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White phosphorus burns managed without copper sulfate: lessons from war.

White phosphorus is an incendiary agent used in fireworks and military ammunitions. White phosphorus burns are chemical burns. The burn is progressive as long as oxygen is available. This thermogenic reaction generates a number of phosphates and oxidates, which bind calcium ions producing hypocalcaemia. It causes potentially lethal deep burns. It is highly lipolytic, which penetrate the tissue producing systemic effects. We present two cases of white phosphorus burns of two soldiers after rocket-propelled grenade blast. They were 22 and 34 years old, with TBSA of 36 and 17%, respectively. These were deep burn wounds but inadequately managed at the primary care hospital. At the site, cloths that may harbor phosphorus particles should be removed and irrigated with water. Wet dressing should be used to cover the wounds, cutting off oxygen to the remaining phosphorus, till the patient is transferred to the specialist unit. This was not carried out on these patients resulting in deeper burns. Resuscitation, thorough wound debridement, and saline irrigation were carried out. On debridement, smoldering phosphorus particles were identified and removed. Even though the literature stated that copper sulfate solution was not used for identification and removal of white phosphorus and ultraviolet light of Wood’s lamp was not available, intravascular haemolysis and renal failure can occur with stronger copper sulfate solutions. Copper sulfate has proved lethal in experimental animal models, and in these patients, water irrigation alone has been a life saving procedure. Both patients required several serial excisions and grafting. Intravenous antibiotics, high protein feeds, and blood transfusions were used accordingly. Renal functions were satisfactory throughout. Hypocalcaemia was not present in both patients. The hospital stay was 13 weeks. Aggressive rehabilitation was followed, and there were no contractures at 1 year. Prompt recognition, thorough debridement, water irrigation, and wet dressing would minimize morbidity and mortality of white phosphorus burns.