- Monday, February 9, 2009
- up-to-date guidelines for the treatment of white phosphorus poisoning
Dr. Ansam Sawalha; Director PCDIC
Dr. Sa'ed Zyoud; Poison Information Specialist
Phosphorus comes in many forms including toxic and non-toxic and is used in many venues currently. There is red, white, yellow, and black phosphorus. White and yellow phosphorus has emerged since their use in fireworks, ammunition, rodenticides, and others. White phosphorus has received increased attention lately due to its use in war. It is considered a toxic and dangerous chemical, with a garlic-like odor. It burns immediately upon contact with oxygen producing fire and a dense white smoke. This can further produce phosphine gas that is also toxic. If a populated area gets exposed to white phosphorus, residents can get poisoning by inhalation, ingestion, or skin contact. This article will focus on the signs and symptoms, and treatment of white phosphorus after inhalation or skin contact.
Adverse health affects that result from contact with white phosphorus:
Eye and nose: conjunctivitis, irritation, lacrimation, and corneal damage
Heart: tachycardia, arrhythmia, heartblock, and shock.
Respiratory system: upper respiratory tract irritation, cough, difficulty breathing, tachypnea, pulmonary edema, and bronchitis.
Skin: sever pain, necrosis, second or third degree burns that are yellowish and smell like garlic.
Central nervous system: headache, seizures, delusions, fatigue, nervousness, dizziness, general weakness, and coma.
Gastrointestinal system: nausea, vomiting (could be bloody), abdominal pain, diarrhea, and smoke-smell being produced from vomitus and stool.
Genitourinary system: blood in urine, and renal failure.
Circulatory system: abnormal lab results for blood analysis.
• Move patient from the toxic environment to fresh air. If cough or difficulty in breathing develops, evaluate for hypoxia, respiratory tract irritation, bronchitis, or pneumonitis.
• Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta adrenergic agonists if bronchospasm develops. Exposed skin and eyes should be flushed with copious amounts of water.
• Remove contact lenses and irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If irritation, pain, swelling, lacrimation, or photophobia persists after 15 minutes of irrigation, an ophthalmologic examination should be performed.
• Keep exposed eyes covered with wet dressings until definitive surgical removal of phosphorus can be accomplished.
• Brush all non-adherent phosphorus from the skin. Avoid application of any lipid based ointments as these may increase the skin penetration of phosphorus.
• Remove clothing and promptly begin continuous water irrigation of the affected site.
• Water or saline-soaked dressings applied to the affected area will allow the patient to be transported without re-ignition of the remaining particles. Keep dressing moist until debridement is accomplished.
• Phosphorus will fluoresce under ultraviolet light. With the exposed areas immersed in water, loose or imbedded phosphorous particles that are visualized under UV light can be mechanically but delicately removed safely under water.
• Traditionally, copper sulfate solution has been topically applied to skin burns caused by yellow phosphorus. The rationale for the use of copper sulfate is based on a chemical reaction that binds up the phosphorus thereby preventing further burning due to phosphorus oxidation. The granules of Cu3P2 are black and decompose easily
• CAUTION - Acute renal failure and massive hemolysis may occur if significant copper sulfate is absorbed from the burn site • A solution of 5 percent sodium bicarbonate, 1 percent hydroxyethyl cellulose, 3 percent copper sulfate, and 1 percent lauryl sulfate has been proposed as a decontaminating agent.
• For deep and extensive injury, consult a burn specialist.
• Partial skin thickness burns from a phosphorus pentachloride splash were treated with 1% silver sulfadiazine cream twice daily. Healing was slow (8 weeks) and painful, and no signs of hypertrophic scarring were evident at follow-up.
• Fluid and electrolytes should be replenished when indicated.
• Prophylactic topical antibiotic therapy with silver sulfadiazine is recommended for all burns except superficial partial thickness (first-degree) burns. For first-degree burns bacitracin may be used, but effectiveness is not documented.
• Systemic antibiotics are generally not indicated unless infection is present or the burn involves the hands, feet, or perineum.
• Depending on the site and area, the burn may be treated open (face, ears, or perineum) or covered with sterile nonstick porous gauze. The gauze dressing should be fluffy and thick enough to absorb all drainage.
• Alternatively, a petrolatum fine-mesh gauze dressing may be used alone on partial-thickness burns.
• Other signs and symptoms are treated based on the used protocols toxicology.