What is the appropriate management of a patient who has ingested yellow phosphorus?

Management of Yellow Phosphorus Poisoning

Immediate Resuscitation and Decontamination

Yellow phosphorus poisoning requires immediate aggressive supportive care with early gastric decontamination within 2 hours of exposure, as this is the single most important factor determining survival. 1

Critical Time-Dependent Actions

• Remove all contaminated clothing immediately and irrigate skin thoroughly with soap and water to prevent continued absorption and secondary exposure to healthcare workers. 2
• Brush off any powdered chemical with gloved hands before water irrigation to reduce the risk of secondary exposure. 2
• Institute gastric decontamination within 2 hours of exposure, as survival rates are significantly higher (97.87%) compared to delayed decontamination (84.62%, p=0.033). 1
• Contact poison control immediately (1-800-222-1222 in the US) and provide details about exposure time, quantity ingested, and product name. 2

What NOT to Do

• Do not give anything by mouth (water, milk, activated charcoal) unless specifically directed by poison control, as this can provoke emesis and aspiration without proven benefit. 2
• Do not delay resuscitation while attempting to identify the specific rodenticide type—delayed resuscitation is a significant mortality predictor. 1
• Healthcare workers must use personal protective equipment when handling gastric contents, as organophosphate-containing rodenticides in emesis can cause severe secondary poisoning requiring atropine, pralidoxime, and even intubation. 3, 4

Clinical Course and Monitoring

The Deceptive Latent Period

Yellow phosphorus poisoning characteristically presents with a conspicuous absence of symptoms during the first 24 hours, followed by fulminant multi-organ toxicity after 24-36 hours (range 18-72 hours). 1

• 72.73% of patients manifest toxidrome only after this lag period, making early asymptomatic presentation falsely reassuring. 1
• All patients require hospital admission and continuous monitoring for at least 72 hours, regardless of initial symptom absence. 1

Laboratory Monitoring Protocol

Monitor the following parameters every 6-12 hours during the first 72 hours:

• Hepatic function: AST, ALT, bilirubin, PT/INR, aPTT 1
• Metabolic status: Arterial blood gas, lactate, glucose 5, 1
• Renal function: Creatinine, urea 1
• Cardiac markers: Troponin, ECG monitoring 6
• Hematologic: Complete blood count (watch for neutropenia) 7

Poor Prognostic Indicators Requiring Escalation

The following findings predict mortality and should trigger immediate consideration for liver transplantation evaluation:

• Jaundice (associated with 77.78% mortality from fulminant hepatic failure) 1
• Hepatic encephalopathy (any grade) 1, 8
• AST or ALT >1000 IU/L 1
• PT/INR prolongation (mean INR 6.6 in transplant candidates) 8
• Metabolic acidosis (significantly associated with mortality, p<0.01) 5, 1
• Hypoglycemia (significantly associated with mortality, p<0.05) 5
• Refractory shock 1

Supportive Management

No Specific Antidote Exists

There is no antidote for yellow phosphorus poisoning—management is entirely supportive. 6

• N-acetylcysteine does not significantly alter disease outcome (p>0.05) despite theoretical hepatoprotective effects. 5
• Focus on aggressive correction of metabolic derangements: hypoglycemia, acidosis, coagulopathy, and hemodynamic instability. 5, 1

Organ-Specific Support

• Hepatic failure: Correct coagulopathy with fresh frozen plasma and vitamin K; manage encephalopathy with lactulose and rifaximin. 8
• Cardiovascular toxicity: Aggressive fluid resuscitation and vasopressor support for shock. 6, 1
• Renal failure: Consider continuous renal replacement therapy (CRRT) as a bridge to transplant. 7
• Rhabdomyolysis: Aggressive hydration and urine alkalinization if myoglobinuria develops. 7

Liver Transplantation Criteria

Emergency liver transplantation is the only definitive treatment for fulminant hepatic failure from yellow phosphorus poisoning and should be considered early when irreversible liver failure is detected. 7, 8

Indications for Transplant Evaluation

• Grade II or III hepatic encephalopathy 8
• INR >6.0 8
• Pediatric End-Stage Liver Disease (PELD) score >30 8
• Child-Pugh score >11 8
• Progressive multi-organ failure despite maximal support 7

Bridge-to-Transplant Therapies

• Plasmapheresis can be used with limited success in selected patients. 7
• CRRT or cytosorb may serve as temporary support while awaiting transplantation. 7

Transplant Outcomes and Limitations

• Living donor liver transplantation has been successfully performed with good results in both adults and children when performed before irreversible multi-organ damage. 7, 8
• However, mortality remains very high (50-67%) even with transplantation if yellow phosphorus toxicity has already caused irreversible brain and cardiac damage in addition to liver failure. 8
• Three of six pediatric transplant recipients died within 1-3 days post-operatively from persistent encephalopathy or cardiac arrest despite well-functioning grafts. 8

Critical Pitfalls to Avoid

• Never be falsely reassured by initial symptom absence—the latent period is characteristic and precedes fulminant toxicity. 1
• Never delay gastric decontamination beyond 2 hours if the patient presents early. 1
• Never delay transplant evaluation once poor prognostic indicators appear—the mean time to death is only 4.22 days (range 2-8 days) after exposure. 1
• Never assume N-acetylcysteine will prevent hepatotoxicity—it has no proven benefit in yellow phosphorus poisoning. 5

Expected Mortality

Overall mortality from yellow phosphorus ingestion is 9-27%, with fulminant hepatic failure being the most common cause of death. 5, 1 Yellow phosphorus is extremely lethal when ingested, and its indiscriminate use in fireworks and rodenticides should be eliminated through public awareness and sale restrictions. 7, 5