Prehospital Care
Direct prehospital management toward the evaluation and management of trauma, as follows:
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Secure the scene, because live munitions may be in the area
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Assess and manage ABCs (airway, breathing, circulation)
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Perform decontamination
For decontamination, irrigate or place saline-soaked and/or water-soaked pads on areas of exposure, to terminate further oxidation of phosphorus. Do not use an oily or greasy dressing because the element is lipid soluble and can penetrate into the tissue. Remove contaminated clothing because the white phosphorus may re-ignite and set the clothing on fire, causing more extended and worse burns.
Emergency Department Care
Continue a trauma-management approach to the patient, as follows:
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Avoid contact with ignited white phosphorus, as that may result in a chemical burn injury to the health care provider.
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Continue irrigation; do not allow areas of exposure to dry, as that may result in re-ignition of white phosphorus.
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Grossly debride as much white phosphorus as possible; the use of a Wood lamp (ultraviolet light) results in the fluorescing of the white phosphorus and may facilitate its removal.
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Ensure that tetanus immunization is current.
Copper sulfate has been found to be an effective in vitro neutralizer of white phosphorus and has been traditionally used to treat burns. [9] Copper sulfate reacts with phosphorus to form cupric phosphate, which is black and assists in visualizing phosphorus. However, copper can be very toxic and can lead to death by causing massive intravascular hemolysis. This phenomenon is believed to be due to copper's activity as an inhibitor of several enzymes of the erythrocyte hexose monophosphate shunt. Silver nitrate may provide safer and more reliable antagonism of white phosphorus dermal absorption. [9]
Irrigation with cool water is necessary. As white phosphorus become liquid at 44 °C,, it is critical that the use of warm water is avoided. However, aggressive irrigation with copious amounts of water may result in adverse effects with phosphorus particles transported to uninvolved areas of the skin and reignite when exposed to the air. Saline soaked gauze for wound coverage facilitates oxygen depletion to any remaining phosphorus particles. [4]
Recent in vitro research has shown that moist gauze was effective in extinguishing white phosphorous from a simulated wound, and could be used to absorb white phosphorus pieces, preventing deeper penetration of white phosphorus particles. This was more effective than a stream of water, which splashed and moved white phosphorus pieces around. [13]
Ingestion of white phosphorus can result in elevation of hepatic trigylceride levels, which can lead to fatty liver. Pretreatment with glutathione and propyl gallate, which are antioxidants and free radical scavengers, has been shown to antagonize the increase in triglycerides. [5]
Fatality is highly likely for patients who ingest white phosphorus and present with concomitant hepatorenal failure and cardiovascular collapse. However, when only hepatic failure develops, liver transplantation can be lifesaving. [14]
Direct inpatient care toward further trauma management and burn care. Consider scar revisions associated with burns later in the patient's hospitalization. Transfer the patient to a trauma center with burn care capabilities if such facilities are not available initially.
Consultations
Consultation with a burn team is mandatory for most patients. In addition, obtain trauma consultation for all patients with a history of significant trauma, especially those who may require surgical debridement of injuries.
