Phosphorus toxicity
Background
- Two naturally occurring forms: red and white phosphorus
- Red is not absorbed well, limited toxicity[1]
- Used in manufacture of methamphetamines and also found in the illicit opioid "Krokodil"[2]
- 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!!)[3]
- 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"[4]
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
- Specific types of burns
- Caustic burns
- Electrical injuries
- Lightning Injuries
- Associated toxicities
Caustic Burns
- Caustic ingestion
- Caustic eye exposure (Caustic keratoconjunctivitis)
- Caustic dermal burn
- Airbag-related burns
- Hydrofluoric acid
- Tar burn
- Cement burn
Evaluation
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
Disposition
External Links
References
- Poisoning & Drug Overdose, 7e
- Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e
- Poisoning & Drug Overdose, 7e
- Katselou M, Papoutsis I, Nikolaou P et al.: A "Krokodil" emerges from the murky waters of addiction: abuse trends of an old drug. Life Sci 102: 81, 2014.
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