Fatal cardiogenic shock following inhalation of aluminum phosphide in a child requiring veno-arterial ECMO support: a rare case and review of extracorporeal strategies

Aluminum phosphide is a pesticide and rodenticide widely used in grain storage and pest management and is associated with high mortality due to refractory shock and multiorgan failure. Although severe cardiogenic shock requiring mechanical circulatory support has been predominantly reported following oral exposure, profound cardiac involvement after inhalational exposure is exceedingly rare. We report the case of a previously healthy 2-year-old girl who developed fulminant cardiogenic shock and malignant ventricular arrhythmias after inhalation of aluminum phosphide. Despite aggressive medical therapy, she experienced recurrent cardiac arrest within the first hours of hospitalization. Transthoracic echocardiography demonstrated severe left ventricular dysfunction, prompting emergent initiation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) within the first 4 h. Multimodal extracorporeal supportive therapies, including continuous renal replacement therapy, therapeutic plasma exchange, and red blood cell exchange, were used as adjunctive measures to manage multiorgan failure. Cardiac function progressively recovered, and the patient was successfully weaned from VA-ECMO on day 11. However, she subsequently developed acute respiratory distress syndrome and suffered cardiac arrest on day 21 following progressive respiratory deterioration. The exact cause of the terminal cardiac arrest could not be determined. While adjunctive extracorporeal therapies may contribute to metabolic stabilization and organ support, this case underscores that early recognition of toxin-induced cardiac failure and timely initiation of veno-arterial extracorporeal membrane oxygenation is essential for initial stabilization in severe aluminum phosphide poisoning.