History

Since most exposures to white phosphorus occur in the military setting with the use of munitions, a history frequently is obtained easily. However, it may be necessary to solicit a history about suicidality or possible accidental ingestion in a patient with signs or symptoms of exposure. Be aware of unconscious individuals with a history of percussion injuries from white phosphorus–containing munitions, who may pose an exposure hazard to the health care provider.

Physical Examination

Direct the physical examination toward the identification of traumatic and burn injuries. Pay particular attention to areas where phosphorus may be embedded as a result of explosion.

Fully expose the patient for the primary survey. Exercise care when handling potentially contaminated clothing to prevent secondary exposure and burns to the health care provider.

Patients who have ingested white phosphorus present with nausea, vomiting, and diarrhea. Those who present with nausea, vomiting, and hypotension generally deteriorate rapidly and may enter a coma.^[10]11 Inhalation of white phosphorus fumes can result in chemical pneumonitis.^[8]

Differential Diagnoses

Francois MR, Stephen F. Phosphorus Compounds. In: Harbison RD, Bourgeois MM, Johnson GT, eds. Hamilton and Hardy’s Industrial Toxicology. 6th ed. Hoboken, NJ: John Wiley & Sons, Inc; 2015. doi: 10.1002/9781118834015.ch51.
National Research Council (US) Subcommittee on Military Smokes and Obscurants. White Phosphorous Smoke. Subcommittee on Military Smokes and Obscurants, Committee on Toxicology, Board on Environmental Studies and Toxicology, Commission on Life Sciences, National Research Council. Toxicity of Military Smokes and Obscurants. 1. Washington, D.C.: National Academies Press (US); 1999. 2: 18-44. [Full Text].
Voie ØA, Johnsen A, Strømseng A, Longva KS. Environmental risk assessment of white phosphorus from the use of munitions - a probabilistic approach. Sci Total Environ. 2010 Mar 15. 408(8):1833-41. [QxMD MEDLINE Link].
Aviv U, Kornhaber R, Harats M, Haik J. The burning issue of white phosphorus: a case report and review of the literature. Disaster Mil Med. 2017. 3:6. [QxMD MEDLINE Link]. [Full Text].
Skaik S, Abu-Shaban N, Abu-Shaban N, Barbieri M, Barbieri M, Giani U, et al. Metals detected by ICP/MS in wound tissue of war injuries without fragments in Gaza. BMC Int Health Hum Rights. 2010 Jun 25. 10:17. [QxMD MEDLINE Link]. [Full Text].
Berndtson AE, Fagin A, Sen S, Greenhalgh DG, Palmieri TL. White phosphorus burns and arsenic inhalation: a toxic combination. J Burn Care Res. 2014 Mar-Apr. 35(2):e128-31. [QxMD MEDLINE Link].
Frank M, Schmucker U, Nowotny T, Ekkernkamp A, Hinz P. Not all that glistens is gold: civilian white phosphorus burn injuries. Am J Emerg Med. 2008 Oct. 26(8):974.e3-5. [QxMD MEDLINE Link].
Okazaki A, Takeda Y, Matsuda Y, Shibata K, Kasahara K. Chemical Pneumonitis Caused by Inhalation of White Phosphorus Fumes. Am J Respir Crit Care Med. 2020 Feb 15. 201 (4):e12. [QxMD MEDLINE Link].
Agency for Toxic Substances and Disease Registry (ATSDR). U.S. Department of Health and Human Services, Public Health Service. Toxicological Profile for White Phosphorus. 1997. [Full Text].
Yilmaz R, Yilmaz E, Ozdemir V, Can M, Pakis I, Piskin IE, et al. An evaluation of childhood deaths in Turkey due to yellow phosphorus in firecrackers. J Forensic Sci. 2015 May. 60 (3):648-52. [QxMD MEDLINE Link].
Gonzalez-Andrade F, Lopez-Pulles R. White phosphorus poisoning by oral ingestion of firecrackers or little devils: current experience in Ecuador. Clin Toxicol (Phila). Aug. 49:29-33. [QxMD MEDLINE Link]. [Full Text].
Muller D, Avissar YY, Kimchi S, Grafit A. An analytical method to identify traces of white phosphorus on burned victim clothes. Forensic Sci Int. 2017 Nov. 280:224-227. [QxMD MEDLINE Link].
Witkowski W, Surowiecka-Pastewka A, Biesaga M, Gierczak T. Experimental Comparison of Efficiency of First Aid Dressings in Burning White Phosphorus on Bacon Model. Med Sci Monit. 2015 Aug 12. 21:2361-6. [QxMD MEDLINE Link]. [Full Text].
Türkmen Şamdanci E, Çakir E, Şahin N, Elmali C, Sayin S. Clinical and Pathological Findings on Intoxication by Yellow Phosphorus After Ingesting Firework Cracker: A Rare Case of Autopsy. Turk Patoloji Derg. 2016. 32 (1):51-3. [QxMD MEDLINE Link].
Geehr EC, Salluzzo RF. Dermal injuries and burns from hazardous materials. Sullivan JB Jr,Krieger GR. Hazardous Materials Toxicology, Clinical Principles of Environmental Health. Williams and Wilkins; 1992. 415-424.
Konjoyan TR. White phosphorus burns: case report and literature review. Mil Med. 1983 Nov. 148(11):881-4. [QxMD MEDLINE Link].
Pande TK, Pandey S. White phosphorus poisoning--explosive encounter. J Assoc Physicians India. 2004 Mar. 52:249-50. [QxMD MEDLINE Link].

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Author

Lisandro Irizarry, MD, MBA, MPH, FACEP Chair, Department of Emergency Medicine, Wyckoff Heights Medical Center

Lisandro Irizarry, MD, MBA, MPH, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Medical Toxicology, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Mollie V Williams, MD Assistant Clinical Professor, Fellow in Disaster Preparedness, Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn

Mollie V Williams, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Geri M Williams, MD Staff Physician, Department of Emergency Medicine, Brooklyn Hospital Center

Geri M Williams, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Medical Society of the State of New York, National Medical Association, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

José Eric Díaz-Alcalá, MD, FAAEM, FACMT Medical and Executive Co-Director, Medical Toxicology Consultant, Administración de Servicios Médicos de Puerto Rico, ASEM Poison Control Center; Chief, Emergency Medicine Unit, Medical Toxicology Consultant, VA Caribbean Healthcare System

José Eric Díaz-Alcalá, MD, FAAEM, FACMT is a member of the following medical societies: American Academy of Emergency Medicine, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Zygmunt F Dembek, PhD, MS, MPH, LHD Associate Professor, Department of Military and Emergency Medicine, Adjunct Assistant Professor, Department of Preventive Medicine and Biometrics, Uniformed Services University of the Health Sciences; Senior Research Scientist, Data Science IV, Battelle Memorial Institute, Battelle Connecticut Operations

Zygmunt F Dembek, PhD, MS, MPH, LHD is a member of the following medical societies: American Chemical Society, American Legion, American Public Health Association, Association of Military Surgeons of the US, Council of State and Territorial Epidemiologists, Delta Omega Public Health Honorary Society, New York Academy of Sciences, Polish Legion of American Veterans, Reserve Organization of America, Society of American Federal Medical Laboratory Scientists, Veterans of Foreign Wars

Disclosure: Nothing to disclose.

Additional Contributors

Mark Keim, MD Founder, DisasterDoc, LLC; Adjunct Professor, Emory University Rollins School of Public Health; Adjunct Professor, Harvard Affiliated Disaster Medicine Fellowship

Mark Keim, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

White Phosphorus Exposure Clinical Presentation

History

Physical Examination

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