Page 84 - JSOM Fall 2023

Phosphorus Burn Management

with Multimodal Analgesia

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Luc Saint-Jean, MD *; Simon-Pierre Corcostegui, MD ;
Julien Galant, MD ; Clément Derkenne,MD 4
3

ABSTRACT
We report the case of a patient suffering from a chemical burn smoke on the patient’s hand as the burning process continued.
caused by white phosphorus, for whom initial management It took approximately 45 minutes for the burning process to
required decontamination using multimodal analgesia. This extinguish until it was completely removed by using a surgical
case report should be familiar to other military emergency brush. The patient’s pain was sharp and evaluated as a 8/10 in
physicians and Tactical Emergency Medical Support for two severity. The question of analgesia immediately arose to allow
reasons: 1) A phosphorus burn occurs from a chemical agent effective decontamination. In the first instance, we opted for
rarely encountered, with minimal research available in the a hand block by regional anesthesia (RA) of radial, median,
medical literature, despite the use of this weapon in the recent and ulnar nerves. A total of 3mL of non-adrenaline lidocaine
Ukrainian conflict, and 2) We discuss the use of multimodal 20% was injected into each nerve, according to the appropri-
analgesia, combining loco-regional anesthesia (LRA) and an ate anatomical landmarks for each of the different nerves. RA
intranasal pathway, which can be used in a remote and austere made it possible to brush the skin, thus removing the chemical
environment. agent in its entirety. The burn was evaluated at 2.50% of total
body surface area (BSA), non-circular, 2nd degree, and severe
Keywords: phosphorus burn; analgesia; intranasal by its localization on an anatomical extremity with potential
implications for functional prognosis (Figure 3).

According to French guidelines, we sought out an expert burn
Case Report
specialist’s opinion in order to consider hospitalization in a
We report the case of a patient suffering from a chemical burn burn treatment center. However, after sending pictures of the
caused by phosphorus, for whom initial management required wound, it was agreed upon that initial management could be
decontamination using multimodal analgesia. This patient, a carried out at the 1st AMS using the usual care for a thermal
42-year-old Explosive Ordnance Disposal (EOD) specialist burn. This includes adorning the blisters, followed by local
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for the “Groupe d’Intervention de la Gendarmerie Nationale” application of silver sulfadiazine (flamazine) in a thick layer
(GIGN), was handling an exercise smoke grenade as part of an and covering it with a dry dressing.
investigation. It contained a chemical agent known as white
phosphorus. When handling the ammunition, some of its con- The incision and debridement of the phalanges was a very
tents spread onto the patient’s left hand, with an orange dust- painful procedure, despite the regional anesthesia hand block.
like appearance (Figure 1). Approximately 30 minutes after the hand block, and just prior
to beginning debridement, it became evident that the pain con-
Contact with the skin immediately caused a sharp burn on trol was insufficient. We then opted for additional analgesia
the palm and back of the hand. He was then treated urgently using intranasal (IN) procedural sedation. The protocol of the
at the 1st Specialized Medical Unit (1ere Antenne Médicale 1st AMS combines ketamine at the dosage of 0.6mg/kg and
Spécialisée (AMS)), where he received his first treatment. 1st sufentanil at 0.5μg/kg.
AMS is a French military medical facility, that ensures the
medical support of the GIGN. The accident happened during In the following days, the patient was evaluated daily at the 1st
EOD training inside GIGN. It took 15 minutes for the pa- AMS to check healing. The patient benefited from a consulta-
tient to arrive at 1st AMS. The patient’s watch and wedding tion in the burn center on the seventh day for further debride-
ring were removed, and these items were placed into a bath of ment of skin necrosis (Figure 4, 5). Once the patient arrived at
copper sulfate solution. His hand was put under a continuous the hospital, he first received an intravenous (IV) treatment of
cold-water jet. The phosphorus stuck to the skin, visibly or- propofol mixed with ketamine (unknown dosage). The anal-
ange in color, and continued to burn the patient (Figure 2). The gesia performed at 1st AMS was local by spraying lidocaine,
phosphorus ignited on contact with air, a particular difficulty and an intranasal bolus of ketamine alone at 0.6mg/kg was
associated with white phosphorus burns. We observed white also added. No hemodynamic adverse effects were observed.
*Correspondence to luc-1.saint-jean@gendarmerie.interieur.gouv.fr
ère
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1 Dr Saint-Jean, Dr Corcostegui, and Dr Derkenne are all affiliated with the 1st Specialized Medical Unit (1 Antenne médicale spécialisée
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Satory), 2nd Army Medical Center of Versailles (2e Centre Médical des Armées de Versailles), Versailles, France. Dr Galant is affiliated with the
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Marseille Battalion of Navy Firefighters, Marseille, France.
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