Persistence of yellow phosphorus paste in gastric content beyond one hour: an observational study using bedside
Neithiya T1, Krishnadutt Chavali1
1Department of Forensic Medicine & Toxicology, All India Institute of Medical Sciences (AIIMS), Raipur, Chhattisgarh, India.
Insights
Yellow phosphorus poisoning requires timely decontamination. This study found phosphine activity persisted up to 24 hours, challenging the one-hour guideline and suggesting activity-guided decontamination for yellow phosphorus ingestion.
Area of Science:
- Toxicology
- Emergency Medicine
- Gastroenterology
Background:
- Yellow phosphorus poisoning is a significant cause of death in South Asia.
- Current guidelines recommend decontamination within one hour of ingestion, based on limited human data regarding intragastric persistence.
- Bedside assessment of gastric activity could improve decontamination decisions, especially for delayed presentations.
Purpose of the Study:
- To investigate the duration of intragastric persistence of yellow phosphorus paste.
- To evaluate the effectiveness of decontamination strategies in yellow phosphorus poisoning.
- To challenge the strict one-hour decontamination time limit.
Main Methods:
- An observational study of 22 patients presenting within 24 hours of yellow phosphorus paste ingestion.
- Gastric aspirates were tested for phosphine activity using silver nitrate and molybdate assays.
- Data on demographics, presentation time, decontamination, organ dysfunction, and outcomes were collected.
Main Results:
- Phosphine activity was detected in 36.3% of patients up to 24 hours post-ingestion.
- Gastric lavage was associated with survival; all patients who received it survived.
- Deaths and major organ failure occurred exclusively in patients who did not receive gastric lavage.
Conclusions:
- Reactive yellow phosphorus material can persist in the stomach for up to 24 hours.
- Findings challenge the conventional one-hour decontamination limit for yellow phosphorus ingestion.
- Activity-guided decontamination strategies warrant further investigation.
Introduction:
Yellow phosphorus poisoning remains a major cause of morbidity and mortality in South Asia. International toxicology guidelines restrict decontamination to within one hour of ingestion, despite limited human evidence defining the duration of intragastric persistence of yellow phosphorus paste. Objective bedside assessment of ongoing gastric activity may help refine decontamination decisions, particularly in delayed presenters.
Methods:
This observational study included 22 consecutive patients presenting within 24 hours of confirmed yellow phosphorus paste ingestion to a tertiary care emergency department over a five-year period. Gastric aspirates were tested using a silver nitrate assay with confirmatory molybdate testing. Demographic data, time to presentation, decontamination measures, organ dysfunction, and in-hospital outcomes were recorded. Given the small sample size over five years, analyses were descriptive.
Results:
Silver nitrate positivity indicating phosphine activity was detected in 8 of 22 patients (36.3%). Positivity was observed in all patients presenting within one hour (2/2), remained frequent at 2-8 hours (4/9, 44%), and persisted at 8-24 hours after ingestion (2/11, 18%). Gastric lavage was performed in nine patients (40.9%), while activated charcoal was administered in four patients, all in combination with gastric lavage. All nine patients who underwent gastric lavage survived. All six deaths (27.3%), due to refractory shock (n = 2) or acute hepatic failure (n = 4), occurred among patients who did not undergo gastric lavage. Major organ failure, mechanical ventilation, and vasopressor use were confined to the non-gastric lavage group.
Discussion:
Detection of gastric phosphine activity across all presentation windows provides clinical evidence that reactive yellow phosphorus material may persist well beyond conventional decontamination time limits. Although outcome differences cannot be interpreted causally, the consistent survival among patients who received gastric lavage is hypothesis-generating and challenges strictly time-based decontamination restrictions.
Conclusion:
Residual gastric activity consistent with yellow phosphorus may persist up to 24 hours after ingestion, supporting prospective evaluation of activity-guided decontamination strategies.
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