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Interventions for treating phosphorus burns

  1. Loai Barqouni1,*,
  2. Nafiz Abu Shaaban2,
  3. Khamis Elessi3

Editorial Group: Cochrane Wounds Group

Published Online: 4 JUN 2014

Assessed as up-to-date: 11 OCT 2013

DOI: 10.1002/14651858.CD008805.pub3


How to Cite

Barqouni L, Abu Shaaban N, Elessi K. Interventions for treating phosphorus burns. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD008805. DOI: 10.1002/14651858.CD008805.pub3.

Author Information

  1. 1

    Islamic University of Gaza, Faculty of Medicine, Gaza, Palestine

  2. 2

    Al Shifaa Hospital, Plastic Surgery and Burns Department, Gaza, Palestine

  3. 3

    Islamic University, College of Medicine, Gaza, Palestine

*Loai Barqouni, Faculty of Medicine, Islamic University of Gaza, Gaza, Palestine. lnb6des@hotmail.com.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 4 JUN 2014

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Characteristics of included studies [ordered by study ID]
Curreri 1970

MethodsRetrospectively assembled case series based on the clinical records of all 111 patients admitted to the US Army Institute of Surgical Research between 1950 and 1986


Participants77 out of a total of 96 patients with phosphorus burns


InterventionsWithout copper sulphate: 37 patients: wounds irrigated with copious amounts of water or saline, debridement with removal of phosphorus particles at least once, and application of wet dressing with thick gauze pads, and irrigation with water or dilute solution of sodium bicarbonate

With copper sulphate: 40 patients treated as above, plus application of copper sulphate before, during and after debridement


OutcomesAverage length of hospitalisation, the time required for eschar separation and incidence if residual contractures


NotesUSA


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskNot randomised

Allocation concealment (selection bias)High riskNo allocation concealment

Summerlin 1967

MethodsRetrospective survey of the clinical records of patients admitted to the US Army Surgical Research Unit between 1965 and 1966


Participants11 patients with phosphorus burns


InterventionsWithout copper sulphate: 3 patients with phosphorus burns treated without copper sulphate

With copper sulphate: 8 patients with phosphorus burns treated with copper sulphate


OutcomesWithout copper sulphate: no complications had been experienced

With copper sulphate: haematuria, haemoglobinuria and mild to severe hypocalcaemia, high level of copper in urine, oliguria and finally renal failure 20 to 72 hours after injury developed in 3 patients out of 8. One required haemodialysis. Eventually all recovered.


NotesUSA


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskNot randomised

Allocation concealment (selection bias)High riskNo allocation concealment

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Al Barqouni 2010Methodologically inappropriate, case report ( Table 2)

Barillo 2004 Methodologically inappropriate, non-comparative retrospective study ( Table 1)

Broekhuizen 1982Methodologically inappropriate, case report ( Table 2)

Carras 1993Methodologically inappropriate, case report ( Table 2)

Chou 2001Methodologically inappropriate, non-comparative retrospective study ( Table 1)

Conner 2007Methodologically inappropriate, case report ( Table 2)

Davis 2002Methodologically inappropriate, case report ( Table 2)

Fang 1987Methodologically inappropriate, case series, and deal with red phosphorus rather than white.

Frank 2008Methodologically inappropriate, case report ( Table 2)

Karunadasa 2010Methodologically inappropriate, case report ( Table 2)

Konjoyan 1983Methodologically inappropriate, case report ( Table 2)

Loveall 2007Methodologically inappropriate, case report ( Table 2)

Mozingo 1988Methodologically inappropriate, non-comparative retrospective study ( Table 1)

Saracoglu 2013Methodologically inappropriate, case report ( Table 2)

Song 1985Methodologically inappropriate, case report ( Table 2)

Weinberger 1978Methodologically inappropriate, case report ( Table 2)

 
Characteristics of studies awaiting assessment [ordered by study ID]
Bonelli 1971

Methods

Participants

Interventions

Outcomes

NotesAwaiting translation - study language: Italian

 
Table 1. Retrospective surveys with no treatment comparison

StudyTypeParticipantsInterventionsOutcomeOther

Chou 2001

Taiwan
Retrospective survey of hospital clinical records between 1984 and 19987 out of 326 chemical burn patients resulted from white phosphorus,

and 2 of these were presented

 
Irrigation and dressing

Copious normal saline irrigation dressing with saline-soaked pads

Identification and removal of phosphorus particles

Identification of phosphorus particles

Use of copper sulphate or ultraviolet light

1% copper sulphate solution for neutralisation

Systemic support

Monitoring for electrolytes and cardiac function

Long-term management

No details provided

Others - none
1 of the 7 died from inhalation injury

Of the 7 patients, 5 required skin grafting when wounds had not healed within 14 days of presentation. Hypocalcaemia was commonly encountered.
Mentioned the use of cold solution in irrigation

Mozingo 1988

USA
Retrospective survey of clinical records in US Army Institute of Surgical Research between 1969 and 1985, mostly in Vietnam49 out of 87 chemically burned patients were burned with white phosphorusIrrigation and dressing

Removal of clothes and copious water irrigation done as soon as possible

Identification and removal of phosphorus particles

Removal of particles from the skin surface

Use of copper sulphate or ultraviolet light

Copper sulphate solution (1% or less) or Woods lamp (ultraviolet light) used

Systemic support

No details provided

Long-term management

No details provided

Others

The report does not allow disaggregation of the management of the 49 patients with white phosphorus burns
Cases of white phosphorus burns remained in hospital longerNoticed the importance of not liquidising the phosphorus particles

 

Barillo 2004

USA
Retrospective survey of clinical records in US Army Institute of Surgical Research between 1950 and 2000146 out of 276 chemically burned patients were burned with white phosphorus

 
Irrigation and dressing

Wounds thoroughly irrigated and then covered with saline or saline-soaked pads

Identification and removal of phosphorus particles

Visible particles of white phosphorus removed and placed in cold water to prevent re-ignition

Immediate surgical debridement necessary and repeated until all phosphorus particles have been removed.

Debrided wounds examined at least twice daily for new particles or smoking areas, which would indicate the need for re-operation

Use of copper sulphate or ultraviolet light

No details provided

Systemic support

No details provided

Long-term management

No details provided

Others - none
Mortality increased from 5.4% between 1950 and 1968 to 13.8% between 1969 and 1985. Mortality from 1986 to 2000 was 0%.

Hospital length of stay decreased from a mean of 90 days in the first 19 years of the study to a mean of 15 days in the most recent 15-year period. The chemical responsible for injury was white phosphorus in 146 cases.
 

 

 

 
Table 2. Case reports, with no treatment comparisons

StudyTypeParticipantsInterventionsOutcomeOther

Frank 2008

Germany
4 casesGerman civilians picking up phosphorus (sometimes mistaken for amber) from North German sea beachIrrigation and dressing

Submerging affected skin in cold water. Saline used for irrigation.

Identification and removal of phosphorus particles

Phosphorus particles removed, debridement of necrotic tissue (sometimes under general anaesthesia)

Use of copper sulphate or ultraviolet light

No details provided

Systemic support

No details provided

Long-term management

Defects in skin covered by allogenic grafts in one case. Vacuum-assisted closure in one case.

Others - none
All survived. First case discharged home after 4 weeks; 2nd after 12 days; 3rd after 20 days; 4th after 11 daysRefers to the use of white phosphorus in World War I, and to the military jargon 'willie pete'

Emphasised the use of cold rather than warm water for irrigation

Karunadasa 2010

Sri Lanka
2 cases2 soldiers injured by an exploding rocket-propelled grenadeIrrigation and dressing

Clothes were not removed, with resulting deep burns. Saline used for irrigation.

Identification and removal of phosphorus particles

Serial excisions and debridement

Use of copper sulphate or ultraviolet light

No details provided

Systemic support

Intravenous antibiotics and blood transfusion

Long-term management

Grafting

Others - none
Both survived. Referred to aggressive rehabilitation after 13 weeks. No contracture observed at 12 months. 

Davis 2002

USA
1 case50-year old male worker at munitions manufactory suffered 36% total body surface area burnsIrrigation and dressing
Clothes were removed. Water used for irrigation.

Identification and removal of phosphorus particles
Debridement and removing of phosphorus particles by metal forceps

Use of copper sulphate or ultraviolet light
No details provided

Systemic support
No details provided

Long-term management
2 skin grafts were placed

Others - none
  

Konjoyan 1983

USA
1 case21 year old male soldier injured after explosion of a defective mortar in an armed personnel carrier. Another soldier was killed by the blast.Irrigation and dressing
Wounds irrigated and dressed with silver sulphadiazine

Identification and removal of phosphorus particles
Debridement of wounds on the left knee, with removal of all visible phosphorus particles

Use of copper sulphate or ultraviolet light
No details provided

Systemic support
Resuscitation with intravenous fluids, analgesics, oxygen and blood transfusion

Long-term management
Closure of wounds that were not healed.

Others - none
Survived. After 23 days, transferred to another government health facility to be closer to his home. 

Song 1985

China
1 case41-year old male patient 7% of surface area, 2nd degree burn on lower extremitiesIrrigation and dressing

Wound rinsed and cleaned with water, covered with wet gauze pad.

Identification and removal of phosphorus particles

No details provided

Use of copper sulphate or ultraviolet light

0.4% copper sulphate applied immediately and with wet gauze pads

Systemic support

No details provided

Long-term management

No details provided

Others - none
The patient gets worse at night, developing nausea and vomiting, haematuria, jaundice and hepatomegaly.

On the 11th day the patient died of acute renal failure as result of copper ion absorption.
Conclusion to use the silver nitrate solution instead, as it can make phosphorus particles non-flammable for 6 months or more, and also use of wet compress of 3% to 5% sodium bicarbonate

 

Conner 2007

USA
1 caseA 19-year-old man presented burns after exposure to an incendiary agentIrrigation and dressing

Burns irrigated with copious saline

Identification and removal of phosphorus particles

Remaining phosphorus particles removed. Surgical debridement if still present.

Use of copper sulphate or ultraviolet light

Examination under ultraviolet light if required

Systemic support

No details provided

Long-term management

No details provided

Others - none
     

Loveall 2007

USA
1 casePatient with hand actively burningIrrigation and dressing

Hand rinsed in warm tap water for an hour, then wrapped with gauze, and soaked in sterile water. Hand later submerged in vegetable oil.

Identification and removal of phosphorus particles

Surgical excision

Use of copper sulphate or ultraviolet light

Examination under ultraviolet light

Systemic support

Inpatient intensive care unit management

Long-term management

No details provided

Others - none
        

Al Barqouni 2010

Palestine
1 case18-year old male patient with 30% surface area burnedIrrigation and dressing

Irrigation with dilute sodium bicarbonate, wet dressing applied

Identification and removal of phosphorus particles

Debridement and removal of phosphorus particles

Use of copper sulphate or ultraviolet light

No details provided

Systemic support

Monitoring of electrolytes and cardiac function

Long-term management

No details provided

Others - none
8 days after admission, the patient was discharged relatively well, and after 16 months of follow-up no permanent complications 

Carras 1993

France
1 case33-year old male with 18% surface area burned, 10% of which were deep burnsIrrigation and dressing

Irrigation with 1.4% sodium bicarbonate

Identification and removal of phosphorus particles

Debridement and removal of phosphorus particles

Use of copper sulphate or ultraviolet light

0.5% copper sulphate

Systemic support

Inpatient intensive care unit management

Long-term management

Transferred to rehabilitation unit after 30 days

Others - none

Saracoglu 2013

Turkey
1 case6-year old boy accidentally injured by a firework, resulting in a full-thickness, 1.5 cm in depth burns in his neck.Irrigation and dressing

Irrigation with sterile distilled water, wet dressing applied 2-3

Identification and removal of phosphorus particles

Debridement and removal of necrotic skin and phosphorus particles daily

Use of copper sulphate or ultraviolet light

ultraviolet light

Systemic support

Antibiotic therapy, fluid resuscitation with dexamethasone, intermittent bronchodilator and oxygen were administered.

monitoring of blood pressure, electrocardiography, peripheral oxygen saturation and temperature

Long-term management

No details provided

Others - high protein diet
The patient gets worse during the first 3 days, developing inspiratory stridor and tachypnoea. Transferred to burn and wound care center.

after 9 days survived without any systemic complication, except total left facial nerve paralysis, so that transferred for facial and reconstructive surgery.

Weinberger 19783

cases
A case series describing the treatment of three patients with phosphorous burns from a single incident of a phosphorous grenade explosion.No specific intervention was described, the paper dealt with the overall management of the three patients.Translated paper

Broekhuizen 19821

case
A case report on a munitions worker wounded in the face by an exploding yellow phosphor high explosive grenade.The patient was immediately treated with water, copper sulphate bandages and surgery.The paper also reported on a BEN HUR solution, designed by Israeli doctors, which is copper sulphate (1%) with Hydroxyethyl cellulose (2%) and natrium bicarbonate (5%). This solution should prevent the uptake of copper sulphate in the bloodstream, and hence lessen the effect of copper sulphate on kidney and liver damage. The authors advocate quick surgical intervention to remove all phosphorous materials from the body.

Translated paper