Indian Journal of Critical Care Medicine

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Related articles

VOLUME 24 , ISSUE 8 ( August, 2020 ) > List of Articles

CASE REPORT

STEMI in Young Befogged by Aluminum Phosphide Toxicity—Role of ECMO as Salvage Therapy and Trimetazidine and Magnesium to Suppress Arrhythmias

Chaitra C Rao, Gunavanthi Jayakumar Himaaldev

Keywords : Aluminum phosphide, Extracorporeal membrane oxygenation, Magnesium, ST elevation myocardial infarction, Trimetazidine

Citation Information : Rao CC, Himaaldev GJ. STEMI in Young Befogged by Aluminum Phosphide Toxicity—Role of ECMO as Salvage Therapy and Trimetazidine and Magnesium to Suppress Arrhythmias. Indian J Crit Care Med 2020; 24 (8):727-730.

DOI: 10.5005/jp-journals-10071-23533

License: CC BY-NC 4.0

Published Online: 21-09-2020

Copyright Statement:  Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Introduction: Aluminum phosphide poisoning (ALP) has a high-mortality rate despite intensive care management, primarily because it causes severe myocardial depression. This case report highlights the subset of ALP patients presenting as ST elevation myocardial infarction (STEMI) with profound myocardial dysfunction and multiorgan failure and successfully treated with extracorporeal membrane oxygenation (ECMO), trimetazidine, and magnesium. Case description: A 25-year-old man without any comorbidities was brought to emergency department with dyspnea and hypotension. His electrocardiograph (ECG) revealed STEMI with elevated troponin levels, arterial blood gas (ABG) showed severe metabolic acidosis, and echocardiography (echo) revealed ejection fraction 15%. He was initiated on venoarterial (VA) ECMO in view of refractory hypotension. History of consumption of three tabs of celphos was revealed later by the family members. He progressed to cardiogenic shock, arrhythmias, respiratory failure, acute kidney injury with severe lactic acidosis, liver injury, pancreatitis, and disseminated intravascular coagulation (DIC). He was successfully supported by ECMO, hemodialysis, magnesium, trimetazidine, N-acetyl cysteine, inotropes, and blood products. He was weaned off ECMO on day 6 and was discharged home on day 12. Despite his severe and confounding clinical presentation, he had complete normalization of end-organ dysfunction with no neurological sequela. This case demonstrates the high index of suspicion required for ALP, given the potential for rapid progression and severe multiorgan toxicity. This report also highlights the importance of early referral to a tertiary care center with ECMO capability and also the role of magnesium and trimetazidine to suppress arrhythmias. Conclusion: Aluminum phosphide poisoning can present as STEMI with cardiogenic shock resulting in acute kidney injury, liver injury, pancreatitis, and DIC. Venoarterial ECMO provides an effective means of support until the recovery of organ function. Trimetazidine and magnesium are helpful in suppressing fatal arrhythmias. This report emphasizes that early recognition and early institution of ECMO can save many young lives who succumb to toxic effects of this poison.


PDF Share
  1. Shadnia S, Sasanian G, Allami P, Hosseini A, Ranjbar A, Amini-Shirazi N, et al. A retrospective 7 years study of aluminum phosphide poisoning in Tehran: opportunities for prevention. Hum Exp Toxicol 2009;28(4):209–213. DOI: 10.1177/0960327108097194.
  2. Sharma A, Dishant VG, Kaushik JS, Mittal K. Aluminum phosphide (celphos) poisoning in children: a 5 year experience in a tertiary care hospital from northern india. Indian J Crit Care Med 2014;18(1):33–36. DOI: 10.4103/0972-5229.125434.
  3. Elabbassi W, Chowdhury MA, Fachtartz AA. Severe reversible myocardial injury associated with aluminium phosphide toxicity: a case report and review of literature. Journal of the Saudi Heart Association 2014;26(4):216–221. DOI: 10.1016/j.jsha.2013.11.006.
  4. Siwach SB, Singh H, Katyal VK, Bhardwaj G. Cardiac arrhythmias in aluminium phosphide poisoning studied by on continuous holter and cardioscopic monitoring. J Assoc Phys India 1998;46(7):598–601.
  5. Soltaninejad K, Beyranvand MR, Momenzadeh SA, Shadnia S. Electrocardiographic findings and cardiac manifestations in acute aluminum phosphide poisoning. J Forensic Leg Med 2012;19(5): 291–293. DOI: 10.1016/j.jflm.2012.02.005.
  6. Akkaoui M, Achour S, Abidi K, Himdi B, Madani A, Zeggwagh AA, et al. Reversible myocardial injury associated with aluminum phosphide poisoning. Clin Toxicol 2007;45(6):728–731. DOI: 10.1080/15563650701517350.
  7. Chugh SN, Malhotra S, Kumar P, Malhotra KC. Reversion of ventricular and supraventricular tachycardia by magnesium sulphate therapy in aluminium phosphide poisoning. report of two cases. J Assoc Phys India 1991;39(8):642–643.
  8. Mohan B, Gupta V, Ralhan S, Gupta D, Puri S, Wander GS, et al. Role of extracorporeal membrane oxygenation in aluminum phosphide poisoning–induced reversible myocardial dysfunction: a novel therapeutic modality. J Emerg Med 2015;49(5):651–656. DOI: 10.1016/j.jemermed.2015.06.071.
  9. Mohan B, Singh B, Gupta V, Ralhan S, Gupta D, Puri S, et al. Outcome of patients supported by extracorporeal membrane oxygenation for aluminum phosphide poisoning: an observational study. Indian Heart J 2016;68(3):295–301.
  10. Merin O, Fink D, Fink DL, Shahroor S, Schlesinger Y, Amir G, et al. Salvage ECMO deployment for fatal aluminum phosphide poisoning. Am J Emerg Med 2015;33(11):1718. DOI: 10.1016/j.ajem.2015.03.054.
  11. Lehoux J, Hena Z, McCabe M, Peek G. Aluminium phosphide poisoning resulting in cardiac arrest, successful treatment with extracorporeal cardiopulmonary resuscitation (ECPR): a case report. Perfusion 2018;33(7):597–598. DOI: 10.1177/0267659118777196.
  12. Tehrani H, Halvaie Z, Shadnia S, Soltaninejad K, Abdollahi M. Protective effects of N-acetylcysteine on aluminum phosphide-induced oxidative stress in acute human poisoning. Clin Toxicol 2013;51(1):23–28. DOI: 10.3109/15563650.2012.743029.
  13. Bayazıt AK, Noyan A, Anarat A. A child with hepatic and renal failure caused by aluminum phosphide. Nephron 2000;86(4):517. DOI: 10.1159/000045849.
  14. Nasa P, Gupta A, Mangal K, Nagrani SK, Raina S, Yadav R. Use of continuous renal replacement therapy in acute aluminum phosphide poisoning: a novel therapy. Ren Fail 2013;35(8):1170–1172. DOI: 10.3109/0886022X.2013.815565.
  15. Bashardoust B, Farzaneh E, Habibzadeh A, Sadeghi MS. Successful treatment of severe metabolic acidosis due to acute aluminum phosphide poisoning with peritoneal dialysis: a report of 2 cases. Iran J Kidney Dis 2017;11(2):165.
  16. Yan H, Chen H, Li Z, Shen M, Zhuo X, Wu H, et al. Phosphine analysis in postmortem specimens following inhalation of phosphine: fatal aluminum phosphide poisoning in children. J Anal Toxicol 2018;42(5):330–336. DOI: 10.1093/jat/bky005.
  17. Chugh SN, Kamar P, Sharma A, Chugh K, Mittal A, Arora B. Magnesium status and parenteral magnesium sulphate therapy in acute aluminum phosphide intoxication. Magnes Res 1994;7(3-4): 289–294.
  18. Dueñas A, Pérez-Castrillon JL, Cobos MA, Herreros V. Treatment of the cardiovascular manifestations of phosphine poisoning with trimetazidine, a new antiischemic drug. Am J Emerg Med 1999;17(2):219–220. DOI: 10.1016/S0735-6757(99) 90075-X.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.