Poisoning is a process in which accumulation of a toxic chemical occurs due to inhalation or swallowing. Wheat pill poisoning is very common mode of suicide in many countries like Pakistan as it is freely available and cheap. The mortality due to wheat pill poisoning in the hospital is 55 to 90%. Here you will get all necessary information about its treatment and management.
Chemical Composition of Wheat Pill:
Aluminum Phosphide = 56%
Inert substances = 44%
Wheat pill is commonly used to
- Control rodents and insects in different type of setting
- Act as indoor and outdoor fumigant
It is available in following dosage forms;
Mechanism of Toxicity:
Due to ingestion of wheat pills different types of gases such as phosphine gas, ammonia and carbon dioxide are liberated when metal phosphide come in contact with water or HCl present in the stomach. Among all gases the most toxic and dangerous gas is phosphine gas.
Damage to Lungs:
Phasphine gas causes lung impairment by damaging cell membrane and increasing or decreasing the levels of certain enzymes such as levels of catalases (enzymes necessary for catalysis of different vital processes) decreases and amount of superoxide dismutase ( higher level is toxic) increases. So both lung system and metabolism will be impaired.
Phosphine gas when interact with moisture present in the lungs form phosphoric acid that causes blistering, edema and adult respiratory distress syndrome (ARDS).
Multi-organ Failure (MOF):
Wheat pill poisoning can cause dysfunction of multiple organs by inhibiting cytochrome e-oxidase non-competitively leading to inhibition of mitochondrial oxidative phosphorylation.
Other Toxic Effects:
- The patient can also suffer gastritis as it is toxic to local tissues of the stomach
- A reduction in oxygen supply can also occur by denaturing oxyhaemoglobin.
Table: Overview of different targeted systems and their possible sign and symptoms
|Targeted System||Sign and Symptoms|
|Gastrointestinal tract (GIT)||Abdominal pain, cramps, nausea, vomiting, burning|
|Cardiovascular system (CVS)||Shock, heart failure, hypotension, arrhythmias, cardiac arrest|
|Respiratory system||Cough, chest tightness, ARDS, dyspnoea|
|Hepatobiliary system||Hepatomegaly, jaundice|
|Renal system||Proteinurea, oligourea|
|Central nervous system (CNS)||Dizziness, anxiety, restlessness, impaired gait|
Treatment of Wheat Pill Poisoning:
Currently there is no antidote available for wheat pill poisoning. Supportive treatment is usually offered to treat signs and symptoms resulted from poisoning.
- Follow ABCD protocol.
- Remove all the particles of the toxin from skin or cloth by brushing and flushing with water for 3-5 minutes.
- Remember; do not induce vomiting if phosphine gas has been inhaled.
- Presence of wheat pill poisoning can be confirmed by instructing the patient to exhale in front of silver nitrate paper that will turn black if phosphine gas is positive in patients.
- Start gastric lavage with 1:1000 potassium permanganate and continue until the patient has phosphine gas negative.
- Use slurry of activated charcoal orally or by using nasogastric (NG) tube. Its dose is 1mg/kg (60 gm for adult)
- Other drugs that can also be used for gastric lavage are mineral oil, olive oil and coconut oil.
Treatment of Shock:
Shock associated with wheat pill poisoning can be treated by;
- Intravenous fluids
- Infuse Dopamine (4-6 ug/kg/min) dobutamin in order to maintain systemic blood pressure above 100mm Hg.
- Administer Intravenous hydrocortisone (200 to 400 mg) after every 4 to 6 hours
Treatment of Arrhythmias:
Arrhythmias can be treated by:
- Administer amiodarone IV at 150 mg over 10 minutes. The dose depends upon the condition of the patient.
- Magnesium sulfate can also be used for the management of supraventricular and ventricular arrhythmias due to its per-oxidant effect. Its IV doses include 1 gm stat and then give 1 gm after every hour up-to three consecutive hours. Then 1 gm after 4 to 6 hours for maximum 5 days.
Treatment of Adult Respiratory Distress Syndrome:
- Deliver oxygen via face mask at a rate of 5-10 liters/min.
- Mechanical support can also be provided if necessary.
Treatment of Metabolic Acidosis:
Some patients may also suffer metabolic acidosis (accumulation of acid in the body) that can be treated by using sodium bicarbonate at a dose of 8.4% 25 ml stat by CV line or use a peripheral line by appropriate dilution 4 hourly (24 to 48 hours).
- Bogle RG, Theron P, Brooks P, Dargan PI, Redhead J. Aluminium phosphide poisoning. Emerg Med J. 2006; 23: 33-5.
- Ranga GS, Dwivedi S, Agarwal M, Kumar D. Aluminium phosphide poisoning in a young adult: A suicidal cardiotoxin simulating myocardial ischaemia. J Indian Acad Clin Med 2004; 5:369.
- McPhee SJ, Papadakis MA, Rabow MW. Current Medical Diagnosis & Treatment 2012. McGraw-Hill Medical, 2010.
- Mahajan VV, Pargal I. Aluminum Phosphide Poisoning: An Agent of Sure Death. Indian Journal of Forensic Medicine & Toxicology. 2012; 6: 231-35.
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