burning and local thermal injuries, resulting in haemorrhages, hypotension, and death (2, 4-5). In addition, it is a strong oxidising agent that causes hemolysis and methemoglobinemia, which contribute to the deterioration of the course of the patient's recovery (6). (B) Do not suction and lavage via a nasogastric tube, as it increases negative pressure in the stomach, which, in turn, provokes internal gas ignition (2, 7-8). (C) Administer an intravenous (IV) lipid emulsion (5). The circulating toxic phosphine is trapped in a blood lipid pool, thereby hindering its site toxic effects. I thank you for your attention to my viewpoints.

Aluminium phosphide poisoning: A case series at two hospitals in the Manzini Region, Eswatini

“…There are authors who are against gastric lavage citing the risk of increasing negative pressure in the stomach which in turn could provoke internal gas ignition. 19 Overall, survivors in the current study either; had vomited post-ingestion, taken the powder form of the poison, ingested expired tablets, had received cooking oil as first aid, had ingested trace amounts of the poison or had received first aid intervention in the form AC and IV fluids. These qualities have been associated with good prognosis in several papers.…”

“…Intravenous administration of Intralipid 20% is thought to be useful, basing the rationale of this practice on the 'lipid sink' theory. 8,19 The Eswatini Standard Treatment guidelines published in 2012 does not include Intralipid 20% which means it is not readily available at either hospital. Its availability would make it possible to extend its use in AlP patients in Eswatini.…”

Development of detection methods for the diagnosis and analysis of highly toxic metal phosphides: A comprehensive and critical review

“…Other popular colorimetric reagent is mercury chloride (HgCl 2 ) in ethanol, acidic KMnO 4 (0.1 N or 79.017 g/L), or 0.5% mercury di-ethyl-thio-carbamate. 73 This analyti-cal procedure can be created semi-quantitatively by suitable configuration and quantification of stain-length 74 or color difference. 37 A simple and sensitive detecting method for PH 3 by Kashi et al 75 was presented through applying paper strips agitated with dimethyl yellow, cresol red, and mercury (II) chloride in methanol.…”

“…Other popular colorimetric reagent is mercury chloride (HgCl 2 ) in ethanol, acidic KMnO₄ (0.1 N or 79.017 g/L), or 0.5% mercury di‐ethyl‐thio‐carbamate 73 . This analytical procedure can be created semi‐quantitatively by suitable configuration and quantification of stain‐length 74 or color difference 37 .…”