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J Indian Acad Forensic Med. October- December 2011, Vol. 33, No. 4 ISSN 0971-0973 Original Research Paper The Study of Aluminium Phosphide Poisoning in a Tertiary Care Hospital, Amritsar *Puneet Khurana, **J.S.Dalal, ***A. S. Multani, ****H.R. Tejpal Abstract: Trend of poisoning had been constantly changing throughout the world, as the advent of new agents, has always replaced the older one due to their innumerable merits and demerits. Similarly in India, the pattern of ingested poisons has also changed. A number of chemical substances which are developed to save the agricultural product from rodents and pests are in fact themselves proving to be disastrous for mankind. Recently in the last two decades aluminium phosphide [Alphos] used as pesticide, rodenticide, fumigant for storage of food grains has created havoc with the human lives differently i.e. suicidal, accidental and very rarely homicidal poisoning agent. Alphos, a solid fumigant used for storage of food grains, freely accessible in the market is commonly used suicidal agent with high mortality rate as no antidote or specific treatment is available. The present study of 50 cases of aluminium phosphide poisoning showed male dominance, common in sikhs and educated persons. Heart is the first organ to be affected. Shock was present in majority of cases. Sufficient time was available for recording dying declaration. Key Words: Aluminium Phosphide, Poisoning, Suicide, Mortality Rate Introduction: Trend of poisoning had been constantly changing throughout the world with advent of new agents. In India, the pattern of ingested poisons has also changed. A number of chemical substances which are developed to save the agricultural product from rodents and pests are in fact themselves proving to be disastrous for mankind. Recently in the last two decades Alphos used as pesticide, rodenticide, fumigant for storage of food grains has created havoc with the human lives differently i.e. suicidal, accidental and very rarely homicidal poisoning agent. Alphos is an inorganic compound Alphos is a solid fumigant in use since 1940s. [1] It has emerged as an ideal fumigant because of its low cost, long lasting effects, easy to handle, its action being in the gaseous form so easy penetration to areas otherwise inaccessible for application (grain storage areas, rodent run away). Corresponding Author: *Asst. Prof, Forensic Medicine & Toxicology, Christian Medical College [CMC], Ludhiana, Punjan ** Prof. & Head, ***Ex. Prof. & Head, Medicine Department, Government Medical College, Amritsar **** Ex. Additional Professor, FMT, GMC, Amritsar 332 It is available as white coloured or dark brown tablets of 3 gm each with 20 mm diameter and 5 mm thickness, packed in a pen shaped air tight plastic/tin container and remains fresh as long as the container is not opened. Each tablet of Alphos consists of 56% w/w Alphos as active ingredient and 44% w/w aluminium carbonate or carbamate as the inert ingredient. It librates phosphine gas (active ingredient) which in its pure form is colourless and odourless but smell like garlic or stale fish due to added impurities. History and Review of Literature: Since 1960, the mean death rate from suicide made by WHO has remained at about 10 per 100,000 (WHO 1974). Currently the rate varies from 5 to 40 per 100000 with high Scandinavian countries. The rate of attempted suicide is 8-10 times more than the completed suicide. [2] There were both accidental and suicidal poisoning with the aluminium phosphide. The number of self poisoning is much more than accidental cases. Majority of patients are from 15-35 years age groups with rural background Fatal Dose: Less than 500 mg of unexposed pellet of aluminium phosphide is lethal for an adult (usual being 150 - 500 mg for a 70 kg individual). The inhalation of phosphine at a concentration of 290- 300 ppm is dangerous to life, 400-600 ppm, it is lethal within half an hour; 1000 ppm, it is rapidly fatal. [3]
J Indian Acad Forensic Med. October- December 2011, Vol. 33, No. 4 ISSN 0971-0973 Fatal Period is One hour to four days. Majority die within twenty-four hours. [4] Singh et al 1989 studied cardiovascular manifestations of aluminium phosphide intoxication and reported massive focal myocardial damage resulting in raised cardiac enzymes. Out of 32 cases studied cardiac arrhythmias were present in 28 cases and hyper magnesia in 13 patients. Twenty two patients died of which 18 cases died with in 24 hours of ingestion of aluminium phosphide. Histopathological examination after autopsy or biopsy of organs showed marked congestion, patchy necrosis and mononuclear cell infiltration, severe peripheral capillary leakage in lungs, heart, stomach, kidney and brain. There is either patchy or global myocardial injury. There is alveolar capillary membrane damage which could cause ARDS. Thickening of alveoli, cellular aggregation around bronchioles, patchy areas of gray hepatisation consistent with ARDS could also occur. [5] Gupta & Rao 1995 studied 30 cases of aluminium phosphide poisoning admitted to emergency medical wards of Rajendra Hospital, Patiala to find out its clinical profile. The poison was taken orally for suicidal purposes in all the 30 cases. M: F ratio was 1.8: 1 and commonest age group was 21-30 Years (53.33%). Cardio respiratory collapse, shock, vomiting with relatively preserved sensorium was hallmark of clinical presentation. Cases which survived for more than 12 hours had end organ damage such as myocarditis [7], ARF [4] and hepatocellular damage. Overall mortality rate was 80% and they concluded that aluminium phosphide although a potent insecticide is a human "killer with high mortality rate” and hence need to check its easy availability. [6] Aims and Objectives: Our study consists of 50 admitted cases to Medicine Department of Guru Nanak Dev Hospital attached to Government Medical College, Amritsar and was done to determine: 1. Various epidemiological features such as age, sex, religion, educational status of the patients. 2. The sequence of signs and symptoms in relation to cardiovascular system. 3. The ECG changes. 4. Time elapsed between the ingestion and admission to the hospital and time for dying declaration. 5. Mortality Rate Material & Methods: Our study was on 50 cases of aluminium phosphide poisoning admitted to Medicine Department of Guru Nanak Dev hospital, attached to Government Medical 333 College, Amritsar during the period from 01-10- 2004 to 15-04-2006. The diagnosis was done by history of ingestion, garlic/decaying fish like odor and confirmation was done by silver nitrate filter paper test with gastric aspirate having high sensitivity even with low concentration of phosphine which darkens the paper and to prevent false positive cases another filter paper impregnated with silver nitrate has to be kept outside as control. The data and information pertaining to the cases were collected by interviewing the patient, relatives or friends of the patient and recorded on the proforma. Procedure: With Gastric aspirate: 5 ml of gastric aspirate is mixed with 15 ml of water, a round strip of filter paper impregnated with AgNO3 (0.1 N) was placed on mouth of flask & heated at 500C for 15-20 min. Blackening of filter paper occurred as follows: [7, 8] 2AlP + 6 H2O → 2Al (OH)3 + 2PH3(↑) 4H2O+8AgNO3+PH3 → 8Ag+H3PO4+8HNO3 (Black) Observations: Table 1: Age & Sex Wise Distribution Male Female Total Age in years No. %age No. %age No. %age 0-10 ----- ----- ----- ----- ----- ----- 11-20 4 8% 5 10% 9 18% 21-30 12 24% 5 10% 17 34% 31-40 10 20% 5 10% 15 30% 41-50 5 10% 2 4% 7 14% Above 50 2 4% ----- ----- 2 4% Total 33 66% 17 34% 50 100% In 50 cases, 33(66%) were males and 17(34%) were females with male dominating the study as shown in table 1. Male: female ratio being 1.94:1. Majority of the patients were i.e. 34% (24% males & 10% females) in the 21-30 years age group. There was no case in the age group of 0-10 years in both males and females. The minimum age was 16 yrs both in males & females. The maximum age was 63 years in males and 42 yrs in females in our study. Table 2: Incidence & Distribution of Religion Male Female Total Religion No. %age No. %age No. %age Hindu 14 28% 04 08% 18 36% Sikh 15 30% 13 26% 28 56% Christian 04 08% ----- ------ 04 08% Total 33 66% 17 34% 50 100% A large chunk (56% patients) belonged to Sikh religion followed by Hindus (36%) of all poisoning cases. Out of these 30% were males and 26% were females in Sikh community and 28% males, 08% females in Hindu community. There were 08% males & no female from Christian community. (Table 2) Table 6: Mortality Rate in Alphos Poisoning Expired Survived No. of patients No. %age No. %age 50 38 76% 12 24%
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