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Chemical Burns

  • Author: Robert D Cox, MD, PhD; Chief Editor: Joe Alcock, MD, MS  more...
 
Updated: Oct 06, 2015
 

Background

Chemical burns can be caused by acids or bases that come into contact with tissue. Acids are defined as proton donors (H+), and bases are defined as proton acceptors (OH-). Bases also are known as alkalis. Both acids and bases can be defined as caustics, which cause significant tissue damage on contact. The strength of an acid is defined by how easily it gives up the proton; the strength of a base is determined by how avidly it binds the proton. The strength of acids and bases is defined by using the pH scale, which ranges from 1-14 and is logarithmic. A strong acid has a pH of 1, and a strong base has a pH of 14. A pH of 7 is neutral.

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Pathophysiology

Most acids produce a coagulation necrosis by denaturing proteins, forming a coagulum (eg, eschar) that limits the penetration of the acid. Bases typically produce a more severe injury known as liquefaction necrosis. This involves denaturing of proteins as well as saponification of fats, which does not limit tissue penetration. Hydrofluoric acid is somewhat different from other acids in that it produces a liquefaction necrosis.

The severity of the burn is related to a number of factors, including the pH of the agent, the concentration of the agent, the length of the contact time, the volume of the offending agent, and the physical form of the agent. The ingestion of solid pellets of alkaline substances results in prolonged contact time in the stomach, thus, more severe burns. In addition, concentrated forms of some acids and bases generate significant heat when diluted or neutralized, resulting in thermal and caustic injury.

The long-term effect of caustic dermal burns is scarring, and, depending on the site of the burn, scarring can be significant. Ocular burns can result in opacification of the cornea and complete loss of vision. Esophageal and gastric burns can result in stricture formation. An oral burn is shown in the images below.

Caustic oral burns. Caustic oral burns.
Caustic burns of tongue. Caustic burns of tongue.
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Epidemiology

Frequency

United States

Burns are a common problem seen in the emergency department. There has been a decrease in the number of burns in the United States through 2000, but this appears to have stabilized since. Most burns are only partial thickness and occur on the extremities. Approximately 5% of individuals with burns presenting to the ED require admission.[1]

In 2011, the American Association of Poison Control Centers (AAPCC) reported 15,616 cases of exposures to acidic substances, 18,960 cases of exposures to alkaline substances, 20,518 cases of peroxide exposures, and 38,613 cases of bleach exposures. During that time, 352 cases of exposure to phenols or phenol products were reported.[2] Chemical injuries account for 2-6% of burn center admissions.[3]

International

Worldwide, corrosive substances are commonly used for chemical assault. The most common substances used are lye and sulfuric acid.[4, 5, 6]

Sex

Assaults with caustic chemicals worldwide are more likely to occur against women.[4]

Age

Adults and children are nearly equally exposed to caustic chemicals. Adults exposed to industrial strength chemicals often suffer more severe burns.

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Contributor Information and Disclosures
Author

Robert D Cox, MD, PhD Professor, Department of Emergency Medicine, Associate Professor, Department of Pharmacology and Toxicology, University of Mississippi Medical Center; Medical Director, Mississippi Regional Poison Control Center

Robert D Cox, MD, PhD is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

Jon Mark Hirshon, MD, MPH, PhD Professor, Department of Emergency Medicine, University of Maryland School of Medicine

Jon Mark Hirshon, MD, MPH, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Public Health Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

References
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  2. Bronstein AC, Spyker DA, Cantilena LR Jr, Rumack BH, Dart RC. 2011 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 25th Annual Report. Clin Toxicol (Phila). 2012 Nov. 50 (10):911-1164.

  3. Barillo DJ, Cancio LC, Goodwin CW. Treatment of white phosphorus and other chemical burn injuries at one burn center over a 51-year period. Burns. 2004 Aug. 30(5):448-52. [Medline].

  4. Mannan A, Ghani S, Clarke A, Butler PE. Cases of chemical assault worldwide: a literature review. Burns. 2007 Mar. 33(2):149-54. [Medline].

  5. Tahir C, Ibrahim BM, Terna-Yawe EH. Chemical burns from assault: a review of seven cases seen in a Nigerian tertiary institution. Ann Burns Fire Disasters. 2012 Sep 30. 25(3):126-30. [Medline]. [Full Text].

  6. Notes from the field: exposures to discarded sulfur mustard munitions - mid-atlantic and new England States 2004-2012. MMWR Morb Mortal Wkly Rep. 2013 Apr 26. 62(16):315-6. [Medline].

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  15. Mozingo DW, Smith AA, McManus WF, et al. Chemical burns. J Trauma. 1988 May. 28(5):642-7. [Medline].

  16. Yano K, Hata Y, Matsuka K. Experimental study on alkaline skin injuries--periodic changes in subcutaneous tissue pH and the effects exerted by washing. Burns. 1993 Aug. 19(4):320-3. [Medline].

  17. Yano K, Hosokawa K, Kakibuchi M, et al. Effects of washing acid injuries to the skin with water: an experimental study using rats. Burns. 1995 Nov. 21(7):500-2. [Medline].

  18. Lin TM, Lee SS, Lai CS, Lin SD. Phenol burn. Burns. 2006 Jun. 32(4):517-21. [Medline].

  19. Bertolini JC. Hydrofluoric acid: a review of toxicity. J Emerg Med. 1992 Mar-Apr. 10(2):163-8. [Medline].

  20. Cox RD, Osgood KA. Evaluation of intravenous magnesium sulfate for the treatment of hydrofluoric acid burns. J Toxicol Clin Toxicol. 1994. 32(2):123-36. [Medline].

  21. Friedman EM, Lovejoy FH. The emergency management of caustic ingestions. Emerg Med Clin North Am. 1984 Feb. 2(1):77-86. [Medline].

  22. Salzman M, O'Malley RN. Updates on the evaluation and management of caustic exposures. Emerg Med Clin North Am. 2007 May. 25(2):459-76; abstract x. [Medline].

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Caustic oral burns.
Caustic burns of tongue.
 
 
 
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