IntroductionSuicide is a Latin word, 'sui' means to kill oneself. It is an act of taking one's own life voluntarily and

1intentionally. Suicide has been committed by people from all walks of life since the beginning of known history. Suicide is often interpreted as a cry for help and attention or to express despair and the wish to

2escape rather than a genuine intent to die.Poisoning is a harmful effect that occurs when a toxic substance is swallowed, inhaled, or comes in contact with the skin, eyes or mucous membranes. The damage caused by poisoning depends on the poison,

3Aluminium Phosphide = 56 %the amount utilized, the age, and the underlying Inert ingredients = 44 %health of the person who takes it. We chose to Paraffinconduct this study in order to evaluate morbidity,

mortality and outcome associated with the intake of Aluminium phosphide is an inorganic phosphide wheat pills during the hospital stay. used to control insects and rodents in a variety of settings. It is mainly used as an indoor fumigant at

4crop transport, storage or processing facilities. It may be used as an out door fumigant for burrowing

5rodents and mole control.

It is available in the form of pellets, tablets, porous

Material and Methods

having previous prostate surgery or history of stricture urethra were excluded from the study. The parameters studied were patients' age, residual urine, traces of uroflowmetry, maximum flow rate (Q ), average flow rate (Q ), flow time and voided max ave

volume.10-15 ml as equivocal and > 15 ml as unobstructed. SPSS version 15 was used for statistical analysis. For the significance level One sample T test

Computer record of uroflowmetry between March 2005 and February 2006 was checked. Patients above the age of 50, having IPSS >20 and post void micturitional residual urine less than 100 ml and voided urine volume greater than 150 ml were included in the study. Patients

Wheat PillChemical composition

Use

Availability:

Rabia Rathore and Muhammad Zafar Ullah Khan

19

Morbidity, Mortality and Management of Wheat Pill Poisoning

Original Article

Background:

Methods:

Results:

Conclusion:

Keywords:

Suicide is one of the leading causes of death worldwide. People adopt different ways to commit suicide.

We enrolled 50 patients presenting to emergency department, Mayo Hospital, Lahore with intake of wheat pills with suicidal intention. The end point was death, discharge or leaving hospital against medical advice. The study was designed to know the effects of wheat pill on various systems of the body and its outcome.

Of the total 50 patients studied, 28 (56%) were males and 22 (44%) were females. 35 (70%) patients died, 8 (16%) were discharged and 7 (14%) left against medical advice. Wheat pill containing Aluminium Phosphide is easily available, cheap and without any ban on its sale. General awareness about the lethal effects of its ingestion should be created among masses and efforts be made to impose legal restrictions on its sale.

It can be concluded that wheat pill poisoning is becoming very common as a mode of committing suicide. Since wheat pill is highly toxic, mortality is significantly higher and painful. Wheat pill is freely available and very cheap so awareness should be created among rural areas and urban peripheries regarding its toxicity and high mortality. A legal ban should be imposed on its over the counter sales. Its possession should be authorized to personnel trained in proper storage and dispensing.

Suicide, Wheat pill, poisoning, arrhythmias, Aluminium Phosphide

blister packs, sachets or powder. causes cation disturbances that alter transmembrane potentials. Ultimately cardiac

Mechanism of Action: arrest, peripheral vascular collapse and Metal phosphides liberate Phosphine gas after pulmonary edema may occur. Pulmonary coming in contact with moisture of grains or edema and pneumonitis are believed to result water or HCL of the stomach after ingestion. from direct cytotoxicity to pulmonary cells. In Other gases liberated are Ammonia (NH3) and fatal cases, centrilobular necrosis of heart has Carbon dioxide (CO2).6 been reported.7

Most deaths occur within first 12-24 hours after Pathophysiology: exposure and are cardiovascular in origin. After 1. It causes non-competitive inhibition of 24 hours usual cause of death is liver failure.8 cytochrome e-oxidase leading to inhibition of mitochondrial oxidative phos Chronic Exposure:phorylation which in turn leads to multiorgan Chronic exposure to very low concentrations dysfunction. may result in anemia, bronchitis, gastrointestinal 2. Once absorbed into the body phosphine can disturbances and usually speech and motor damage cell membranes and enzymes important disturbances.for respiration and metabolism like decrease in Carcinogenicity:catalases and increase in harmful enzymes like The EPA has determined that phosphine is not superoxide dismutases etc. classifiable as to its human carcinogenicity9. 3. It has been seen that phosphine causes decrease in Magnesium intracellularly and its Reproductive and Developmental Effects:concentration increases extracellularly. Phosphine is not included amongst reproductive 4. When phosphine is inhaled it can react with and developmental toxicants, No teratogenic moisture in the lungs to form phosphoric acid effects from acute exposure are known.which can cause blistering and edema leading to ARDS. Table: system wise symtomatology pertaining to 5. I t a l so causes the denatur ing o f wheat pill poisoning. oxyhaemoglobin leading to decreased Oxygen delivery to body tissues. 6. Local trauma to the gastric tissues leading to gastritis.

Characteristics of Phosphine Gas:Description colorless gas, odor of garlic or decaying fish.Molecular weight 34.0 Daltons.Melting point: - 209o F (-134o C)Boiling point -126o F (-87.7o C) (at 760 mmHg)Vapour pressure > 760 mmHg at 68o F (20o C)Gas density: 1.17 (air = 1)Water solubility: Slightly water soluble (0.3 % at 68° F (2°c)Flammability: Extremely flammable and explosive, may ignite spontan- Management Guidelines for Wheat Pill eously on contact with air. Poisoning

There is no specific antidote for wheat pill Acute Exposure: (Aluminium phosphide). Supportive measures Phosphine interferes with enzymes and protein are done till phosphine is excreted.synthesis primarily in mitochondria of heart and § Brush all visible particles from clothes, skin lungs.7 Metabolic changes in heart muscles and hair. Thoroughly flush exposed skin and

System Symptoms

G.I.T. 100% Thirst, nausea, vomiting, burning

epigastrium, abdominal cramps.

CVS 100% Hypotension, shock, brady/tachy-

congestive cardiac failure and ult-

-cardia, arrhythmias, myocarditis,

Respiratory Dyspnoea, crackles/ rales, pulmo- nary edema (ARDS), chest tight-50-60% -

-ness, cough.

20-30% raised transaminases, increased

bilirubin.

Renal 5-10% oliguris, proteinuria, bematuria or acture renal failure.

CNS Anxiety, apprehension, restlessn-

ess, convulsions, coma, headac=

he, dizziness, impaired gaist, do-

uble vision.

Electrolytes Blood gas analysis reveals combi- ned respiratory and metabolic aci- dosis. There is hepomagnesaemia

-mately cardiac arrest.

Hepatobiliary Jaundice, tender hepatomegaly

hair. Thoroughly flush exposed skin and hair with water for 3-5 minutes; then wash with mild soap. - Oxygen is delivered through face mask at §If Phosphides have been ingested, do not induce moderate flow rates of 5-10 litres/min. 100

emesis. percent of oxygen to achieve PaO of 60-70 2

§Confirm the presence of wheat pill poisoning by percent with lowest FiO 2use of AgNO (Silver Nitrate) paper. This can be 3 - Mechanical support is needed if above measures done by placing Silver Nitrate paper in front of fail. patient's mouth and asking him or her to exhale repeatedly; the colour of the paper will turn black

10 No agent of proven efficacy as it rapidly binds to in case the patient is phosphine gas positive. enzyme systems and produces cellular dysfunction. §Gastric lavage with 1:1000 potassium ++However, Mg is thought to have anti peroxidant, permanganate – till patient is confirmed anti arrhythmic and membrane stabilizing effects, phosphine gas negative by silver nitrate paper.hence, has been tried with some success.§Slurry of activated charcoal at 1 mg/kg (adults 60-

90 gm) orally or through a nasogastric tube. Mineral oil or coconut oil may be used for gastric

ØOne gm of Magnesium Sulphate IV stat, thenlavage.ØOne gm after every hour for next 3 hours and §Maintain two intravenous lines with wide bore

then canula.ØOne gm after every 4-6 hours up to a maximum

of 5 days.With this dose, serum Magnesium levels remain between 3.0 to 4.6 mEq/L which is safe. Lower and higher doses have been employed without

ØIntravenous fluids (3-4 liters of fluid out of which any success.50% should be normal saline under CVP Another regime for giving MgSO is 3 gm of MgSO 4 4

guidance. in 500 ml of Dextrose water in first three hours, ØDopamine (4-6 ug/kg/min) with Dobutamine to followed by 6 gm of MgSO4 in 500 ml of Dextrose

keep the systolic blood pressure above water over 24 hours starting next day and continued 100mmHg. for 3-5 days.

ØIntravenous hydrocortisone 200-400 mg after Intravenous Sodium Bicarbonate 50-100 meq in 1000 every 4-6 hours to be administered ml normal saline every 8 hours to keep bicarbonate a. To reduce the dose of dopamine level around 18-20 meq and pH above 7.1 (300 b. To check capillary leakage in lungs. meq/day)c. To potentiate responsiveness of shock to

endogenous catecholamines.d. To compensate for low levels of cortisol

ØPhosphine is stable and is excreted through found in cases with severe poisoning.

breath and partially in the urine.ØSteps to enhance its excretion through urine:

ØPatent airway & Oxygen inhalation through a. Adequate hydration.mask. b. Renal perfusion by IV fluid and

ØAssisted ventilation if needed. c. Low dose dopamine (4-6 ug/kg/min).ØMonitor blood gas analysis 4 hourly. ØDiuretics and dialysis are not employed due to

haemodynamic instability, however may be used if patient develops acute renal failure and ØAmiodarone has been claimed to be of some becomes haemodynamically stable. success in a study.

ØMagnesium sulphate has been tried with success in reversion of supraventricular and ventricular arrhythmias. It has anti peroxidant effect and Admission and Follow-upremains stable in hypoxic cell environment. ·Monitoring of delayed effects

ØAtropine is not effective to combat bradycardia or - Pulmonary edema and liver damage may be bradyarrhythmias of this poisoning. delayed for 72 hours or more so patients with

Adult Respiratory Distress Syndrome

Steps to reduce systemic toxicity

Dosage Schedule

Treatment of Sequel or other related problemsShock

Steps to Increase Ph Excretion3

Hypoxia

Arrhythmias

Post Hospital Management

involvement with intense thirst, 5(10%) patients - significant exposure should be admitted and developed pulmonary edema and none of the patient observed carefully (survival for 4 days usually had renal involvement. predicts full recovery).

·Patient release 12- Asymptomatic patients with normal initial Suicide is a leading cause of death world wide. There

examination, minimal exposure, and no signs of are four major groups of people who commit suicide. toxicity after observation for 4 to 6 hours may be By far the greatest number falls into situational discharged with instructions to return to the problems i.e. patients commit suicide in younger age emergency department if symptoms of toxicity groups usually due to unsuccessful love affairs and develop. social inhibitions, economic situations due to

13joblessness and failure in examination. In fourth decade it is usually a fight with spouse or financial problems, whereas in old age usually due to family ØFactors:inattention or chronic illness, otherwise suicidal - Freshness of pills. attempt is clearly a stratagem for controlling or - Dose consumed.hurting others. Suicide can be attempted due to severe - Onset of symptoms.depression or psychiatric illness. The gender ratio in - Emptiness of stomach i.e. vomiting etc. our study is similar to accepted view of male

- Delay in arrival in hospitaldominance that has been reported in many countries

- Delay in institution of therapy. 14as well as in other local studies. ØMortality

Suicide is the second common cause of mortality in - Supportive therapy alone 70-100 %

15-34 year olds. The rate increases with age peaking - Supportive therapy & Magnesium Sulphate 25-45 15

for women in their sixties and men in their seventies. %In our study 40 patients were in the age group of 10-30 years, 7 patients were in the age group from 30-60 years whereas only 3 patients over the age of 60 years

Fifty patients were enrolled who presented to the committed suicide. The finding goes against the emergency of West Medical Ward, Mayo Hospital, increasing incidence of suicide with age. Lahore with history of ingesting wheat pills with Patients presenting to emergency with intake of suicidal intention during the period between August wheat pills usually belong to rural areas who indulge 2006 and April 2007. End point was leaving the in out door activities of harvesting, processing and hospital either dead, discharged or leaving against storage of crops. The higher mortality is associated medical advice. with intake of freshly bought wheat pills from the

market (probably freshly prepared), intake of more than one pills and time lapse of more than 4 hours before coming to emergency.Of the total 50 patients studied, 28 (56%) were males It can be concluded that wheat pill poisoning is and 22 (44%) were females. 35 (70%) patients died, 8 becoming very common as a mode of committing (16%) were discharged and 7(14 %) patients left suicide. Since wheat pill is highly toxic, mortality is against medical advice. Age distribution showed 10 significantly higher and painful. Wheat pill is freely patients were in second decade (11-20 years), 22 available and very cheap so awareness should be patients in third decade (21-30 years), 8 patients in created among rural areas and urban peripheries fourth decade (31-40 years), 7 in fifth decade (41-50) regarding its toxicity and high mortality. A legal ban and 3 in sixth decade (50-60 years).should be imposed on its over the counter sales. Its 35 (70 %) out of 50 patients had cardiac involvement possession should be authorized to personnel i.e. 12 patients had atrial fibrillation, 4 had ventricular trained in proper storage and dispensing. fibrillation, 4 had ventricular tachycardia, 5 had

complete heart block, 2 developed sinus bradycardia and 8 patients had non specific T wave and ST

Department of Medicine,segment changes. 19 (38%) patients had CNS King Edward Medical College, involvement i.e. became very irritable. 6 (12%) theesculapio@hotmail.compatients had hepatic involvement with raised

www.sims.edu.pk/escuplapio.html.aminotransferases, 30 (60%) patients had GIT

Discussion:

Mortality (50-90 %)

Patients and Methods

Results

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2. Bluglass R, Bawden P (eds). 6. Klimmer OR. Contribution to PL. Beneficial effect of Principles and practice of the study of action of phosphine. xan th ino l n ico t ina te in F o r e n s i c P s y c h i a t r y . Archiv fur Toxikologie, 1969; exper imental a luminium Edinburgh: Churchill Living 24 (23): 164-187. phosphide poisoning. Indian Stone; 1990: 213-606. 7. Leuschner F. Evaluation of the Journal of Pharmacology 1992,

3. Royal Society of Chemistry. acute toxicity of Phostoxin 24: 134-137.1991 (as updated). The (Active ingredient: aluminum 12. Maris RW. Suicide. Lancet Agrochemicals Handbook, phosphide) to rainbow trout. 2002; 360:319-326.Royal Society of Chemistry Laboratory for Pharmacology 13. Kim WJ, Singh T. Trends and I n f o r m a t i o n S e r v i c e s , and Toxicology. Hamburg, dynamics of youth suicides in Cambridge, UK. German Federal Republic 1984. developing countries. Lancet

4. Garry VF, Griffith J, Danzl TJ, 8. Waseem T, Bhatti NB, Khan 2004; 363: 1090-1091.Nelson RJ, Whorton EB, AH, Nasir N. Acute poisoning 14. Sultana K. Proportion of Krueger LA et al. Human due to wheat preservative suicidal deaths among autopsy. g e n o t o x i c i t y : p e s t i c i d e aluminum phosphide. Pak J. Ann Abbasi Shaheed Hosp Khi applicators and Phosphine. Cardiol 1997; 8(3-4): 43-48. Med Dent Coll 2002; 7:317-8.Science 1989;246(35): 251- 9. U.S. Environmental Protection 15. Snowdon J. Suicide rates and 254. Agency. 1994. File: Aluminum methods in different age

5. Newton PE, Shroeder RE, Phosphide Integrated Risk groups: Australian data and Sullivan JB, Busey WM, Banas Information System (IRIS) US perceptions. Int J Geriatr DA. Inhalation toxicity of EPA, Washington, DC. Psychiatry 1997; 12 (2): 253-8.Phosphine in the rat: acute, 10. Chugh SN. Metal Phosphide

References