BLOG: White Phosphorus Burns
- Rachel Smith
- 20 hours ago
- 4 min read
This month, we’re ‘borrowing’ from the incredible Krissie Stiles (check her out on LinkedIn for
some awesome CPD), a burns and plastics nurse whose passion for her subject is infectious.
Krissie recently posted about white phosphorus burns in the context of conflict, but this
particular type of burn is a risk at sea too, as white phosphorus is one of the components in
some marine flares.
White phosphorus burns are not something that is regularly seen in modern medicine though
white phosphorus munitions are never too far from modern conflicts. This type of burn causes
devastating health impacts and significant challenges for their medical management.
We completely understand that not all manufacturers utilise this in their pyrotechnics. However, because its presence remains a industry-wide consideration, and is one of the components in some military marine flares we believe it is simply best practice to ensure everyone has a clear, standard protocol ready just in case.
What is white phosphorus?
Quite simply, it’s a chemical warfare agent that can also be used as a smoke-screen, in signalling flares, for illumination and as a weapon.
It’s pyrophoric, which means it ignites spontaneously in the presence of oxygen at 30°C when exposed to air, it burns intensely at temperatures >800°C, it has high lipid solubility allowing it to cause deep and extensive thermal and chemical burns when in contact with skin.
It burns with a yellow flame and dense smoke, forming phosphorus pentoxide - a strong desiccant and dehydrating agent, which is corrosive to the tissues.
It can be lethal when inhaled, ingested, or absorbed through burned skin, and presents a high risk as it continues to burn until it's either deprived of oxygen, the particles are removed or burn themselves out.
Injuring mechanism
As if that wasn’t enough, White phosphorus causes deep and extremely painful burns, as it is highly fat-soluble, resulting in deep extension of the thermal and chemical burn injury into the fatty subcutaneous tissues.
Grey and yellow skin discolouration is produced almost immediately once white phosphorus comes in contact with skin, causing tissue necrosis, and emitting white fumes with a garlic-like odour.
Within hours of exposure, systemic absorption can result in serious physiological alterations and multiple organ dysfunction.
Treatment
First aid for white phosphorus burns involves the common sense measures of acting promptly to remove the patient's clothes, irrigating the wound(s) with water or saline continuously, and removing white phosphorus particles.
Before starting treatment
Always use special protective clothing and face and eye protection when handling white phosphorus, as it is highly toxic, and represents a fire and explosive hazard, where contact with even small amounts can lead to serious burns.
Run-off may be corrosive and/or toxic, and may cause pollution. If the situation allows, control and properly dispose of run-off. Collect any effluent, especially as white phosphorus is insoluble in water and can contaminate surroundings, and will re-ignite when re-exposed to air.
Stop the burning process by removing any contaminated clothing and shoes, as they may ignite or re‐ignite.
Place soiled clothing in a water-filled sealed container clearly labelled as a biohazard.
Brush away any large and easily identifiable solid particles and store these in a container of cold water to reduce the risk to medical personnel and others.
Use a Wood’s lamp to facilitate the identification and removal of smaller or embedded particles, which will appear fluorescent under ultraviolet light.
Immerse affected areas in water, visualise any loose or embedded phosphorus particles under UV light, and mechanically but delicately remove these safely under water.
Use pieces of moist gauze to remove any remaining white phosphorus.
Continuous irrigation of the burn site with copious amounts of saline or water can prevent further oxidation and allow removal of particles from the skin surface without re-ignition.
As white phosphorus has a low melting point of 44°C, irrigation with cool, as opposed to warm, irrigant is essential.
Water irrigation can transport white phosphorus particles to unaffected areas of the skin, causing injury to a larger surface area.
Removal through aggressive water irrigation may pose a risk to first responders due to splashing of broken white phosphorus particles in an unpredictable trajectory.
Cover with water- or saline-soaked gauze application to the affected wounds facilitates oxygen depletion to any remaining white phosphorus particles.
Moist gauze is especially effective in extinguishing white phosphorus, as it removes and absorbs the majority of the particle mass from the skin surface, preventing deeper penetration into tissues.
The moist gauze dressing should be pressed and kept in place for 3–5 minutes.
Wet soak application enables patient transfer without the risk of re-ignition of the remaining white phosphorus particles.
The attending responders and receiving hospital must be aware of the risk of immediate spontaneous re-ignition when dressings are removed.
Cautions
Irrigation attempts may induce hypothermia, especially in children and elderly, or where large burns are present. Aggressive hypothermia prevention, identification and mitigation is essential, as it's independently linked to increased mortality in major burns.
Avoid applying any lipid- or oil-based ointments, which may increase the absorption of white phosphorus.
Do not use copper sulphate to assist visualisation of phosphorus particles for removal as it hasn't been proven to achieve better outcomes than water irrigation. Systemic absorption of copper sulphate is evidenced to have significant adverse effects, such as intravascular haemolysis and renal failure.
Onward care
White phosphorous injuries warrant the expertise of experienced military/burn surgeons, with larger wounds requiring radical surgical excision.
Delayed grafting is the preferred surgical method, as the wound bed can take up to 7 days post chemical damage to stabilise and accept a graft.
Please let us know if you have any experience of white phosphorus burns, at sea or on land as it’s such a rare occurrence and would be good to share thoughts and lessons from any experience.
We hope you’ve found this CPD useful and picked up a few pointers. Please let us know if there are any topics you would like to see in the future.
The Red Square Medical Team
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