Case Report

Not all that glistens is gold: civilian white phosphorus burn injuries

Abstract

White phosphorus is an incendiary agent used in particular types of ammunition. Exposure to phosphorus-containing compounds may cause severe burn injuries. Systemic effects may be fatal for the casualty even though only a small surface of the body is burned. We report 4 cases of white phosphorus burn injuries due to an exceptional accident mechanism. All casualties were holidaymakers in a coastal area at the Baltic Sea and confused white phosphorus ammunition residues with amber on a beachwalk. The supposed treasure was taken into the pants pocket. The phosphorus substances ignited spontaneously when they dried because of the body heat. injury patterns combined simultaneous full thickness burn injuries of both hands with a Burn injury of one thigh or the abdominal region. The acute treatment and the controversy surrounding decontamination of such patients are discussed. In addition, pathology of tissue damage and systemic injury are elucidated.

The incidence of burn injuries in armed conflicts varies between 2% and 18% in conventional warfare [1]. Since World War I, white phosphorus (WP or, in military jargon, “Willie Pete”) burn injuries have been feared for their devastating consequences [2]. Fortunately, burn injuries due to phosphorus are very rare today [3].

We report 4 cases of civilian white phosphorus burn injuries that have an extraordinary cause of accident in common.

A 69-year-old woman was searching for pieces of amber at the coast of the Baltic Sea. Having found some yellow- translucent supposed piece of amber, she took it in her pants pocket. After a while, the substance ignited spontaneously. The woman vainly tried to get rid of the burning clothing. The casualty was stripped of her clothing and decontaminated using copious amounts of water by responders to the scene. The patient was transferred to the emergency department. Initial assessment revealed full thickness burn injuries of the left hand (total body surface area [TBSA] 2%) and the left thigh (TBSA 4%). The injuries appeared as necrotic areas with a yellowish color and an odor like garlic (Figs. 1 and 2). The defects were partly covered by a firm scab. Subtle decontamination and Surgical debridement were performed

under general anaesthesia. Saline was used for irrigation. No alterations of hepatic or renal laboratory parameters were found. Respiratory disorders due to smoke inhalation were not observed. cardiac monitoring was performed because of decreased serum calcium levels, and electrocardiogram (ECG) abnormalities were not observed. The defects were covered by allogenic split Skin graft on day 5 after admission. After a 4-week hospital stay, she was discharged.

A 51-year-old male holidaymaker found some yellow translucent flotsam and jetsam on a beachwalk. He picked it up and took it in his pants pocket. After a while, a yellow flame that produced a dense white smoke ignited in his pants pocket and caused severe burning pain. Trying to remove his pants, he smudged the sticky substance to both hands, which led to burn injuries of both hands. After, he extinguished the fire with seawater. The casualty was taken to a family physician, who covered the burnt skin with moist dressing and referred the patient to the emergency department, where full thickness phosphorus burn injuries of both hands (TBSA 1%) and the right thigh (TBSA 2%) were observed (Fig. 3). Decontamination, meticulous surgical debridement, and irrigation were performed. wound healing was secondary, and no further reconstructive procedures were necessary. The patient was discharged 12 days after admission.

A 17-year-old woman found some colorless translucent wax-like substance while on a beachwalk with her parents. Considering it as a piece of amber, she took it in her pants pocket. During a drive 5 hours later, the substance ignited spontaneously, producing dense white smoke and causing a full thickness burn injury of the lower abdominal region (TBSA 3%). Trying to extinguish the fire, she suffered additional partial thickness burn injuries of both hands (TBSA 2%). The patient was transferred to a Burn unit after primary management (decontamination, irrigation, and debridement) in the emergency department. The abdominal defect was covered with an allogenic split skin graft. posttraumatic stress disorder occurred, which could be treated efficaciously by psychotherapy and pharmacotherapy. The patient was discharged from the burn unit after 20 days. A 65-year-old woman considered some yellow translu- cent flotsam and jetsam as a piece of amber and took it into her pants pocket during a beachwalk. The substance ignited spontaneously 1 hour later, causing full thickness burn injury of the left thigh (TBSA 2%). Trying to extinguish the fire, both hands were also injured (full thickness, TBSA 1%)

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Fig. 1 A 69-year-old woman suffered full thickness burn injury of the left hand. The patient tried to remove a burning phosphorus object from a left trouser pocket (case 1).

Fig. 3 A 51-year-old man suffered combined full and partial thickness burn injury of the right thigh after self-ignition of a phosphorus object in a right pants pocket (case 2).

(Fig. 4). The patient was referred to the emergency department, where a subtle debridement of all contaminated and devitalized tissue was performed. Laboratory clinical chemistry findings showed decreased serum calcium levels. electrocardiogram abnormalities were not observed. Vacuum-assisted closure was used for conditioning the defect at the left thigh. Secondary wound closure was performed. The patient was discharged 11 days after admission.

White phosphorus was used most often during World War II in military formulations for smoke screens, marker shells, incendiaries, hand grenades, smoke markers, colored flares, and tracer bullets. Coastal waters in the northern part of Germany were subjects of military operations during World War II owing to their strategic significance. Particularly, the former Army Research Centre Peenemunde was targeted by air raids. After World War II, military residues containing white phosphorus were dumped into the Baltic Sea. Ongoing corrosion processes might have revealed hazardous contents in the course of time. The casualties that were subject of this case series were all derived from a coastal area of the Baltic Sea near the former Army Research Centre.

The fact that phosphorus residues bear a similarity with amber, which is found along the shores of the Baltic Sea in the northern part of Germany, cannot be denied. Especially

Fig. 2 Emergency management revealed combined full and partial thickness burn injury of the left thigh (case 1). Systemic effects showed mild hypocalcemia.

after stormy Weather conditions, pieces of amber torn from the seafloor are cast up by the waves and can be collected at the beaches. By the same mechanism, phosphorus residues seem to leave the seabed and are washed ashore. Similar to amber, phosphorus clots are translucent and kind of waxen. The chemical element bears the symbol P and the atomic number 15. It bears a density of 1.82 g/cm³ and a melting point of 44.1?C; the boiling point is reached by 280?C. When exposed to air, it spontaneously ignites and burns at a temperature up to 1300?C. In the cases we presented, the clots ignited when they dried in the pants pocket and came close to body temperature.

The tissue damage combines a thermal and chemical burn. Secondary to heat, tissue damage occurs owing to the corrosive effects of phosphoric acids, from the heat of the chemical reaction resulting in phosphorus pentoxide (P₂O₅). After all, damage results from the hygroscopic action of the phosphorus pentoxide itself [4-6]. Systemic effects may lead to hypocalcemia and hyperphosphatemia. Postburn ECG abnormalities, including prolongation of QT interval,

Fig. 4 A 65-year-old woman suffered full thickness burn injury of the fingers of the left hand after contact to phosphorus-containing ammunition residues found on the beach (case 4).

Case Report 974.e5

bradycardia, and ST-T wave changes, are also identified. These ECG changes may explain early sudden death occasionally seen in patients with apparently inconsequential white phosphorous burns [7]. Therefore, monitoring by electrocardiogram is mandatory until normalization of electrolyte alterations. White phosphorus fume can cause severe eye irritation with blepharospasm, photophobia, and lacrimation. Malignant lesions may rarely occur as a long- term consequence [8].

First and foremost is immediate removal of contaminated clothing, followed by submersion of phosphorus-contacted skin in cool water. Warm water should be avoided because white phosphorous becomes liquid at 44?C, which makes effective decontamination more difficult. Phosphorus parti- cles from the victim’s skin should be removed and submerged in water. Burned skin should be covered with towels soaked in cool water during transport to the emergency department. The main goal of emergency treatment is the urgent removal of active phosphorus from the burn site and to perform sufficient decontamination [9]. Controversy exists regarding the use of topical copper sulfate solution in the treatment of white phosphorus burn injuries. It is important to know that copper sulfate is not an antidote or neutralizing agent but seems to make debridement easier by blackening remaining phosphorus particles [2]. Copper sulfate solution is easily absorbed through the wound and may cause intravascular hemolysis and acute renal and cardiovascular failure [6]. Owing to these negative effects and the lack of evidence, saline, not copper sulfate solution, is used for irrigation in our treatment protocol. A Wood’s lamp may help to identify remaining luminescent particles [10]. The administration of volume in this series was guided by urine output per hour, aiming on an output rate of 0.5 to 1 mL kg^-1 h^-1 [11].

The patients in this series have been adequately managed

in a nonmilitary level I trauma center. Although some guidelines have been published to assist nonspecialists who do not treat burns on a regular basis, early referral to a specialized unit should be taken into consideration after primary management in the emergency department [12].

Matthias Frank Uli Schmucker

Thomas Nowotny Axel Ekkernkamp

Peter Hinz

Trauma and Orthopaedic Surgery

Emergency Department Ernst-Moritz-Arndt-University Greifswald Sauerbruchstrasse, 17475 Greifswald, Germany E-mail address: [email protected]

doi:10.1016/j.ajem.2008.03.011

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