AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Two major types of metal incendiaries exist, those that are magnesium based and those of the thermite/thermate type. Most types generally are encountered only in the military or industrial setting.

Magnesium, a silvery white metal of atomic weight 24.32, ignites at 632°C and burns at 1982°C, with magnesium oxide (MgO) as its combustion product. In an exothermic reaction, metallic magnesium can ignite to produce magnesium dihydroxide (ie, Mg(OH)₂) and hydrogen. Magnesium is used in either powdered or solid form as an incendiary agent for both illumination and antipersonnel purposes. Various alloys of magnesium (eg, aluminum/zinc/magnesium alloy found in US M126 round) are mechanically sturdier but also can be ignited easily.

Thermite is a mixture of powdered or granular aluminum and powdered iron oxide. When combined with other substances, such as binders, the material is termed a "thermate." All such materials react vigorously when heated to the combustion temperature of aluminum. This reaction produces aluminum oxide, elemental iron, and sufficient heat to melt the iron. The reaction temperature is approximately 2200°C.

Because the burning temperature of these chemicals is so high, standard hazardous-materials clothing (even Level A self-contained and chemical-proof clothing) is not protective.

Pathophysiology

Burning thermite or magnesium produces predominantly thermal injury, but residual particles (especially of magnesium) may produce chemical injury to the eyes, skin, and respiratory tract.

Most injuries are thermal burns, which may be considered identical to deep partial or full-thickness thermal burns (see Burns, Thermal).

Mortality/Morbidity

Outcome of thermite or ignited magnesium burns is essentially the same as for identical thermal burns.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The history usually makes the nature of the exposure evident, as the patient or rescuer describes the circumstances leading to exposure to thermite or magnesium incendiaries. In the event that a patient presents with burn injury and is unable to give a history, consider exposure to magnesium, thermite, or other hazardous materials.

Obtain the patient's relevant medical history. In decision making, consider diseases that may affect healing (eg, diabetes mellitus, vascular disease) as well as drug allergies.

Physical

Incendiary agents produce predominantly dermatologic and respiratory effects.

• Vital signs
• • As with all resuscitations, first priority is to maintain and support airway, breathing, and circulation (ABC). Patients with airway burns or significant fume exposure may require endotracheal intubation and ventilatory support. Acute respiratory distress syndrome (ARDS) may develop.
  • Patients with significant dermal burns require aggressive fluid resuscitation, following a formula such as the Parkland burn resuscitation guidelines, and require monitoring of urinary output and other vital signs.
• Inhalation of magnesium dust can produce respiratory irritation with the following potential signs and symptoms:
• • Nasal catarrh
  • Productive cough
  • Pneumonitis, including metal fume fever
  • ARDS
  • Hypoxia and tachypnea
  • Airway burns (eg, edema, charring) or lung burns, with potential airway obstruction
  • Wheezes or crackles on lung examination
• Thermal burns
• • Dermal exposure to incendiary agents produces thermal burns. Thermite burns, being predominantly due to molten iron, essentially are thermal burns with minimally reactive metal particles embedded in the tissue. Assume that these burns are deep partial thickness or full thickness until proven otherwise.
  • Magnesium particle reactions with tissue fluid also may produce magnesium dihydroxide, which produces an alkali chemical burn.
  • Retained magnesium particles in skin may produce a lesion that mimics gas gangrene, with tissue death and intratissue gas bubbles due to hydrogen gas formed from the same reaction.

Causes

Exposure to thermite or burning magnesium likely would occur in the context of military or paramilitary actions (including terrorist activities) or as a result of an industrial or scientific laboratory accident. Exposure potentially could occur as a result of a transportation accident.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Metal fume fever

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Order lab studies as needed to manage thermal burns and associated lung injury. No specific studies are required for thermite or ignited magnesium exposure.

Imaging Studies

• Perform chest radiography on patients with possible pulmonary involvement.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• Remove patients from the burning environment, with appropriate attention to personal safety.
• Flush thermite burns with copious amounts of water and brush or debride them to remove contaminating particles.
• Initial care for magnesium burn wounds should include removal of all unburned particles by mechanical means, including wound debridement, if needed. If particles are present, do not flush with water until particles have been removed. If water irrigation is needed for burn treatment or other decontamination, use copious amounts to rapidly flush away residual magnesium before the resulting chemical reaction can cause harm.
• Treat burns with standard thermal burn treatment techniques. Undertake standard support of the ABCs, including intubation and fluid resuscitation if needed.
• Cover burned areas with dry sterile dressings. Avoid large areas of wet dressings due to the risk of hypothermia.
• Narcotic analgesia may be useful if the patient's hemodynamic status permits.

Emergency Department Care

• Institute airway support.
• Start fluid resuscitation, guided by formulas for similar thermal burns.
• Perform wound debridement to remove residual particles of magnesium or iron.
• Aggressively seek and treat associated traumatic injuries (eg, from blast).
• Institute analgesia.
• Consider all incendiary burns tetanus prone and administer appropriate tetanus prophylaxis.

Consultations

• A burn surgeon or other appropriate surgeon (eg, plastics, trauma) should be involved in care.
• Consult an ophthalmologist if eye injury has occurred.
• Continuing critical care expertise may be required if injury severity is high.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Major drugs of use are fluids for resuscitation, oxygen for respiratory support, tetanus prophylaxis, and analgesia. Follow standard therapeutic protocols for thermal burn injury. Antibiotic therapy, including topical agents (eg, silver sulfadiazine) and IV or oral agents, may be needed.

Drug Category: Gases

To support respiration and metabolism.

Drug Category: Electrolytes

Used to maintain hydration and salt balance.

Drug Category: Topical burn treatment

Topical burn-healing and antimicrobial properties.

Drug Category: Topical antibiotics

Antibacterial and to aid in burn healing.

Drug Category: Immunizing agents

Used to immunize patients against tetanus.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Inpatient care is identical to care for other thermal burns, and it usually involves topical antibiotics (eg, silver sulfadiazine) and surgical debridement. Skin grafting may be needed; institute life-support measures as necessary.

Further Outpatient Care

• Outpatient care is identical to care for other thermal burns. A physician experienced in burn management usually should provide follow-up care for patients. Treatment may include dressings, topical antibiotics, analgesia, and grafting.

In/Out Patient Meds

• Medications are standard therapies for thermal burn care and analgesia.

Transfer

• Transfer patients with thermal burns to a burn center if they meet any of the following burn center criteria:
• • Partial thickness burns over 20% body surface area
  • Full-thickness burns over 10% body surface area
  • Burns involving hands, feet, eyes, ears, and/or perineum
  • Airway involvement
  • Significant underlying illness
  • Age younger than 1 year or older than 65 years

Prognosis

• Prognosis depends on the extent of the burn injury, the underlying medical history of the victim, and the extent of care available.

Patient Education

• For excellent patient education resources, visit eMedicine's Bioterrorism and Warfare Center. Also, see eMedicine's patient education articles Chemical Warfare and Personal Protective Equipment.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to involve an appropriate burn specialist early in the care of patients with burn wounds may result in poor prognosis and poor functional or cosmetic outcome.
• Failure to seek associated traumatic injuries (eg, from blast) can lead to significant morbidity or mortality.
• Failure to investigate underlying conditions or drug allergies.
• Failure to administer tetanus prophylaxis as needed.
• Failure to perform adequate fluid resuscitation.

Special Concerns

• Special concerns mirror those for any burn injury. Patients with poor nutrition, underlying illness retarding healing, immunocompromise, or of extremes of age have a poorer prognosis from such injuries.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Curreri PW, Asch MJ, Pruitt BA. The treatment of chemical burns: specialized diagnostic, therapeutic, and prognostic considerations. J Trauma. Aug 1970;10(8):634-42. [Medline].
• J R Army Med Corps. Chemical casualties. Smokes, fuels, and incendiary materials. J R Army Med Corps. Dec 2002;148(4):395-7. [Medline].
• Klaasen CD, ed. Casarett and Doull's Toxicology. 6th ed. New York: McGraw Hill;2001.
• Mendelson JA. Some principles of protection against burns from flame and incendiary munitions. J Trauma. Apr 1971;11(4):286-94. [Medline].
• Schwartz SI, ed. Principles of Surgery. 7th ed. New York: McGraw Hill;1999.
• Stewart CE, Sullivan JB, eds. "Military Munitions and Antipersonnel Agents" In: Hazardous Materials Toxicology. 1992;1007-1008.
• US Department of Transportation. Emergency Response Guidebook. 2000.

Article Last Updated: May 16, 2006