Phosphorus toxicity

Background

• Two naturally occurring forms: red and white phosphorus
• Red is not absorbed well, limited toxicity
  • Used in manufacture of methamphetamines and also found in the illicit opioid "Krokodil"
  • Toxicity largely due to inadvertent production of white phosphorus or phosphine gas during manufacture
• White phosphorus is VERY toxic
  • White-yellow waxy substance
  • Exposure predominantly from use as incendiary munition by armed forces (though occasionally used in manufacture of fertilizers, food additives, and cleaning compounds)
  • Caustic and cellular poison; ignites spontaneously in air, forms phosphorus pentoxide, which then reacts with water to form phosphoric acid
  • Damage due to both thermal and chemical burns

Clinical Features

• Vomit and other secretions may have garlic-like odor
• Phosphorus particles may fluoresce under Wood's lamp
• Skin/eye contact causes severe, partial to full-thickness dermal/ocular chemical and thermal burns
• Inhalation: cough, wheeze, pneumonitis, pulmonary edema
• Ingestion: mucus membrane irritation/burns, abdominal pain, nausea/vomiting, GI bleeding, diarrhea (with smoking stools due to spontaneous combustion on exposure to air!!)
• Systemic effects
  • Headache, delirium, seizures, coma
  • Dysrhythmias; prolonged QT and QRS, both atrial and ventricular arrhythmias
  • AKI, electrolyte abnormalities
  • Hepatotoxicity- may be delayed 2-3 days after exposure
• Chronic exposure associated with mandibular osteonecrosis ("phossy jaw")
• Phosphorus in Krokodil likely contributes to the significant skin, vascular, and muscle damage that earned it the nick name "the flesh-eating drug"

Differential Diagnosis

Heavy metal toxicity

• Aluminum toxicity
• Antimony toxicity
• Arsenic toxicity
• Barium toxicity
• Bismuth toxicity
• Cadmium toxicity
• Chromium toxicity
• Cobalt toxicity
• Copper toxicity
• Gold toxicity
• Iron toxicity
• Lead toxicity
• Lithium toxicity
• Manganese toxicity
• Mercury toxicity
• Nickel toxicity
• Phosphorus toxicity
• Platinum toxicity
• Selenium toxicity
• Silver toxicity
• Thallium toxicity
• Tin toxicity
• Zinc toxicity

Burns

• Smoke inhalation injury (airway compromise)
• Chemical injury
  • Acrolein
  • Hydrochloric acid
  • Tuolene diisocyanate
  • Nitrogen dioxide
• Systemic chemical injury
  • Carbon monoxide toxicity
  • Cyanide toxicity
• Specific types of burns
  • Caustic burns
    • Airbag-related burns
    • Tar burn
    • Cement burn
  • Electrical injuries
    • Lightning Injuries
• Associated toxicities
  • Carbon monoxide toxicity
  • Cyanide toxicity
  • Hydrogen fluoride toxicity

Caustic Burns

• Caustic ingestion
• Caustic eye exposure (Caustic keratoconjunctivitis)
• Caustic dermal burn
• Airbag-related burns
• Hydrofluoric acid
• Tar burn
• Cement burn

Evaluation

• CMP, UA, EKG, CXR (if inhalational)
• Serum phosphorus level NOT helpful in diagnosing (though may want to monitor if concern for other electrolyte abnormalities)
• Consider EGD if concern for GI burns

Management

• Wear PPE to prevent exposure!
• Decontamination
  • Remove contaminated clothing, wash exposed areas with soap and water
  • Submersion in water/wet dressings can prevent spontaneous ignition of phosphorus particles
  • Manually debride/remove remaining phosphorus particles- may need wood's lamp to find
  • Unclear role of charcoal/whole bowel irrigation in ingestion
• Supportive/symptomatic management
  • Inhalation: manage airway (may have significant irritation/edema), give oxygen therapy, bronchodilators, treat pulmonary edema
  • Rehydrate if significant GI losses, correct electrolyte abnormalities
  • Consider EGD if concern for GI burns

See Also

• Toxicology (main)
• Heavy metals
• White phosphorus
• Chemical weapons
• Caustic burns