Ratol (Aluminium Phosphide) Poisoning - Clinical Management

What is Ratol?

• Lethal dose: 150-500 mg for adults (1 tablet = ~3 g AlP)
• Mortality: ~54% even with treatment (pooled data from 3449 Indian patients, Kumar et al., 2025)
• Intentional ingestion accounts for ~94% of cases
• There is no specific antidote

Step 1: Immediate Assessment and Resuscitation (CAB First)

On Arrival - Do These Simultaneously:

1. Remove from source - take patient to fresh air/well-ventilated area; phosphine is absorbed cutaneously too
2. Skin decontamination - remove clothes, wash skin with soap and water
3. Airway - secure with endotracheal intubation if GCS is reduced or respiratory distress is present; prevent aspiration pneumonitis
4. Breathing - high-flow supplemental oxygen; prepare for mechanical ventilation
5. Circulation - establish central venous access (peripheral IV is acceptable initially); give 0.9% normal saline bolus for hypotension; start vasopressors (norepinephrine/dopamine) early - hypotension is severe and refractory
6. Do NOT induce vomiting - this increases phosphine gas inhalation risk
7. Do NOT give milk or alkaline solutions orally before confirming gastric decontamination plan

Step 2: Investigations

• Filter paper moistened with silver nitrate turns black in the presence of phosphine
• Add a drop of ammonium molybdate - paper turns blue (confirmation)
• Gold standard: gas chromatography with nitrogen-phosphorous detector on gastric content/viscera

Step 3: Gastrointestinal Decontamination

• Gastric lavage with coconut oil or liquid paraffin (50-100 mL): Oil inhibits phosphine release from AlP tablets - this is a key intervention. Coconut oil has the strongest evidence (Shadnia et al.; Hafez et al. meta-analysis 2024)
• After oil lavage, perform standard water/saline lavage
• Sodium bicarbonate (SBC) added to lavage fluid may further reduce phosphine liberation
• Activated charcoal (1 g/kg): has limited efficacy for AlP but can be tried if patient is alert and not vomiting; dose - child: 25-50 g
• Do NOT use cathartics routinely

Step 4: Specific/Adjunctive Treatments

Antioxidants (reduce oxidative stress - key mechanism of toxicity):

Cardiovascular Support:

• Vasopressors: Norepinephrine first-line for refractory hypotension
• Inotropes: Dobutamine for cardiogenic shock component
• Glucose-Insulin-Potassium (GIK) infusion: Has shown mortality benefit in clinical studies - acts as metabolic cardioprotection
• Digoxin + Glucagon combination: Reported as beneficial in some case series (for refractory hemodynamic compromise)
• ECMO (Extracorporeal Membrane Oxygenation): Consider early in centers with availability - has shown survival benefit in severe cases (systematic review PMID 37387512)
• Magnesium sulfate: IV infusion - membrane stabilization, anti-arrhythmic, antioxidant. Evidence mixed; check Mg levels first to avoid hypermagnesemia

Metabolic/Acid-Base:

• IV Sodium bicarbonate: For metabolic acidosis - "aggressive acidosis correction" protocol significantly improved outcomes (30% vs 55% mortality reduction in one study)
• Insulin (for stress hyperglycemia): Target glucose <180 mg/dL

Renal Replacement:

• Hemodialysis/peritoneal dialysis: Not effective for removing phosphine itself, but indicated for renal failure, severe acidosis, or fluid overload
• Peritoneal dialysis has been used successfully in cases with severe metabolic acidosis

Methemoglobinemia (if present):

• Methylene blue 1% solution: 2 mg/kg IV over 5 minutes - can repeat if cyanosis persists

Step 5: Monitoring in ICU

• Continuous cardiac monitoring - fatal arrhythmias can occur at any time in first 24-48 hours
• Serial ABGs every 2-4 hours
• Hourly urine output
• Serial echocardiography for cardiac function
• Blood glucose every 2-4 hours

Step 6: Prognostic Markers (Poor Prognosis)

• Severe hypotension at admission (most common presentation: ~78% of patients)
• Severe metabolic acidosis (pH <7.1)
• Hyperglycemia at admission
• Large ingested dose (>1.5 g - though survivors reported even at 9 g)
• Delayed presentation (>6 hours)
• Refractory arrhythmias

Step 7: Since This is a 16-Year-Old Female

• Depression and suicidal ideation
• Underlying psychosocial stressors
• Family dynamics and safety at home
• Arrange follow-up with adolescent psychiatry before discharge

Summary Algorithm

Arrival → CAB Resuscitation
         ↓
Remove from exposure + Skin decontamination
         ↓
Urgent investigations (ECG, ABG, electrolytes, glucose, LFTs, RFTs, CBC)
         ↓
Gastric lavage with coconut oil/liquid paraffin (within 6 hours)
         ↓
Vasopressors + Inotropes for hemodynamic support
         ↓
NAC + Vitamin E (antioxidants)
         ↓
IV Sodium bicarbonate for metabolic acidosis
         ↓
GIK infusion + Magnesium sulfate (check levels)
         ↓
ICU admission - continuous cardiac monitoring
         ↓
Dialysis if renal failure/severe acidosis
         ↓
ECMO if refractory cardiorespiratory failure
         ↓
Medical stabilization → Psychiatric evaluation