الفهرس 
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Abstract
Aluminum phosphide is a solid pesticide that is considered one of the major causes of poisoning as it is used broadly due to its ideal properties and powerful effect.
Its low cost, easily availability and high toxicity with low survival rate, combined with the lack of definitive treatment or antidote for acutely poisoned patients, resulted in a significant public health problem in Egypt and worldwide.
Aluminum phosphide emits a highly toxic phosphine (PH3) gas when exposed to moisture and an acidic environment.
Phosphine gas induces mitochondrial dysfunction by inhibiting the cytochrome C oxidase and adenosine triphosphate (ATP) formation.
In addition, it inhibits antioxidant enzymes like catalase (CAT) and releases reactive oxygen species (ROS), resulting in cellular apoptosis and various organs damage especially those with the greatest oxygen requirement such as brain and heart.
Aluminum phosphide and phosphine gas have a direct corrosive effect added to their systemic toxic effect on body systems, especially the cardiovascular system.
Several studies reported that mortality rate from ALP poisoning exceeds 68%, where refractory hypotension and severe metabolic acidosis are the two most common presentations of poisoning.
Evaluation of prognostic factors is a vital step to improve treatment and outcome in ALP intoxicated cases.
The present study aimed at evaluating the value of APACHE II and SOFA scores in the prediction of outcome in patients with aluminum phosphide poisoning admitted to the PCC-ASUH and construction of a simple crucial predictive score for aluminum phosphide poisoning cases.
This study was conducted on 110 adult patients of both sex presented to the PCC-ASUH with acute ALP poisoning during the period from the beginning of August 2022 to the end of April 2023.
An informed written valid consent was taken from the patients or their relatives. Approval of the Research Ethical Committee of Ain Shams university was obtained. All personal data were kept anonymous to ensure confidentiality of records.
The diagnosis of acute ALP poisoning was established according to history of exposure and clinical examination. Patients under 16 years, pre-existing chronic diseases, pregnant females and mixed intoxication were excluded from the study.
Investigations were done for every patient on admission were: Arterial blood gases (ABG), random blood glucose, serum sodium & potassium levels, serum creatinine, liver enzymes (ALT, AST & total bilirubin), complete blood count (TLC, platelet count & hematocrite value) and Electrocardiogram (ECG).
Outcome of the studied patients was recorded whether complete recovery and discharge, death or development of complications.
The current study showed that the median age of acute ALP poisoned patients was 22.5 years (18–31) and the majority of cases were males (51.8%) while females represented 48.2%.
Regarding the residence, most of the studied patients were from Elfayoum (34.5%), 27.3% from Cairo, 18.2% from Elkalyoubia, 14.5% from Beni-Suef and 5.5% only from Giza.
The median delay time was 4 hours (2-5) in the studied groups. Regarding the ingested amount of ALP, more than half of cases (59.1%) ingested one tablet, 20.9% half tablet, 7.3% two tablet and 12.7% ingested unknown amount with a highly statistical significant difference between both groups.
All the studied patients took ALP through ingestion. As regards the manner of poisoning, the majority of patients (95.5%) attempted suicide while 4.5% only exposed to it accidentally with statistical significant difference between both groups.
Concerning the preconsultation treatment, 22.7% of the studied patients received preconsultation treatment in the form of IV fluids (16.4%), IV NaHCO3 (10.9%), antiemetic drugs (5.5%), proton pump inhibitors (3.6%) and hydrocortisone (0.9%). Proton pump inhibitors only showed a statistical significant difference between the studied groups.
Preconsultation gastrointestinal decontamination (Gastric lavage) was done in 50% of cases. The majority of cases received paraffin oil (43.6%), 1.8% coconut oil, 1.8 % potasium permenganat, 0.9% saline, 0.9% NaHCO3 and 0.9% received castor oil.
Regarding vital data, the mean heart rate was 92.90 ± 20.6 beat/minute. More than half of patients (58.2%) had normal pulse, while 36.3% were tachycardic and 7.27% only had bradycardia.
There was a highly statistical significant decrease in blood pressure (systolic, diastolic and mean arterial blood pressure) and temperature and increase in respiratory rate in group II when compared with group I.
Concerning skin examination, pallor and cold extermities noticed nearly in half of the studied patients while cyanosis noticed only in 4.5% of cases.
The most common gastrointestinal symptoms were vomiting and colic that occurred in 89.1% and 52.7% of the studied patients respectively while diarrhea occurred only in 8.2% of patients.
Respiratory system examination revealed that respiratory distress was observed in 16.4% of the studied cases and coarse crepitations in 8.18% that were found only in group II.
Regarding cardiovascular manifestations, more than half of patients (59.1%) had shock while chest pain was found in 10% of patients.
Regarding neurological manifestations, majority of the studied patients (72%) were conscious while 28.2% of them had disturbed conscious level and 14.5% developed agitation. The mean glasgow coma scale (GCS) was 14.34±0.95 ranged from 12 to 15.
There was a statistical significant difference between the studied groups as regards all clinical manifestations.
Regarding arterial blood gas analysis, there was a highly statistical significant decrease in group II compared with group I as regards values of PH, HCO3 and PO2 while there was non statistical significant difference as regards PCO2 value.
The median of random blood sugar was 105 mg/dL (87–141) with a non statistical significant difference between the studied groups.
As regards serum sodium, there was a statistical significant difference between the studied groups while there was a non significant difference in serum potassium between the the studied groups.
Concerning serum creatinine, there was a highly statistical significant increase in group II compared with group I with mean value 1.04 ± 0.49.
As regards liver enzymes, ALT and total bilirubin were statistically increased in group II when compared to group I, while there was a no significant difference regarding AST level between the studied groups.
Concerning total leukocytic and platelet count, they showed a statistical significant difference between the studied groups while hematocrite value showed a non statistical significant difference between both groups.
Electrocardiographic abnormalities were observed in 68.2% of the studied patients. The most common ECG abnormalities were sinus tachycardia 30%, followed by ventricular tachycardia (28.2%), prolonged QTc (23.6%) and wide QRS complex (14.5%).
Statistical analysis reveled that there was a statistical significant difference between the studied groups as regards sinus bradycardia, prolonged QTc, wide QRS complex, ST segment depression, inverted T wave, supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, atrial fibrillation and right bundle branch block
However, sinus tachycardia, ST segment elevation, premature ventricular contractions and left bundle branch block showed a non statistical significant difference between both groups.
The mean duration of ICU stay was 1.05±0.79 days with a highly statistical significant difference between the studied groups.
Outcome of the studied patients was determined as the following; more than half of the studied patients (52.7%) died and 47.3% were recoverd and discharged.
from the complications which had been developed in acute ALP intoxicated patients were cardiogenic shock (59.1%), cardiac arrest (52.7%), need for mechanical ventilation (43.6%), myocardial infarction (22.7%) and pericarditis (3.6%).
APACHE II and SOFA scores were applied on 110 patients of acute ALP poisoning to evaluate their values in the prediction of outcome.
The median of APACHE II score was 9 (4-13) and ranged from 0 to 24 while the median of SOFA score was 5 (0-8) and ranged from 0 to 11. There was a highly statistical significant increase in the median and range of APACHE II and SOFA scores in group II when compared with group I.
By applying receiver operating characteristic (ROC) curve analysis to predict the mortality. The cut off point of APACHE II score was > 6 and AUC was 0.969 with 98.28% sensitivity and 86.54% specificity with positive predictive value of 89.1% and negative predictive value of 97.8% while, the cut off point of SOFA score was > 2 and AUC was 0.983 with 100% sensitivity and 86.54% specificity with positive predictive value of 89.2% and negative predictive value of 100%.
By applying univariate and multivariate logistic regression analysis of variables associated with mortality in patients with ALP poisoning, an initial univariate logistic regression analysis determined that GCS, MAP, respiratory rate, PH value, HCO3 level, PO2, serum creatinine, AST, ALT, total bilirubin, TLC and abnormal ECG findings were significant for predicting mortality.
Furthermore, a multivariate logistic regression analysis revealed that GCS, MAP, PH value, HCO3 level, PO2 and abnormal ECG findings were the most predictive factors of mortality.
According to the results of multivariate regression analysis and beta (β) coefficient, each risk index was assigned to make logistic scoring system including PO2, PH, GCS, MAP, HCO3, and abnormal ECG parameters.
According to ROC curve analysis of these six parameters, the cut off value of PO2 was < 90% mmHg, PH <= 7.28, GCS <=12, MAP <70 mmHg, HCO3 <= 12.6 mEq/L were able to predict mortality in this study.
A new ALP scoring system was then constructed of six parameters each took a constant logistic score to give a total score of 33. It consists of PO2 < 90% which took 8 points, PH <= 7.28 took 7 points, glasgow coma scale <=12 took 6 points, mean arterial pressure <70 took 5 points, HCO3 <= 12.6 took 4 points and abnormal ECG took 3 points.
The new ALP predictive score was applied on 110 patients with acute ALP poisoning to show that the median of the new score was 20 (0 – 27) and ranged from 0 to 33 with a significant increase in the median and range of the predictive score in group II when compared with group I.
By applying receiver operating characteristic (ROC) curve analysis for the new predictive score, the best cut off point of the new score was > 19 and AUC was 0.999 with 96.55% sensitivity and 100% specificity with positive predictive value of 100% and negative predictive value of 96.3%.
from the current study, it is concluded the higher sensitivity and specificity values with excellent AUC value which reflect the usefulness of the new ALP predictive score and recommended its use as a simple method to predict the outcome of acute ALP poisoned patients in the emergency room.