Survival following Severe Aluminum Phosphide Poisoning with Refractory Shock, Lactic Acidosis, and Multi-organ Involvement

Abstract Aluminum phosphide (ALP) poisoning is a leading cause of suicidal death in rural South Asia, carrying a case fatality rate exceeding 70% in most published series. No specific antidote exists. Mortality is closely linked to the severity of refractory cardiogenic and distributive shock and the rapidity with which supportive treatment is initiated. A 29-year-old male presented approximately 2 h after intentional ingestion of two tablets of ALP (estimated total dose 6 g of elemental ALP). On arrival, the patient was hemodynamically unstable (blood pressure 70/30 mmHg; heart rate 120 bpm) with distributive shock, altered mentation, tachypnea, and oxygen saturation 95% on room air. Arterial blood gas analysis demonstrated severe lactic acidosis (pH 7.33; lactate 5.5 mmol/L; bicarbonate 12.7 mmol/L). Electrocardiography revealed supraventricular tachycardia with premature ventricular complexes and diffuse ST-T wave changes. Serial investigations documented transient acute kidney injury and pronounced hepatic transaminase peaking on Day 5. The patient was managed in the medical intensive care unit (ICU) with immediate gastric lavage, dual vasopressor support (norepinephrine and dopamine), intravenous sodium bicarbonate, magnesium sulfate, colloidal resuscitation with 20% albumin, and corticosteroids. Hemodynamic improvement occurred within 6 h following initiation of multimodal hemodynamic support that included colloid infusion. Metabolic acidosis and cardiac rhythm abnormalities resolved by Day 3. Renal and hepatic dysfunction recovered fully by the 3 rd week. The patient was discharged neurologically intact on Day 21 with psychiatric follow-up arranged. This case documents survival following ALP poisoning complicated by refractory shock, severe lactic acidosis, dysrhythmia, aspiration pneumonia, acute kidney injury, and significant hepatotoxicity. Early presentation, prompt gastric decontamination, and aggressive multi-modal ICU support were the principal determinants of the favorable outcome. This case highlights rapid hemodynamic recovery despite vasopressor-refractory shock and demonstrates the potential reversibility of severe multi-organ dysfunction following aggressive early multimodal ICU support.