White phosphorus toxicity

Background

Dropping of white phosphorus bomb.

• White phosphorus is classically among only 2 chemical burns (other is Hydrofluoric Acid) that required an antidote
  • The antidote of copper sulfate is controversial and is not universally recommended
• Incendiary agent that spontaneously burns in air and used during WWI, WWII, Vietnam, Korean wars; most recently in Iraq (OIF)
• Usually not seen unless in military or patients exposed to fireworks
• Damage due to both chemical and thermal burns
• The lethal dose when white phosphorus is ingested orally is 1mg per kg of body weight
• Particles that penetrate tissue continue to cause caustic damage until debrided

Clinical Features

White phosphorus injuries

• Hypocalcemia
• Hypophosphatemia
• Hepatic necrosis
• Death may occur from burns of only 10-15% total body surface area (TBSA)

Differential Diagnosis

• Thermal Burns
• Acute Respiratory Distress Syndrome
• Chemical Burns
• Hydrofluoric Acid

Chemical weapons

• Blister chemical agents (Vesicants)
  • Lewisite (L)
  • Sulfur mustard (H)
  • Phosgene oxime (CX)
• Pulmonary chemical agents (Choking agents)
  • Ammonia toxicity
  • Methyl isocyanate
  • Methyl bromide
  • Hydrochloric acid
  • Chlorine gas
  • Phosgene
• Incendiary agents
  • Agent orange
  • White phosphorus
• Cyanide chemical weapon agents (Blood agents)
  • Prussic acid (AKA hydrogen cyanide, hydrocyanic acid, or formonitrile)
• Nerve Agents (organophosphates)
  • Acetylcholinesterase inhibitors
  • Household and commercial pesticides (diazinon and parathion)
  • G-series (sarin, tabun, soman)
  • V-series (VX)
• Lacrimating or riot-control agents
  • Pepper spray
  • Chloroacetophenone
  • CS

Management

• ABCs to secure airway especially if there is any sign of oral or facial burns.
• Remove all O2 tanks and tubing from patient
• As healthcare provider, avoid contact with ignited white phosphorus
• Continuous irrigation and grossly debride (use Wood's lamp if available to fluoresce the white phosphorus)
• Wet dressings that cut off O2 exposure to remaining white phosphorus
• Monitor Calcium and Phosphorus levels
• Copper sulfate
  • Traditionally used to both convert white phosphorus and visualize end product (cupric phosphate)
  • However, is systemically absorbed and may lead to intravascular hemolysis, renal Failure, and cardiovascular collapse
• Update Tetanus

Disposition

• Transfer the the patient to a burn care center

See Also

• Chemical weapons