Phosphorus toxicity

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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
  • 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

Burns

Caustic Burns

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

Disposition

See Also

External Links

References

  1. Poisoning & Drug Overdose, 7e
  2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e
  3. Poisoning & Drug Overdose, 7e
  4. 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.

Authors:

Claire