Emergency Management of Ratol (Yellow Phosphorus) Poisoning
Immediate Actions
Contact your regional Poison Control Center immediately and activate EMS, as yellow phosphorus poisoning is a life-threatening emergency requiring expert toxicological guidance and rapid transport to a hospital capable of liver transplantation. 1, 2
- Remove all contaminated clothing and jewelry to prevent continued exposure while avoiding self-contamination 1
- Do NOT administer anything by mouth, including water, milk, or attempts at dilution, unless specifically directed by poison control 1
- Do NOT induce vomiting or administer ipecac, as this provides no clinical benefit and may cause aspiration 3, 1
- Do NOT delay EMS activation to attempt home interventions 1
- Implement immediate life-support measures including CPR according to standard protocols if cardiorespiratory arrest occurs 1
Gastric Decontamination
Activated charcoal (1 g/kg) via small-bore nasogastric tube may be administered ONLY if specifically recommended by poison control, though evidence for efficacy is limited. 3
- Gastric decontamination should be instituted within 2 hours of exposure when possible, as survival rates are significantly higher (97.87%) compared to delayed decontamination (84.62%) 4
- Transportation to the emergency department should not be delayed for administration of activated charcoal 5
Clinical Course and Monitoring
Yellow phosphorus poisoning characteristically presents with a conspicuous absence of signs and symptoms during the first 24 hours, followed by delayed toxidrome manifestation at 24-36 hours (range 18-72 hours). 4
Dominant Clinical Manifestations (in order of frequency):
- Abdominal pain (52.53%) 4
- Jaundice (22.21%) 4
- Coagulopathy (15.15%) 4
- Multi-organ failure (17.17%) 4
- Hepatic encephalopathy (10.10%) 4
- Shock (10.10%) 4
- Acute kidney injury (7.08%) 4
Laboratory Abnormalities to Monitor:
- Elevated AST (48.47%) and ALT (49.50%) 4
- Bilirubin elevation (22.21%) 4
- PT/INR prolongation (15.15%) 4
- Metabolic acidosis (10.12%) 4
- Serum creatinine elevation (7.08%) 4
Predictors of Poor Outcome and Mortality
The following are reliable predictors of bad outcome requiring urgent consideration for liver transplantation: 4
- Delayed resuscitation (time to hospital presentation) 4
- Jaundice 4
- Hepatic encephalopathy 4
- AST and ALT elevation >1000 IU/L 4
- Metabolic acidosis 4
- Refractory shock 4
Advanced Management
For patients who develop acute liver failure (characterized by hepatic encephalopathy, coagulopathy, and lactic acidosis), liver transplantation is often necessary and has shown very promising success rates. 6, 2
- Plasmapheresis, continuous renal replacement therapy (CRRT), or cytosorb can be used as a bridge to transplant in selected patients 6, 2
- The mean time for death is 4.22 days since exposure (range 2-8 days), with fulminant hepatic failure being the most common mode of death (77.78% of fatalities) 4
- Mortality rate is approximately 9.1%, with the majority dying from fulminant hepatic failure 4
Additional Complications to Monitor
- Cardiotoxicity 6
- Rhabdomyolysis 6
- Neutropenia 6
- Acute pancreatitis (rare but reported post-transplant) 7
Critical Pitfalls to Avoid
- Do not assume safety based on absence of early symptoms—the characteristic lag period of 24-36 hours before toxidrome manifestation is a dangerous window 4
- Do not delay hospital transfer for patients with any dose uncertainty or intentional ingestion 2
- Do not underestimate the need for early transplant evaluation in patients meeting poor prognostic criteria 2, 4