الفهرس 
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Abstract
Aluminum phosphide (ALP) is a well-known pesticide which is used in many countries with high mortality rate in the first 12 to 24 hours due to severe lactic acidosis and end organ damage.
The main problem that there is no available antidote for the ALP toxicity up till now.
This study aimed to assess the usefulness of measuring separately blood cortisol and lactate levels as predictors for early predicting and estimating the outcome in aluminum phosphide patients admitted to the Poison Control Centre, Ain Shams university hospitals (PCC-ASUH).
The current work was done on 40 patients who came to the PCC-ASUH with acute ALP intoxication who came with maximum delay time 48 hours from the first of June 2022 till the end of March 2023 and the diagnosis of ALP was based on history of exposure to ALP and by the clinical manifestations of ALP poisoning. Patients with co-ingestion of other toxins, history of use of steroid, cardiac, hepatic, endocrine, renal, diabetic, and septic patients were excluded from the study.
An informed valid consent was taken from the patients’ legal guardians and their information was kept anonymous. An observational sheet which was fed by patients’ data on admission and during hospital stay was fulfilled for all patients.
At the end of the study, the recorded data of all the studied patients were tabulated for statistical analysis.
All the patients were subjected to general examination included systolic and diastolic blood pressure, pulse, respiratory rate, temperature. The conscious level was evaluated by Reed coma scale, the skin was examined. Examination for the pupils, was done for size either normal, constricted or dilated, equality and reaction to light.
As for the systemic examination, gastrointestinal examination, cardiovascular examination, respiratory system examination, neurological examination, were done separately.
The investigations that were done to each patient were as follows laboratory investigations: laboratory investigations on admission which include: arterial blood gases (ABG) including the blood lactate level, cortisol, electrolytes (sodium and potassium), random blood glucose, liver function tests (AST and ALT), kidney function tests (BUN and serum creatinine), complete blood count (CBC), coagulation profile including (PT, PTT, INR), cardiac enzymes ( CK-MB, troponin) then serial lab investigations were done daily.
Twelve lead ECG was done on admission to all patients then continuous cardiac monitoring was done once the patient entered the ICU and ALP treatment was done according to the treatment protocol of PCC-ASUH.
Outcome of the studied patients was recorded weather survival, occurrence of complications or death.
The current study showed that the median age was 22 years with a range of 13-52 years old, most of them were females with incidence 52.5% while the males were 47.5% and they came from rural areas predominantly from the Fayoum governorate with no significant difference between the survivors and deaths in the age, sex, or the residence.
Mainly the patients took the ALP intentionally for suicidal attempt through ingestion with incidence 95%, intoxication by 1 complete tablet represented the highest incidence 62.5% in 25 patients and no significant difference was found between the survivors and deaths in the manner, route, or amount.
The delay time less than 2 hours represented 32.5%, while the highest incidence 57.5% was found with delay time more than 2 till 6 hours while the least incidence 10% was found when the delay time was more than 6 till 24 hours.
The hospital stay time was distributed as follows less than 12 hours, 12 hours till 24 hours, more than 24 till 48 hours, and more than 48 hours with incidence 35%, 7.5%, 47.5%, 10% respectively.
The most common gastrointestinal symptom was vomiting that occurred in 90% of the studied patients. Thirst sensation was in 22.5%.
Concerning the cardiovascular manifestations, the shock was the most common cardiovascular symptoms with incidence 42.5%, then the hypotension occurred in 37.5% of the studied patients and only 5% had complained of dyspnea and chest pain.
ECG was found normal in 60% of the studied patients, while the ECG changes among the studied patients were mainly sinus tachycardia represented 25% then the sinus bradycardia represented 15%, single extrasystole was found in 10%, while wide QRS, ST segment elevation, inverted T wave, and ventricular tachycardia each represented 2.5%.
Respiratory system examination revealed tachypnea in 62.5% of the studied patients, regards the MV 17.5% had been mechanically ventilated.
Regarding the neurological manifestations, 35% had agitation, 30% had DCL.
As regard the routine lab investigations of sodium, potassium, RBS, AST, ALT, BUN, serum creatinine, PT, PTT, INR, Hb, TLCs, there was no significant difference between survivors and deaths. However, a high significant difference was found as regard Platelets.
Regarding arterial blood gas analysis, there was a high significant difference between survivors and deaths as regard pH, HCO3, SaO2 and lactate while no significant difference was found between them as regard PCO2.
The current study showed by the ROC curve that lactate blood level can be used as a predictor for death for ALP intoxication at a level of ≥6.25 mmol/L, with 100% sensitivity and 91.4% specificity.
As regard the cortisol blood level there was a significant difference between the survivors and deaths, with higher mean levels among deaths and a cut off level was found in the ROC curve that cortisol can be used as a predictor for death from ALP intoxication at a level of ≥28.3 µg/dL, with 100% sensitivity and 45.4% specificity.
No significant difference was found between the survivors and deaths as regard the delay time and pre-consultation treatment.
A high significant difference between survivors and deaths was found as regard hospitalization stay time.
A significant difference was found between survivors and deaths as regards normal heart rate and high significant difference was found between survivors and deaths regarding bradycardia; however, no significant difference was found between survivors and deaths as regard respiratory rate.
A high significant difference was found between survivors and deaths as regard shock and MV.
A significant difference was found between the survivors and deaths regarding the normal ECG and a high significant difference was found regarding bradycardia between survivors and deaths. Presence of any ECG abnormality was highly significantly found in deaths than survivors.
No significant difference between survivors and deaths as regard cardiac enzymes levels.
Complications occurred in 65% of the total studied patients. Survival in 55% and the deaths represented 45%.
Conclusion
Biochemical abnormality of hyperlactatemia was found significantly more among deaths and thus it can be used as a predictor of mortality in ALP intoxicated patients.
Blood cortisol level was statistically increased among deaths in ALP patients and so it can be used as a predictor for mortality.
Measurement of both blood lactate and cortisol blood levels on admission for the ALP intoxicated patients can predict the mortality for these patients.
Cardiovascular manifestations of bradycardia and shock found to be major contributors for mortality.
Vomiting was the commonest clinical manifestation detected while sinus tachycardia was the commonest ECG change recorded.
Presence of any ECG abnormality was highly found among the deaths.
Potentially lethal ALP intoxication can be predicted by hypoxemia and metabolic acidosis.
Requirement of MV may points to possibility of mortality.
Mortality following ALP poisoning remains high despite adequate respiratory support, intensive care and supportive therapy.
Recommendations
This study highlights that careful monitoring of blood lactate and cortisol levels provide important predictors for early estimation of the outcome in acute ALP intoxicated patients.
The present study recommended the physician to consider clinical manifestations of bradycardia and shock in addition to requirement of mechanical ventilation as predictors of mortality in acute ALP intoxication and aggressive correction of reversible risk factors.
Hypoxia and metabolic acidosis were identified as prognostic factors for mortality in acute ALP intoxication early aggressive treatment and prevention of these factors is recommended to reduce mortality.
Further prospective studies involving larger sample size should be conducted to verify the findings of the current study and to estimate the usefulness of these prognostic factors toward adverse outcome.
Raising the awareness about proper usage and hazards among people handling ALP due to its lethal effects.
Keeping ALP away from the reach of children and other vulnerable family members.
Restrict ALP sale and distribution to prevent further deaths as it must be sold under restricted conditions for the farmers under the supervision of the agricultural ministry.
Finding another safe method for using it as a rodenticide other than the ALP.