Wheat Pill; Efforts to curtail mortality

1. In the name of Allah,
the most beneficent,
the most merciful.

2. Wheat Pill Poisoning
Pathophysiolo
gy and
Management

3. SUICIDAL POISON

4. INCIDENCE

5. Chemistry of Wheat Pill
• Control rodents and
insects in different
types of settings.
• Act as indoor and
outdoor fumigant.
USES
• Tablets
• Pellets
• Powder
AVAILABILITY
• AlP
CHEMICAL
FORMULA
• Celphos
• Fumitoxin
• Phostoxin
• Quick Phos
TRADE
NAMES

6. Biochemistry
Due to ingestion of wheat pills
different types of gases are
liberated when metal phosphide
comes in contact with water or
HCl present in the stomach such
as;
•Phosphine gas,
•Ammonia
•Carbon dioxide.
Among all gases the most toxic
and dangerous gas is phosphine
gas.
FATAL DOSE: 0.15gm to 0.5gms
AlP + H2O AlP + Acid

7. Pathophysiology
Phosphine has following
effects:
Non-competitive
inhibition of
cytochrome e-oxidase
leading to inhibition of
mitochondrial oxidative
phosphorylation.
Damages cell
membranes &
enzymes after
absorption like
decreasing catalases
& increasing
superoxide
dismutases.
Inhaled phosphine forms
Phosphoric Acid with
moisture in lungs causing
blisters & edema leading
to ARDS.
Decrease in
oxyhaemoglobin.
Decrease in
intracellular
Magnesium
Local trauma to
gastric wall
causing Gastritis.

8. Inhibits
Cytochrome
oxidase
Gastritis
ARDS
Destabilizes
Membranes
Denatures
OxyHb

9. ACUTE
EXPOSURE
• Metabolic changes in
heart muscle causing
cation disturbances that
alter trans-membrane
potentials resulting in
Cardiac Arrest.
• Pulmonary Edema &
Pneumonitis from direct
cytotoxicity.
• Death in first 12-24 hours
due to cardiovascular
events, post 24 hours
mostly due to liver failure.
CHRONIC
EXPOSURE
• Anemia
• Bronchitis
• Gastrointestinal
disturbances
• Speech & motor
disturbances

10. Signs & Symptoms
System Involved Signs & Symptoms
GIT 100% Thirst, burning, nausea, vomiting, epigastric pain and abdominal cramps
CVS 100% Hypotension, shock, brady/tachycardias, arrhythmias, myocarditis, congestive cardiac failure ultimately cardiac arrest!
Respiratory 50-60% Dyspnea, crackles/rales, pulmonary edema(ARDS) chest tightness, cough
Hepato-biliary 20-30% Jaundice, tender hepatomegaly, raised transaminases
Renal 5-10% Oliguria, proteinuria, hematuria, ARF
CNS Anxiety, convulsions, headache, dizziness, impaired gait, double vision, coma
Electrolytes Combined Respiratory & Metabolic Acidosis plus Hypomagnesemia.

11. Management
There is no specific antidote for this poison. So supportive
measures have to be effectuated till it gets excreted.
GETTING RID OF THE POISON IS THE FIRST STEP!
Thoroughly flush exposed skin & hair with water and then with
soap by brushing.
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. It’s more
useful in first 2 hours of intake
Use slurry of activated charcoal orally or by using nasogastric (NG)
tube. Its dose is 1mg/kg (60 gm for adult). Mineral or olive oil may
also be used.
Maintain two IV lines with wide cannulas.
Do not induce emesis if the pill ingestion has been confirmed.

12. TREATMENT OF SEQUELAE
SHOCK
Intravenous fluids
Infuse Dopamine & Dobutamine
in order to maintain systemic
blood pressure above 100mm Hg.
Administer Intravenous
hydrocortisone (200 to 400 mg)
after every 4 to 6 hours to
•Reduce dose of dopamine
•Check capillary leakage in lungs
• Potentiate responsiveness to
endogenous catecholamines
•Compensate for low levels of
cortisol
HYPOXIA
Patent airway
(intubate if
necessary)
and oxygen
inhalation
Monitor
Arterial Blood
Gases 4
hourly.

13. ARRHYTHMIAS
• 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.
• Atropine is not found to be much
effective in bradyarrhythmias caused by
this poison.
Adult Respiratory Distress
Disorder
Deliver oxygen via face mask
at a rate of 5-10 liters/min.
Mechanical support can also
be provided if necessary.

14. STEPS TO REDUCE SYSTEMIC
TOXICITY
No agent of proven efficacy as it
rapidly binds to enzymes systems
and produce cellular dysfunction.
However Mg++ is thought to have
anti per-oxidant, anti arrhythmic,
and membrane stabilizing effects
and has been used with
somewhat success
Dosage of MgSO4 Two regimens
1st: 1gm of MgsO4 IV stat Then
1gm every hour for next three
hours Then 1 gm IV 4-6 hourly up
to a maximum of 5 days
2nd: MgSO4 3gm in 500ml D/W in
first three hours Then MgSO4
6gm in 500ml D/W for 24hrs
starting from next day and
continued for 3-5 days. With this
dose serum magnesium level
remains b/w 3.0-4.6 mEq/L which
is safe.
STEPS TO INCREASE PHOSPHINE EXCRETION
& MAINTENANCE OF ACID BASE BALANCE
Ph3 excretion Phosphine is excreted through
breath and partially through urineSteps to
enhance its excretion through urine:
• Adequate hydration
• Renal perfusion by IV fluids Low dose dopamine 4-
6ug/kg/min
• Diuretics and dialysis are not employed due to
hemodynamic instability, however may be used if patient
develops acute renal failure, severe acidosis or fluid overload
and becomes hemodynamically stable

15. SUMMARY OF STEPS OF MANAGEMENT
•IF PATIENT PRESENTS WITHIN 1-2 HRS, GASTRIC LAVAGE WITH KMNO4 or OLIVE OIL 250-
500 ML. (NO WATER BASED LIQUIDS) UNTIL THE SILVER NITRATE PAPER DETECTS NO
PHOSPHINE.
•Inj-MgSO4 , 1GM X STAT , THEN 1G EVERY 1 HOUR FOR 3 HOURS,AND THEN 1G 4
HOURLY.(24-48 HOURS)
•Inj. CALCIUM GLUCONATE 10% , 10 ML OVER 10 MIN SLOW IV STAT AND THEN 4
HOURLY(24-48 HOURS)
•Inj. Hydrocortisone 100 MG I.V STAT THEN 4 HOURLY (24-48 HOURS)
•Inj. NaHCO3 50-100 mEq WITH DILUTION,AND THEN 4 HOURLY (24-48 HOURS)
•Inj. OMEPRAZOLE 40MG IV STAT THEN 12HOURLY.
•VERY CLOSE VITAL SIGNS & ECG MONITORING for MYOCARDIAL FAILURE AND SEVERE
ACIDOSIS - ABGs 12 HOURLY.
•I.V.FLUIDS ACCORDING TO HAEMODYNAMICS (CAREFUL REPLACEMENT AFTER 12-24
HOURS DUE TO TOXIC MYOCARDITIS/LVF)
•INOTROPS(DOPAMINE,DOBUTAMINE,NOR-ADRENALINE) THROUGH CV LINE,TARGET MAP
65 mmHg.
•INTUBATE / VENTILATE ACCORDING TO PATIENT CLINICAL STATUS / ACIDOSIS
•KEEP NPO (24-48HRS)
•ROUTINE LABS, TROP-I, CARDIAC ENZYMES, ECG, CXR all 12HRLY.
•ANTI-ARRYTHMICS (CARDARONE 150MG IVI OVER 10 MIN,LOAD AS PER CONDITION) in
case of arrhythmia.
•INFORM THE FAMILY ABOUT THE GUARDED PROGNOSIS.
INFORM ICU (INTENSIVE
CARE UNIT) TEAM AND
BETTER SHIFT TO ICU FOR
AT LEAST 48 - 72 HOURS.

16. TAKE HOME MESSAGE
With these steps, mortality can be pruned from about 90 percent to
around 65-70 percent. But still this is a very high mortality rate and
these are all only endeavours to curtail it. So the attendants must be
warned and counselled about the worst outcome.
THANK YOU
By
Arsalan
Masoud