Toxicological aspects of Phosphorus with emphasis on its forms, uses, poisoning: types, diagnosis, treatment, autopsy features and medico-legal importance.

1. .
Phosphorus poisoning
Adhavan. M
Ⅱ MBBS
IGMC&RI
Puducherry

2. • Forms
• Uses
• Poisoning
• Types
• Diagnosis
• Treatment
• Autopsy features
• Medico-legal importance

3. Phosphorus
• Inorganic, non-metallic element
• 2 varieties - yellow/white & red
• Yellow phosphorous - yellowish, crystalline solid with garlicky
odour; on exposure to air forms whitish fumes; highly
combustible; ignites at 34℃; luminescent & phosphorescent
• Red phosphorus - reddish, amorphous, odourless, insoluble;
Not absorbed in GIT - relatively harmless
• Derivatives - Phosphoric acid, phosphine, aluminium
phosphide, zinc phosphide

4. Uses
1.Matches - Lucifer matches - strike anywhere - 1906 Berne convention -
safety matches - Potassium chlorate + antimony sulphide
2.Fireworks - Banned in western countries, not in India
3.Military use - Tracer bullets, incendiary bombs, smoke screens, rescue
flares
4.Insecticide & rodenticide - Zinc phosphide - cockroaches, rats - e.g.
Ratol
5.Fertilizer
6.Medicinal - In homeopathy

5. Poisoning
• Fatal dose - 60mg (1mg/kg body weight)
• Mode of action - protoplasmic poison, hepatotoxin; cause
shock, CVS collapse; skin, mucosa irritant; oils enhance
absorption
• Poisoning types
1. Fulminant
2. Acute
3. Chronic

6. Fulminant poisoning
• Ingestion of massive doses - <2g
• Peripheral vessel collapse
• Death in 12 to 24 hours
• Signs of hepatic, renal damage not seen

7. Acute poisoning
• Common type
• Stages Ⅰ Ⅱ & Ⅲ
• Stage Ⅰ - up to 3 days
• Local side effects - burning pain, vomiting,
diarrhoea, pain abdomen, haematemesis
• Garlic odour breath
• Vomitus, stool - luminous; fumes from stools

8. • Stage Ⅱ - up to several days after stage-Ⅰ
• Symptom-free
• Patient well enough to be discharged
• Stage Ⅲ
• Due to systemic effects after absorption
• GI symptoms reappear, more severe
• Prominent liver damage manifestations - hepatomegaly,
jaundice, pruritus, bleeding, hepatic encephalopathy -
drowsiness, confusion, ataxia, flapping tremor, stupor, coma

9. • Stage Ⅲ contd.
• Mousy odour of breath - foetor hepaticus
• Renal damage- oliguria, haematuria, albuminuria, renal
failure
• ECG changes - tachycardia, ST & T wave changes, QT
prolongation, low voltage QRS, arrhythmias
• Terminal convulsions before death
• Dermal contact - painful corrosion with yellow, necrotic,
severely painful 2nd, 3rd degree chemical burns with garlic
odour; absorption from damaged skin - systemic poisoning

10. Chronic poisoning
• Long term occupational exposure to
phosphorus pentoxide fumes
• Phossy jaw, Glass jaw, Lucifer’s jaw
• Toothache - recurrence - extraction -
bone exposed - necrosis,
sequestration, osteomyelitis of lower
jaw
• Red phosphorus - dermatitis

11. Diagnosis
• Garlicky odour of breath, vomitus
• Fuming, luminous vomitus & stools
• Evidence of hepatic, renal failure
• Hypoprothrombinaemia, thrombocytopenia,
haematemesis, haematochezia, haematuria,
haemorrhages of skin, mucous membranes
• Hypokalaemia, hyperchloraemia, hypocalcaemia,
hyperphosphataemia, hypophosphataemia

12. Treatment
• Acute poisoning
1. Gastric lavage with KMnO₄, CuSO₄ - risk of combustion
2. Do not administer milk, fatty foods
3. IV fluids
A. Isotonic saline, sodium lactate - treats shock,
dehydration, acidosis
B. Glucose - hypoglycaemia
C. Calcium gluconate - hypocalcaemia

13. 4. Whole blood, FFP - agglutination defects
5. Steroids - shock
6. Anticonvulsants - seizures
7. N-acetyl cysteine - prevents progression of liver
damage
• Chronic poisoning
1. Remove patient from source of exposure
2. Dental treatment, follow up

14. • Dermal burns
• Flush with water; clean with soap & water; remove
loose, non-viable tissue; give IV analgesics
• Should not debride closed blisters
• Prophylactic topical antibiotics - silver sulfadiazine,
bacitracin
• Analgesics - paracetamol, codeine for pain relief

15. • Embedded phosphorus removal
1. Visualise by UV lamp
2. Remove with metal forceps
3. Remaining particles - discontinue moist dressing -
smoke from crystals - remove manually
4. Deep, extensive injury - consult burns specialist

16. Autopsy findings
• External
1. Emaciation, purpuric rashes, jaundice, garlicky
smell
2. Mucous membrane of mouth is corroded
3. Dark brown coloured hypostasis

17. • Internal
1. Multiple haemorrhages in muscles, mucosa, serosa GIT, RS,
liver, kidney, heart, peritoneum, lungs, brain
2. Stomach and intestines - mucous membranes: yellowish or
greyish-white, softened, thickened, inflamed, corroded in
patches; stomach contents - luminous, garlicky smell
3. Liver - swollen, yellow, soft, fatty, friable
4. Kidneys - enlarged, greasy, yellow
5. Heart - flabby, pale, shows fatty degeneration
6. Lungs - fat emboli in pulmonary arterioles, capillaries

18. Medico-legal importance
• Accidental poisoning - ingestion of cockroach, rat
poisons, fireworks by children; contaminated food
• Suicidal poisoning - Rat pastes like Ratol; formerly in
western countries - match heads+brandy+sugar
• Homicidal poisoning - formerly used - mixed in soups,
jams, rum - smell of garlic - unsuspected
• Arson - covered with dung or wet cloth & thrown on huts
• Abortifacient - oral, vaginal

19. References
• Pillay VV. Inorganic non-metallic poisons. In:
Comprehensive medical toxicology. 2nd edition.
Hyderabad: Paras medical publisher; 2008. p 95-99.
• Biswas G. Non-metallic and mechanical irritants. In:
Review of forensic medicine and toxicology. Third
edition. New Delhi: Jaypee brothers medical
publishers(P)Ltd; 2015. p 514-516.

20. Thank you