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emission of whitish smoke on contact with skin. The result is analgesia with procedural sedation with via the IN route. The
deep bedsores that are extremely painful, quickly suppurated, 1st AMS, as well as the other French medical units supporting
and whose healing is very slow. White phosphorus burns re- the Special Operations Forces units, are particularly interested
quire a debridement and removal of phosphorus particles; this in this topic, given their practice in remote environments and
8
can be accomplished via a thorough and prolonged wash un- care under fire. The IN route has been the subject of numer-
der cold running water. Then, a large excision of the affected ous scientific evaluations over the past two years, alleging its
tissues must be carried out before wet dressings or hydrogels advantages in tactical medicine. 13,14 The doses of the protocol
are placed. The possible use of skin covering techniques (arti- used, as well as its ability to be titrated, allow the practitioner
ficial skin and/or autografts) is decided at the hospital, under to limit undesirable effects.
the guidance of a specialist. 4–7
Conclusion
In the case report, we described the use of a copper sulfate
buffer solution for the decontamination of the watch and the The management of chemical injuries is time-consuming for
patient’s wedding ring. This solution is known to be a chelator emergency medical teams and can put them at risk. Until
of phosphorus, forming copper phosphate. Copper phosphate now, the occurrences of such chemical emergencies have been
precipitates in the form of black granules, which can be re- mainly accidental. However, recent international news regard-
moved easily, and hence why we used it on the patient’s watch ing the conflict in the Ukraine serves as a reminder that these
and ring. A 2014 Cochrane review based on two older obser- are not weapons of the past. 15
vational studies concluded that there was no recommendation
4
for the use of copper sulfate directly on burn. Their analysis References
was concerning for possible systemic iatrogenic harm. 4 1. Recommendations de Pratiques Professionnelles. Societe Fran-
caise d’Anesthesie et Reanimation. https://www.sfmu.org/upload/
Phosphorus can cause systemic effects and electrolyte abnor- consensus/rpp_brul%C3%A9_2019.pdf. Accessed 12 April 2023.
malities, such as hyperphosphatemia and hypocalcemia, as 2. Santora M, Specia M, Gladstone R. Western powers look into
an unverified claim of possible use of a chemical agent in Mariu-
well as acute renal failure and hemolytic anemia. There is no pol. The New York Times. https://www.nytimes.com/2022/04/12/
link between the severity of the burn and the risk of systemic world/europe/chemical-weapons-russia-mariupol.html. Accessed
impairment. The patient’s prognosis is linked to the likelihood 12 April 2023.
of hypocalcemia, which can lead to lengthening the QT seg- 3. Testud F. Phosphore et composés inorganiques. EMC – Pathol
ment and subsequent ventricular rhythm abnormalities. It is Prof Environ. 2011;6(3):1–10.
thus necessary to carefully monitor the patient, perform an 4. Barqouni L, Abu Shaaban N, Elessi K. Interventions for treat-
ing phosphorus burns. Cochrane Database Syst Rev. 2014;2014
EKG, and finally to carry out a phospho-calcium assessment (6):CD008805.
by blood test. We did not perform a blood sample during the 5. Al Barqouni LN, Skaik SI, et al. White phosphorus burn. Lancet.
4
initial management of our patient, as we are a primary-care 2010;376(9734):68.
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comparative experimental study of various forms of treatment.
Burns. 1991;17(3):198–200.
Analgesia is the second interesting point in this case report, as 7. Ng NYB, Abdullah A, Milner SM. A phosphorus burn. Eplasty.
it was necessary to allow effective management of the burn, 2015;15:ic15.
both in terms of decontamination and blister debridement. In- 8. Travers S, Carfantan C, Luft A, et al. Five years of prolonged field
deed, the treatment of pain is a major issue in the overall care care: prehospital challenges during recent French military opera-
of the patient. Poor pain control is correlated with increased tions. Transfusion (Paris). 2019;59(S2):1459–1466.
morbidity and mortality in those wounded by war. A corollary 9. De Rocquigny G, Dubecq C, Martinez T, et al. Use of ketamine
can be established for a severely traumatized patient in a civil- for prehospital pain control on the battlefield: a systematic re-
view. J Trauma Acute Care Surg. 2020;88(1):180–185.
8,9
ian environment. While treating this patient, it seemed wise 10. Mahiou P, Darren R, Desebbe O, et al. Intérêts des anesthésies
to us to first propose a hand block by regional anesthesia, in locorégionales périphériques en milieu périlleux. J Eur Urgences
order to achieve a peripheral nerve block of the radial, median, Réanimation. 2021;S221142382100078X.
and ulnar nerves. There is strong interest in the use of periph- 11. Freysz M, Ricard-Hibon A, Adnet F, et al. Société française
10
eral nerve blocks for anesthesia in hostile environments. Of d’anesthésie et de réanimation. Annales Françaises d’Anesthésie
note, the success of the procedure is correlated with the ex- et de Réanimation. 2004; 23:167–176
perience of the physician performing it. 11,12 In our case, the 12. Carles M, Beloeil H, Bloc S, et al. Anesthésie loco-régionale péri-
nerveuse (ALR-PN). Anesth Réanimation. 2019;5(3):208–217.
block proved to be partially effective. The volume of 3mL we 13. Montagnon R, Dubecq C, Pasquier P. Use of the intranasal route
injected per nerve was slightly lower than the amount recom- for administration of ketamine by Special Operations medical
mended by the “Société Française d’Anesthésie-Réanimation” personnel during training mishaps. J Spec Oper Med. 2021;21(3):
(SFAR), in the 2004 recommendations. They recommended 96–97.
11
reducing volume to prevent local toxicity, though this proba- 14. Butler FK Jr, Kotwal RS, Buckenmaier CC 3rd, et al. A triple-op-
bly explained its partial effectiveness in this patient. We chose tion analgesia plan for Tactical Combat Casualty Care: TCCC
guidelines change 13-04. J Spec Oper Med. 2014;14(1):13–25.
to inject a smaller volume to avoid side effects, as we rarely 15. Coleman A, Devlin K. Ukraine conflict: Russian chemical attack
perform regional anesthesia in emergency cases. We did not claim fact-checked. BBC News. 15 May 2022. https://www.bbc.
use ultrasound guidance and had no neurostimulator to assess com/news/61439398. Accessed 12 April 2023.
the quality of the block performed. We then supplemented the
PMID: 37302143; DOI: 10.55460/N0QE-PCTE

84 | JSOM Volume 22, Edition 3 / Fall 2023