Phosphorus burns

# Overview
Phosphorus burns are a rarely encountered chemical burn, typically occurring in battle, industrial accidents, or from fireworks. Death may result even with minimal burn areas. Early recognition of affected areas and adequate resuscitation is crucial.

# Pathophysiology

## Effects on Humans
White phosphorus (WP) can cause injuries and death in three ways;
- By burning deep into tissue
- By being inhaled as a smoke
- By being ingested
Extensive exposure in any way is fatal.

### Effects of Exposure to White Phosphorus
Incandescent particles of WP cast off by a WP weapon's initial explosion can produce extensive, deep (second and third degree), burns. Phosphorus burns carry a greater risk of mortality than other forms of burns due to the absorption of phosphorus into the body through the burned area, resulting in liver, heart and kidney damage, and in some cases multi-organ failure. These weapons are particularly dangerous to exposed people because white phosphorus continues to burn unless deprived of oxygen or until it is completely consumed.  In some cases, burns are limited to areas of exposed skin because the smaller WP particles do not burn completely through personal clothing before being consumed. "White phosphorus results in painful chemical burn injuries."

### Exposure and Inhalation of Smoke
Burning WP produces a hot, dense white smoke. Most forms of smoke are not hazardous in the kinds of concentrations produced by a battlefield smoke shell. Exposure to heavy smoke concentrations of any kind for an extended period (particularly if near the source of emission) does have the potential to cause illness or even death.
WP smoke irritates the eyes and nose in moderate concentrations. With intense exposures, a very explosive cough may occur. However, no recorded casualties from the effects of WP smoke alone have occurred in combat operations and to date, there are no confirmed deaths resulting from exposure to phosphorus smoke.
The Agency for Toxic Substances and Disease Registry has set an acute inhalation Minimum Risk Level (MRL) for white phosphorus smoke of 0.02 mg/m3, the same as fuel oil fumes. By contrast, the chemical weapon mustard gas is 30 times more potent: 0.0007 mg/m3.

### Oral Ingestion
The accepted lethal dose when white phosphorus is ingested orally is 1 mg per kg of body weight, although the ingestion of as little as 15 mg has resulted in death.
It may also cause liver, heart or kidney damage. There are reports of individuals with a history of oral ingestion who have passed phosphorus-laden stool ("smoking stool syndrome").

# Treatment

## Medical Therapy
First aid for this type of burn is complicated by the fact that white phosphorus particles ignite upon contact with air. Superficial burns caused by simple skin contact or burning clothes should be flushed with water and treated like thermal burns. Partially embedded white phosphorus particles must be continuously flushed with water and removal with whatever tools are available (i.e., tweezers, pliers, forceps). This is done quickly but gently. Firmly or  deeply  embedded particles that cannot be removed must be covered with a saline soaked dressing, which must be kept wet until the victim reaches a medical treatment facility. 
The wounds containing  embedded phosphorus particles may then be rinsed with a dilute, one percent freshly mixed solution of copper sulfate. This  solution combines with phosphorus on the surface of the particles to form a blue-black cupric phosphite covering, which both impedes further oxidation and facilitates identification of retained particles.
Under no circumstances should the copper sulfate solution be applied as a wet dressing. Wounds must be  flushed thoroughly with a saline solution following the copper sulfate rinse to prevent absorption of excessive amounts of copper, since copper has been associated with extensive intravascular hemolysis.
An adjunct to the management of phosphorus burn injuries is the identification of the retained  phosphorescent particles in a darkened room  during debridement.
Combustion of white phosphorus results in the formation of a severe pulmonary irritant. The ignition of phosphorus in a closed space such as the BAS tent or sickbay may result in the development of irritant concentrations sufficient to cause acute inflammatory changes in the tracheobronchial tree. The effects of this gas, especially during debridement, can be minimized 4-80 by placing a moist cloth over the nose and mouth to inactivate the gas and by ventilating the tent.