Emergency War Surgery NATO Handbook: Part I: Types of Wounds and Injuries: Chapter III: Burn Injury

Chemical Burns And White Phosphorus injury

United States Department of Defense

The depth and severity of chemical burns are related to both the concentration of the agent and the duration of contact with the tissues. These are the only burn injuries which require immediate care of the burn wound. The offending agent must be washed from the body surface as soon as possible. Full thickness, third-degree injury of the skin caused by strong acids may result in tanning or bronzing of the skin which will be waxy, yet pliable to the touch, leading the unwary to underestimate the extent of burn.

Many antipersonnel weapons employed in modern warfare contain white phosphorus. Fragments of this metal, which ignite upon contact with the air, may be driven into the soft tissues; however, most of the cutaneous injury resulting from phosphorus burns is due to the ignition of clothing, and is treated as conventional thermal injury. First aid treatment of casualties with imbedded phosphorus particles consists of copious water lavage and removal of the identifiable particles, following which the involved areas are covered with a saline-soaked dressing and kept moistened until the patient reaches a definitive treatment installation. If transfer will require more than 12 hours, the involved areas should be covered by a liberal application of topical antimicrobial agent to prevent microbial proliferation and the reignition of retained phosphorus particles.

At the site of definitive treatment, the wounds containing imbedded phosphorus particles may be rinsed with a dilute (1%) freshly mixed solution of copper sulfate. This solution combines with the phosphorus on the surface of the particles to form a blue-black cupric phosphide covering which both impedes further oxidation and facilitates the identification of retained particles. If sufficient copper is absorbed through the wound to cause intravascular hemolysis, acute renal failure may result. To avoid this potential complication, copper sulfate solution should never be applied as a wet dressing, and all wounds must be lavaged thoroughly with saline following a copper sulfate rinse to prevent absorption of excessive amounts of copper. As an alternative to the use of a copper sulfate rinse, a Woods lamp can be used in a darkened operating room, or the lights in the operating room may be turned off to identify retained phosphorescent particles during debridement. The extracted phosphorus particles must be immersed in water to avoid their ignition in the operating room. Inflammable anesthetic agents should not be used with these cases.

Combustion of white phosphorus results in the formation of phosphorous pentoxide, a severe pulmonary irritant. The ignition of phosphorus in a closed space may result in the development of concentrations of phosphorous pentoxide sufficient to cause acute inflammatory changes in the tracheobronchial tree. The effects of this gas can be minimized by placing a moist cloth over the nose and mouth to inactivate the gas and prevent endobronchial irritation. Hypocalcemia and hyperphosphatemia have been described as effects of white phosphorus injury and have been associated with electrocardiographic changes and sudden deaths. Hypocalcemia associated with cardiac arrhythmia should be corrected by the administration of calcium.

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Operational Medicine 2001

Health Care in Military Settings

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