Napalm Exposure 

Updated: Nov 04, 2019
Author: Lisandro Irizarry, MD, MPH, FACEP; Chief Editor: Zygmunt F Dembek, PhD, MPH, MS, LHD 

Overview

Practice Essentials

Napalm, invented by Fieser in 1942, is an incendiary substance made by the simple procedure of adding a "gelling" powder, composed of naphthalene and palmitate (hence "napalm"), to gasoline in varying concentrations to form a sticky, combustible substance.

This white, cloudy, jellylike substance has unique properties that render it an effective incendiary agent. Napalm is extremely stable, tolerating temperatures well above 150°F (effective in the tropics) and as low as -40°F (bomb shelters, cold weather environments). It is not shattered easily by explosives and can be stored for long periods without significant breakdown.

Gelation of this substance occurs in 3-20 minutes. Gel formation enhances its effectiveness by allowing for a controlled, contained, and prolonged burn. Gelation also enhances its stability, with napalm requiring much higher temperatures to ignite than gasoline. There is no "off-sourcing" of hydrocarbon fumes associated with the nonignited compound. In fact, ignition requires the use of trinitrotoluene (TNT) to explode and ignite white phosphorus, the ignited temperature of which is high enough to result in the combustion of napalm.

Napalm has been used primarily in the form of incendiary bombs, firebombs, land mines, and flamethrowers. During World War II, firebombs, in the form of 165-gallon containers, were the primary method for the disbursement of napalm. One firebomb released from a low-flying airplane was capable of producing damage to a 2500-yd2 area. During the Korean War, the United States dropped approximately 250,000 pounds of napalm per day.

Napalm's increased viscosity enhanced the effectiveness of flamethrowers, which were frequently used in World War II. Because of gasoline's increased instability, volatility, and its rapid burning and self-consumption, its effectiveness was limited to within 30 yards. Napalm, through its unique properties, extended the effective range of flamethrowers to 150 yards.

After World War II, the United States conducted an intensive effort to enhance the properties and effectiveness of napalm as an incendiary agent. This effort resulted in the development of napalm B (super napalm, NP2), which substituted polystyrene and benzene for naphthalene and palmitate. The resulting substance continued to bear the name napalm, although it lacked the two components of its namesake. Conventional napalm burns for 15-30 seconds, whereas napalm B burns for up to 10 minutes.

Napalm B provided the United States with an incendiary substance with enhanced stability and controllability and, as such, became the weapon of choice during the Vietnam War. Such enhanced stability required an igniting agent such as white phosphorus, which burns at a higher temperature of 4532°F. White phosphorus replaced thermite, the ignitor previously used for traditional napalm.

Epidemiology

The United Nations Convection on Certain Coventional Weapons (1980) banned the use of napalm against civilian populations. This eventaully led to the complete destruction of the US stockpile stored at the Fallbrook Naval Weapons Station by April 2001. Despite this, allegations of napalm use by the United States have been made as recently as the 2003 Gulf War. The United States denied those allegations, acknowledging the deployment of Mark 77 incendiary devices, whose functions are similar to those of napalm when used in combat but whose chemical composition differs from that of napalm.[1]

Prognosis

The prognosis is dictated by extent of physical injury, burns, and existing metabolic complications. Morbidity and mortality are related directly to the extent of injuries received from trauma and extensive burns from exposure, in addition to asphyxiation from carbon monoxide exposure and hypoxia. No cases have been reported of systemic poisoning of individuals in contact with nonignited napalm.

German post-war estimates reveal approximately 25,000 deaths and 30,000 wounded individuals during a 2-day attack on Dresden, Germany, with the use of 3.4 kilotons of incendiary, half of which was napalm. According to a memorandum released by the Ministry of Foreign Affairs of the People's Republic of Korea, after the Korean War more than 10,000 napalm bombs were released during a 20-day period, killing 12,000 individuals and wounding 2,500 others.[1]

 

Presentation

History

Exposure history usually is obvious. Patients will recount hearing the sounds of an explosion and seeing flames, and will have excruciatingly painful burns from the exposure.

Napalm produces carbon monoxide as a by-product of combustion. Thus, also evaluate individuals exposed to burning napalm for carbon monoxide exposure. In particular, consider individuals who are found with altered levels of consciousness near burning napalm to have been exposed to toxic levels of carbon monoxide until proven otherwise.

Physical Examination

Immolation, asphyxiation, and burns are the mechanisms by which incendiary weapons kill or wound. Immolation results in a rapid decrease in blood pressure, leading to unconsciousness and death.

Asphyxiation usually occurs as a result of napalm ignition, which causes rapid deoxygenation of surrounding air. This rapid deoxygenation produces an atmosphere of approximately 20% carbon dioxide.

Severe burns (second and/or third degree) of skin exposed to burning napalm are a common finding. Airway injury due to elevated air temperature may result in respiratory embarrassment.

Increased ambient environmental temperature from burning napalm has been known to cause the deaths of individuals in raid shelters as a result of radiant heat and dehydration. This was a frequent cause of death in the bombing raids carried out over Hamburg, Germany, during World War II. The result of this phenomenon frequently was referred to as Bombenbrandschrumpfleichen (incendiary-bomb–shrunken bodies).

 

DDx

 

Workup

Approach Considerations

The workup of patients exposed to napalm is the same as that for any burn patient. See Initial Evaluation and Management of the Burn Patient. Depending on the history, patients may also require evaluation for trauma from percussion of blast or projectiles.

 

Treatment

Prehospital Care

Give care to extinguishing flames and removing smoldering napalm from the skin. Remove contaminated clothing to prevent continued burning from hot napalm. If carbon monoxide exposure is a concern, provide 100% oxygen via a nonrebreather mask en route or endotracheal intubation with venitilatory suport as needed.

Also see CBRNE - Personal Protective Equipment and CBRNE - Chemical Decontamination.

Emergency Department Care

Rapid intervention to stop cutaneous burning from napalm is of paramount importance. As with all burn patients, provide respiratory support and multiorgan evaluation. Perform full exposure and removal of the offending agent.

Follow the standard ABC approach to resuscitation, paying special attention to respiratory evaluation, since patients may experience severe respiratory injury secondary to elevated ambient air temperature. Take care to evaluate patients for carbon monoxide exposure.

Evaluate burns and calculate the exposed area. This can be done by either of two common methods. The first involves using an affected individual's palmar surface, which roughly represents 1% of total body surface area (TBSA) of that individual. The second uses the "rule of nines" method.

Calculation of the percentage of TBSA involved assists in determining disposition and/or transfer of the patient to a regional burn center. American Burn Association criteria for burn-center admission include the following[2] :

  • Partial thickness burns greater than 10% TBSA
  • Third-degree burns 
  • Burns involving critical areas (eg, face, hands, feet, genitals)
  • Circumferential burns of the thorax or extremities
  • Inhalational injuries
  • Significant chemical injuries, electrical burns, or trauma
  • Significant preexisting medical conditions

Base fluid resuscitation on the Parkland formula (2-4 mL/kg/h of intravenous crystalloid). Maintain urine output at 1-2 mL/kg/h.

Perform a full trauma evaluation because patients may sustain injury from percussion of blast or projectiles. If indicated, transfer patients to a regional trauma and/or burn center.

 

Consultations

Consultations to consider include the following:

  • Burn team, for the evaluation and management of burns

  • Trauma team, for the evaluation and management of traumatic injuries from explosions associated with napalm disbursement

  • Pulmonary/critical care medicine, for monitoring of respiratory status and evidence of pulmonary injury

 

Medication

Medication Summary

Implement medical therapy as indicated by the patient's medical condition. Remember to administer tetanus prophylaxis if indicated.

Toxoid

Class Summary

Toxoid is used for immunization; a booster injection in previously immunized individuals is recommended.

Tetanus toxoid adsorbed or fluid

Used to induce active immunity against tetanus in selected patients. The immunizing agents of choice for most adults and children >7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life.

Pregnant patients should receive only tetanus toxoid not a diphtheria-antigen-containing product.

In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is the mid thigh laterally.

Analgesics

Class Summary

These agents ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained injuries.

Morphine sulfate (Duramorph, Astramorph, MS Contin, MSIR, Oramorph)

DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.

Various IV doses are used; commonly titrated until desired effect obtained.

Meperidine (Demerol)

Analgesic with multiple actions similar to those of morphine; may produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.

Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

These agents have analgesic, antiinflammatory, and antipyretic activities. Mechanism of action is not known but may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell-membrane functions, may exist as well.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Naproxen (Aleve, Naprelan, Naprosyn, Anaprox)

For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.

Topical antibiotics

Class Summary

Therapy must be comprehensive and cover all likely pathogens in the context of this clinical setting.

Neomycin/polymyxin B/bacitracin topical (Neosporin)

Used in treatment of minor infections. Inhibits bacterial protein synthesis and growth. Polymyxin B disrupts bacterial cytoplasmic membrane, permitting leak of intracellular constituents and causing inhibition of bacterial growth.

Silver sulfadiazine (Silvadene, Thermazene, SSD, SSD-AF)

Useful in prevention of infections from second-degree or third-degree burns. Has bactericidal activity against many gram-positive and gram-negative bacteria, including yeast.