Phosphorus, Elemental (alias of 1381)

CAS RN:7723-14-0

Treatment Overview

0.4.2 ORAL EXPOSURE
  • A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    • 1) Treatment is symptomatic and supportive. Following dermal exposure, wash exposed areas with large volume of water. Phosphorus absorbed from damaged skin may result in acute systemic phosphorus poisoning. Cutaneous burns in which white or yellow phosphorus are embedded should be immersed in water or kept very wet to prevent an exothermic reaction in the presence of oxygen, debrided surgically, and then copiously irrigated with a large volume of water. Particles removed should be immediately immersed in cool water to avoid ignition. Avoid the application of any lipid or oil based ointments as these may increase the absorption of phosphorus through the skin. Following thorough decontamination, burn management may be needed. Irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If present, carefully remove contact lenses. Manage mild hypotension with IV fluids.
  • B) MANAGEMENT OF SEVERE TOXICITY
    • 1) Treatment is symptomatic and supportive. Following an inhalational exposure, move the patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta-2 adrenergic agonists and systemic corticosteroids if bronchospasm develops. Treat severe hypotension with IV 0.9% NaCl at 10 to 20 mL/kg. Add dopamine or norepinephrine if unresponsive to fluids. Treat seizures with IV benzodiazepines; barbiturates or propofol may be needed if seizures persist or recur. Phosphorus may cause prolongation of the QT interval. Treat torsades de pointes with IV magnesium sulfate, and correct electrolyte abnormalities, overdrive pacing may be necessary. Treat ventricular dysrhythmias using ACLS protocols.
  • C) DECONTAMINATION
    • 1) PREHOSPITAL: Emesis is not recommended because of the corrosive potential of phosphorus. Phosphorus absorption is enhanced when dissolved in solvents (eg, alcohol, digestible fats, oils). These agents are contraindicated in the management of oral or dermal phosphorus exposure. Activated charcoal is never indicated. Following dermal exposure, prompt removal of all clothing, including jewelry, and copious irrigation with cool water should occur as soon as possible. Following an inhalational exposure, move the patient to fresh air. Monitor for respiratory distress. Irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If present, carefully remove contact lenses.
    • 2) HOSPITAL: ORAL EXPOSURE: Emesis is not recommended because of the corrosive potential of phosphorus. Phosphorus absorption is enhanced when dissolved in solvents (eg, alcohol, digestible fats, oils). These agents are contraindicated in the management of oral or dermal phosphorus exposure. Consider the insertion of a small, flexible nasogastric or orogastric tube to suction gastric contents after recent large ingestions; the risk of further mucosal injury or iatrogenic esophageal perforation must be weighed against potential benefits of removing any remaining phosphorus from the stomach. Caution should be used to prevent any healthcare providers from being injured by the lavage material. Gastric contents that are removed should be immersed in water. Activated charcoal may bind to white phosphorous but there is no evidence to support its use. DERMAL EXPOSURE: Prompt removal of all clothing, including jewelry, and copious irrigation with cool water should occur as soon as possible. Phosphorus becomes liquid at 44 degrees C (or 111 degrees
  • F) which can make decontamination more difficult. Immerse exposed areas in water or cover with wet dressings at all times. Continuous cool water irrigation can prevent further oxidation and allow removal of phosphorus particles from the skin without ignition. Particles removed should be immediately immersed in cool water to avoid ignition. Avoid application of any lipid or oil based ointments as these may increase the absorption of phosphorus through the skin. Visualization of phosphorus particles may fluoresce under an ultraviolet light source (black light, Wood's lamp). With the exposed areas immersed in water, loose or imbedded phosphorus particles that are visualized under UV light can be mechanically but delicately removed safely under water. EYE EXPOSURE: Irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If present, carefully remove contact lenses.
  • D) AIRWAY MANAGEMENT
    • 1) Patients with phosphorus exposure can develop multiorgan failure and require early intubation for airway protection. In addition, due to the intense pain of these burns, adequate pain control may lead to respiratory depression and precipitate intubation.
  • E) ANTIDOTE
    • 1) None.
  • F) VENTRICULAR DYSRHYTHMIAS
    • 1) Institute continuous cardiac monitoring, obtain an ECG, and administer oxygen. Evaluate for hypoxia, acidosis, and electrolyte disorders. Lidocaine and amiodarone are generally first line agents for stable monomorphic ventricular tachycardia, particularly in patients with underlying impaired cardiac function. Because phosphorus exposure can cause QTc prolongation and torsades de pointes, amiodarone should only be used with extreme caution. Unstable rhythms require immediate cardioversion.
  • G) ENHANCED ELIMINATION
    • 1) There is no role for dialysis or extracorporeal elimination. Hemodialysis may be efficacious if oliguric or anuric renal failure occurs.
  • H) PATIENT DISPOSITION
    • 1) HOME CRITERIA: Patients with white or yellow phosphorus exposure should be evaluated in a healthcare facility.
    • 2) OBSERVATION CRITERIA: In some cases of oral ingestion, early gastrointestinal symptoms may resolve after a few hours. A relatively asymptomatic period may follow before more severe toxicity becomes apparent. Early improvement should not be interpreted as meaning that serious exposure has not occurred. Patients with phosphorus exposure should be monitored during the first 48 hours after exposure with frequent laboratory checks. Patients that remain asymptomatic after this monitoring period can be discharged.
    • 3) ADMISSION CRITERIA: Patients with severe symptoms should be admitted to the hospital. Patients with persistent cardiac dysrhythmias, mental status changes, seizures, and respiratory failure should be admitted to an ICU setting. Patients with significant burns should be admitted to a burn center.
    • 4) CONSULT CRITERIA: Due to the unusual nature of this exposure, consult a medical toxicologist or a regional poison center for any patient with systemic symptoms, severe exposure, or in whom the diagnosis is unclear. Patients with severe burns will also need burn specialist consultation.
  • I) PITFALLS
    • 1) Forgetting to keep phosphorus exposed skin areas irrigated with cool water or wrapped in cool water soaked gauze after gentle removal of visible phosphorus residue from skin.
  • J) TOXICOKINETICS
    • 1) Absorbed phosphorus may be metabolized to hypophosphoric acid. Conversion to phosphates occurs in the body. Some phosphorus may be slowly oxidized to harmless acids and excreted via the kidneys.
  • K) DIFFERENTIAL DIAGNOSIS
    • 1) Phosphorus burns may be confused with other forms of thermal, electrical, or chemical burns. Acute liver failure may be caused by viral infections, autoimmune conditions, biliary disorders, and many other toxicants. Multisystem organ failure may be caused by sepsis or other toxicants (eg, colchicine, antineoplastic medications, and radiation).
0.4.3 INHALATION EXPOSURE
  • A) Following an inhalational exposure, move the patient to fresh air. Monitor for respiratory distress. If cough or difficulty breathing develops, evaluate for respiratory tract irritation, bronchitis, or pneumonitis. Administer 100% humidified supplemental oxygen, perform endotracheal intubation and provide assisted ventilation as required. Administer inhaled beta-2 adrenergic agonists and systemic corticosteroids if bronchospasm develops.
0.4.4 EYE EXPOSURE
  • A) Irrigate exposed eyes with copious amounts of room temperature 0.9% saline or water for at least 15 minutes. If present, carefully remove contact lenses.
  • B) Keep exposed eyes covered with wet compresses.
  • C) The patient should be referred for evaluation at a health care facility and formal ophthalmologic examination.
0.4.5 DERMAL EXPOSURE
  • A) OVERVIEW
    • 1) SUMMARY
      • a) Prompt removal of all clothing, including jewelry, and copious irrigation with cool water should occur as soon as possible. Phosphorus becomes liquid at 44 degrees C (or 111 degrees
  • F) which can make decontamination more difficult. Immerse exposed areas in water or cover with wet dressings at all times. Continuous cool water irrigation can prevent further oxidation and allow removal of phosphorus particles from the skin without ignition. Particles removed should be immediately immersed in cool water to avoid ignition. Avoid application of any lipid or oil based ointments as these may increase the absorption of phosphorus through the skin. Visualization of phosphorus particles may fluoresce under an ultraviolet light source (black light, Wood's lamp). With the exposed areas immersed in water, loose or imbedded phosphorus particles that are visualized under UV light can be mechanically but delicately removed safely under water.
    • 2) DECONTAMINATION
      • a) Prompt removal of all clothing, including jewelry, and copious irrigation with cool water should occur as soon as possible. Phosphorus becomes liquid at 44 degrees C (or 111 degrees
  • F) which can make decontamination more difficult (Frank et al, 2008).
    • b) Immerse exposed areas in water or cover with wet dressings at all times.
    • c) Continuous cool water irrigation can prevent further oxidation and allow removal of phosphorous particles from the skin without ignition (Mozingo et al, 1988). Particles removed should be immediately immersed in cool water to avoid ignition.
  • 1) Controversy exists regarding the use of topical copper sulfate solution which can make debridement easier because it blackens any remaining phosphorus particles. However, it is not an antidote or neutralizing agent. It can also be easily absorbed through an open wound and potentially cause intravascular hemolysis, and acute renal and cardiovascular failure; it is NOT routinely recommended (Frank et al, 2008). Some authors recommend that contaminated wounds be washed several times with a solution of 5% sodium bicarbonate AND 3% copper sulfate AND 1% hydroxy-ethyl-cellulose AND 1% sodium lauryl sulfate; rinse thoroughly with saline between washings (Ben-Hur, 1978)
    • d) Avoid application of any lipid or oil based ointments as these may increase the absorption of phosphorous through the skin.
    • e) Visualization of phosphorus particles may be enhanced under an ultraviolet light source (black light, Wood's lamp). Phosphorus particles should fluoresce under UV light. With the exposed areas immersed in water, loose or imbedded phosphorus particles that are visualized under UV light can be mechanically but delicately removed safely under water.
    • f) Monitor the patient for the development of systemic signs or symptoms of phosphorus poisoning.
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