Topical Chemical Burn

Table of Contents

Aliases

Chemical Burn

Patient Care Goals

  1. Rapid recognition of a topical chemical burn
  2. Initiation of emergent and appropriate intervention and patient transport

Patient Presentation

Inclusion Criteria

  1. Patients of all ages who have sustained exposure to a chemical that can cause a topical chemical burn may develop immediate or in some cases a delayed clinical presentation
  2. Agents that are known to cause chemical burns include alkali, acids, mustard agent, and lewisite

Exclusion criteria

None recommended

Patient Management

  1. Don the appropriate PPE
  2. Remove the patient’s clothing, if necessary
  3. Contaminated clothing should preferably be placed in double bags
  4. If deemed necessary and manpower resources permit, the patient should be transported by EMS providers who did not participate in the decontamination process, and in an emergency response vehicle that has not been exposed to the chemical
  5. Information regarding the chemical should be gathered while on scene including materials safety data sheet if available
  6. Communicate all data regarding the chemical to the receiving facility

Assessment

  1. Clinical effects and severity of a topical chemical burn is dependent upon:
    1. Class of agent (alkali injury or acid injury)
    2. Concentration of the chemical the (higher the concentration, the greater the risk of injury)
    3. pH of the chemical
      1. Alkali-increased risk with pH greater than or equal to 11
      2. Acid-increased risk with pH less than or equal to 3
    4. Onset of burn
      1. Immediate
      2. Delayed (e.g. hydrofluoric acid)
  2. Calculate the estimated total body surface area that is involved
  3. Prevent further contamination
  4. Special attention to assessment of ocular or oropharyngeal exposure – evaluate for airway compromise secondary to spasm or direct injury associated with oropharyngeal burns
  5. Some acid and alkali agents may manifest systemic effects

Treatment and Interventions

  1. If dry chemical contamination, carefully brush off solid chemical prior to flushing the site as the irrigating solution may activate a chemical reaction
  2. If wet chemical contamination, flush the patient’s skin (and eyes, if involved) with copious amounts of water or normal saline
  3. Provide adequate analgesia per the Pain Management guideline
  4. Consider the use of topical anesthetic eye drops, Tetracaine, for chemical burns of the eye
    1. 1 drop in each affected eye
  5. For eye exposure, administer continuous flushing of irrigation fluid to eye –
    1. If available, Morgan lens may facilitate administration
    2. Nasal Cannulas may be adapted to facilitate administration
  6. Early airway intervention for airway compromise or spasm associated with oropharyngeal burns
  7. Take measures to minimize hypothermia
  8. Initiate intravenous fluid resuscitation if necessary to obtain hemodynamic stability

Hydrofluoric Acid

Hydrofluoric acid (HF) is a highly corrosive substance that is primarily used for automotive cleaning products, rust removal, porcelain cleaners, etching glass, cleaning cement or brick, or as a pickling agent to remove impurities from various forms of steel. Hydrofluoric acid readily penetrates intact skin and there may be underlying tissue injury. It is unlikely that low concentration HF will cause an immediate acid-like burn however there may be delayed onset of pain to the exposed area. Higher concentration HF may cause immediate pain as well as more of a burn appearance that can range from mild erythema to an obvious burn. An oral or large dermal exposure can result in significant systemic hypocalcemia with possible QT prolongation and cardiovascular collapse.

  1. For all patients in whom a hydrofluoric acid exposure is confirmed or suspected:
    1. Vigorously irrigate all affected areas with water or normal saline for a minimum of 15 minutes
    2. Apply a cardiac monitor for oral or large dermal exposures significant HF exposures
    3. If available, apply calcium preparation:
      1. Calcium prevents tissue damage from hydrofluoric acid
      2. Topical calcium preparations:
        1. Commercially manufactured calcium gluconate gel
        2. Apply generous amounts of the calcium gluconate gel to the exposed skin sites to neutralize the pain of the hydrofluoric acid
          1. Leave in place for at least 20 minutes then reassess
          2. This can be repeated as needed
    4. Although generally low yield, there may be benefit to intravenous pain medication along with the topical calcium gluconate gel for pain control
    5. If fingers are involved, apply the calcium gel to the hand, squirt additional calcium gel into an exam glove, and then insert the affected hand into the glove.
    6. For patients who have ingested hydrofluoric acid or who have a large dermal exposure consider intravenous calcium chloride, 20 mg/kg, 0.2 mL/kg, max of 10 cc , as symptomatic hypocalcemia can precipitate rapidly as manifest by muscle spasms, seizures, hypotension ventricular arrhythmias and QT prolongation

Notes – Topical Chemical Burn