Chemical Burns

Chemical burns are a unique subset of burns that require specialised management due to the nature of the substances involved. Proper initial management is critical to prevent further tissue damage and systemic complications. 

The majority of acid burns cause coagulative necrosis and cytotoxicity leading to skin and mucosal changes that limit deeper injury. Alkali burns result in liquefaction necrosis, allowing for deeper tissue injury as well as vascular injury that can lead to both local and systemic toxicity [1].

Here, we provide an overview of the management of chemical burns in the emergency setting, focusing on actions to be taken before referring the patient to a burns centre.

Introduction

Initial Assessment and Stabilization

Ensure that the scene is safe for both the patient and the healthcare providers. Use appropriate personal protective equipment (PPE) to avoid secondary contamination. An MDT approach between the emergency team, anaesthetists/intensivists and burns surgeons may be required if available.

Primary Survey (ABCDE Approach)

  • Airway – Early involvement of an anaesthetist is crucial as intubation may be necessary. Evidence of airway compromise includes:
    • History of inhalation injury or suspicion of ingestion.
    • Chemical burn injury in and around mouth and nose
    • Swelling of oromucosal surfaces
    • Stridor and hoarse or painful voice
  • Breathing – Assess respiratory rate, respiratory effort and oxygen saturation. Administer high-flow oxygen if indicated and consider arterial blood gas (ABG).
  • Circulation
    • Assess heart rate, blood pressure, peripheral and central CRT, pulses and 3 lead ECG.
    • Blood tests: FBC, U&Es, coagulation screen, electrolytes including calcium depending on the chemical involved (see below under ‘Decontamination’).
    • Establish IV access and begin fluid resuscitation with 250ml boluses of 0.9% Sodium Chloride or Hartmanns if indicated, monitoring for signs of shock.
  • Disability – Assess neurological status using AVPU (Alert, Voice, Pain, Unresponsive) or Glasgow Coma Scale (GCS). Check temperature and blood glucose levels. Assess pupillary reaction to light.
  • Exposure
    • Expose the patient in a systematic manner while keeping remaining body areas covered e.g. 1 limb at a time, to reduce the risk of hypothermia.
    • Remove clothing which may be contaminated with chemicals and jewellery which may cause constriction if swelling occurs.
    • Keep the patient warm using force air warmers such as Bairhugger.

Secondary survey:

  • Top to toe examination to exclude any other injuries as per ATLS guidelines.
  • Particular sensitive areas to consider in chemical burns are mucosal surfaces and eyes which may warrant early Ophthalmology referral.

Obtain History

Gathering a thorough history is crucial for guiding treatment and anticipating complications. The AMPLE framework offers a structured approach [2].

A Allergies

M Medications

P Past medical history

L Last meal and drink

E Events surrounding the injury:

  • Time of chemical burn.
  • First aid done pre-hospital.
  • Type of chemical and strength.
  • Was the patient wearing any protective equipment?

Decontamination

  • Immediate Irrigation – Begin copious irrigation of the affected area with water or saline. This should be done continuously for at least 20-30 minutes. Remove contaminated clothing and avoid using neutralizing agents, as they can cause exothermic reactions and further injury [3].
  • National Poisons Information Service (0344 892 0111) and TOXBASE have useful information on special chemicals and are accessible 24/7.
  • Specific Chemical Protocols:
  • Hydrofluoric acid (HF): HF releases fluoride ions which bind irreversibly to calcium and magnesium in the circulation which can cause life-threatening arrhythmias due to hypocalcaemia and hypomagnesaemia even with small areas affected [4]. Calcium gluconate gel (2.5%) should be applied topically to affected areas after thorough irrigation to bind free fluoride ions. In severe cases, intra-arterial calcium gluconate may be required [5,6,7]. Continuous cardiac monitoring is essential due to the risk of hypocalcaemia-induced cardiac arrhythmias. Be prepared to treat arrhythmias promptly [8]. Monitor serum calcium levels frequently to assess response to treatment and detect early evidence of deterioration.
  • Lime: It is crucial to remove as much of the substance as possible from the skin by brushing it off before any contact with water [9].
  • Phenol: Polyethylene glycol (PEG) is the preferred decontamination agent. However, if PEG is not immediately available, irrigation with water can be initiated. Phenol exposure can lead to significant skin damage and systemic effects. These systemic effects can include central nervous system (agitation, seizures, and coma), as well as cardiac (hypotension and dysrhythmias) [10, 11].
  • Reactive metals (sodium, potassium etc): Apply mineral oil and remove visible particles as irrigating these can cause an exothermic reaction and potentially increase the burn area.

Assessment of Burn Depth and Extent

  • Burn Depth – Assess the burn depth using the below table as a guide, keeping in mind that chemical burns may take several days to fully declare their depth, which may lead to inaccuracies in the initial assessment.
 Presence of blistersBurn ColourExudateCapillary refillSensationTime to healing*
EpidermalNoRedNoneYesPresent +/- tender<7 days
Superficial dermalYesPinkWetYesPainful<3 weeks
Mid-dermalYesDeep pinkWetProlonged+/->3 weeks
Deep dermalNoPatches of deep redMinimal/dryNoneNot presentMonths
Full thicknessNoWhite/brown/blackDryNoneNot presentMonths to year(s)
*Approximate time, multiple factors will affect this
  • Burn extent – Use the Rule of Nines or Lund-Browder chart to estimate the total body surface area (TBSA) affected [12].

Pain Management

Administer appropriate analgesia. Consider opioids for severe pain, along with adjuncts like NSAIDs if there are no contraindications.

Preparation for Transfer

  1. Ensure the patient is hemodynamically stable before transfer. This includes adequate pain control, fluid resuscitation, and stabilization of any systemic complications.
  2. Provide detailed documentation of the initial assessment, treatment provided, and the patient’s response to interventions.
  3. Contact the burns centre to provide a thorough handover, including the nature of the chemical involved, the extent of the burns and any specific treatments initiated.

Summary

Chemical burns require prompt and effective management to minimize tissue damage and systemic toxicity. The initial steps involve ensuring safety, performing a thorough primary and secondary survey and initiating decontamination. Specific protocols, such as those for hydrofluoric acid burns, must be followed to address unique complications like hypocalcaemia and cardiac arrhythmias. Proper stabilization and detailed communication with the burns centre are essential for optimal patient outcomes. This overview aligns with the framework provided by the Emergency Management of Severe Burns (EMSB) course, emphasizing systematic assessment and evidence-based interventions [13].

Written by Dr Hamzah Iqbal (Junior Clinical Fellow) and Reviewed by Mr Jonathan Tan (Plastic Surgery Registrar)

References
  1. VanHoy TB, Metheny H, Patel BC. Chemical Burns. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
  2. ATLS Subcommittee; American College of Surgeons’ Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013 May;74(5):1363-6. doi: 10.1097/TA.0b013e31828b82f5. PMID: 23609291.
  3. Leonard LG, Scheulen JJ, Munster AM. Chemical burns: effect of prompt first aid. J Trauma. 1982 May;22(5):420-3. doi: 10.1097/00005373-198205000-00013. PMID: 7077702.
  4. Schwerin DL, Hatcher JD. Hydrofluoric Acid Burns. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441829/
  5. Hall AH, Blomet J, Gross M, Nehles J. Hexafluorine solution for emergent decontamination of hydrofluoric acid eye/skin splashes. Semiconductor Safety Assoc J. 2000;14:30–334.
  6. Yamaura K, Kao B, Iimori E, Urakami H, Takahashi S. Recurrent ventricular tachyarrhythmias associated with QT prolongation following hydrofluoric acid burns. J Toxicol Clin Toxicol. 1997;35(3):311-3. doi: 10.3109/15563659709001218. PMID: 9140328.
  7. Thomas, D., Jaeger, U., Sagoschen, I. et al. Intra-Arterial Calcium Gluconate Treatment After Hydrofluoric Acid Burn of the Hand. Cardiovasc Intervent Radiol 32, 155–158 (2009).
  8. Kirkpatrick JJ, Enion DS, Burd DA. Hydrofluoric acid burns: a review. Burns. 1995;21(7):483-93
  9. Walsh K, Hughes I, Dheansa B. Management of chemical burns. Br J Hosp Med (Lond). 2022 Mar 2;83(3):1-12. doi: 10.12968/hmed.2020.0056. Epub 2022 Mar 4. PMID: 35377199.
  10. Spiller HA, Quadrani-Kushner DA, Cleveland P. A five year evaluation of acute exposures to phenol disinfectant (26%). J Toxicol Clin Toxicol. 1993;31(2):307-13. doi: 10.3109/15563659309000397. PMID: 8492343.
  11. Vearrier D, Jacobs D, Greenberg MI. Phenol Toxicity Following Cutaneous Exposure to Creolin®: A Case Report. J Med Toxicol. 2015 Jun;11(2):227-31. doi: 10.1007/s13181-014-0440-1. PMID: 25326371; PMCID: PMC4469710.
  12. Murari A, Singh KN. Lund and Browder chart-modified versus original: a comparative study. Acute Crit Care. 2019 Nov;34(4):276-281. doi: 10.4266/acc.2019.00647. Epub 2019 Nov 29. PMID: 31795625; PMCID: PMC6895471
  13. Emergency Management of Severe Burns Course Manual, 18th Edition, January 2020, UK Version for The British Burn Association, Australia and New Zealand Burn Association Ltd 1996.

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