eMedicine Specialties > Emergency Medicine > Environmental

Burns, Chemical

Updated: Jan 10, 2008

Introduction

Background

Acids are defined as proton donors (H⁺), and bases are defined as proton acceptors (OH^-). Bases also are known as alkalies. 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.

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, 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.

Frequency

United States

In 2005, the American Association of Poison Control Centers (AAPCC) reported 26,300 cases of exposures to acidic substances, 40,800 cases of exposures to alkaline substances, 23,300 cases of peroxide exposures, and 59,500 cases of bleach exposures. During that time, 1,532 cases of exposure to phenols or phenol products were reported.¹ Chemical injuries account for 2-6% of burn center admissions.²

International

Worldwide, corrosive substances are commonly used for chemical assault. The most common substances used are lye and sulfuric acid.³

Mortality/Morbidity

In the 2005 report of the American Association of Poison Control Centers, exposures to acids and acid-containing products and chemicals resulted in 9 deaths, 129 cases of major toxicity, and 2380 cases of moderate toxicity. Exposures to alkali products and chemicals resulted in 8 deaths, 226 cases of major toxicity, and 3615 cases of moderate toxicity. Exposures to peroxides resulted in 1 death, 5 cases of major toxicity, and 108 cases of moderate toxicity. Exposures to bleaches and chlorite-containing products resulted in 8 deaths, 82 cases of major toxicity, and 2862 cases of moderate toxicity. Exposures to phenol-containing products resulted in 1 death, 5 cases of major toxicity, and 108 cases of moderate toxicity.¹

Sex

Assaults with caustic chemicals worldwide are more likely to occur against women.³

Age

Adults and children are nearly equally exposed to chemical burns.

Clinical

History

Clinical signs and symptoms vary depending on the route of exposure and the particular substances involved. Because of the variety of presentations, the emergency clinicians must be prepared to handle all possibilities. Some exposures, such as hydrofluoric acid, may present without immediate pain and should be considered in patients with complaints of slow-onset deep pain occurring after exposure to an appropriate product.
Patient history should include the following:
- Offending agent, concentration, physical form, pH
- Route of exposure
- Time of exposure
- Volume of exposure
- Possibility of coexisting injury
- The timing and extent of irrigation

Physical

If the exposure was by ingestion, the immediate concern is to protect the patient's airway. If there is evidence of airway compromise (eg, oropharyngeal edema, stridor, use of accessory muscles), consider establishing a definitive airway.
Dermal exposures
- Size
- Depth
- Location
- Circumferential burns
Ocular exposures
- Visual acuity
Presence of periorbital dermal lesions
- Scleral and corneal lesions (eg, ulcerations, fluorescein uptake)
- Leakage of vitreous humor
Ingestions
- Presence of oral burns or edema, drooling
- Dysphagia, stridor, wheezing, dyspnea, tachypnea
- Abdominal tenderness, guarding, crepitus, subcutaneous air (Hamman crunch)

Causes

A large number of industrial and commercial products contain potentially toxic concentrations of acids, bases, or other chemicals that can cause burns. Some of the more common products are listed as follows:

Acids
- Sulfuric acid is commonly used in toilet bowl cleaners, drain cleaners, metal cleaners, automobile battery fluid, munitions, and fertilizer manufacturing. Concentrations range from 8% acid to almost pure acid. The concentrated acid is very viscous and denser than water. It also generates significant heat when diluted. These attributes make sulfuric acid an effective drain cleaner. Concentrated sulfuric acid is hygroscopic. Thus, it produces dermal injuries by dehydration, thermal injury, and chemical injury.
- Nitric acid is commonly used in engraving, metal refining, electroplating, and fertilizer manufacturing.
- Hydrofluoric acid is commonly used in rust removers, tire cleaners, tile cleaners, glass etching, dental work, tanning, semiconductors, refrigerant and fertilizer manufacturing, and petroleum refining. This is actually a weak acid, and, in dilute form, it will not cause immediate burning and pain on contact.
- Hydrochloric acid is commonly used in toilet bowl cleaners, metal cleaners, soldering fluxes, dye manufacturing, metal refining, plumbing applications, swimming pool cleaners, and laboratory chemicals. Concentrations range from 5-44%. Hydrochloric acid is also known as muriatic acid.
- Phosphoric acid is commonly used in metal cleaners, rustproofing, disinfectants, detergents, and fertilizer manufacturing.
- Acetic acid is commonly used in printing, dyes, rayon and hat manufacturing, disinfectants and hair wave neutralizers. Vinegar is dilute acetic acid.
- Formic acid is commonly used in airplane glue, tanning, and cellulose manufacturing.
- Chloroacetic acids
  - Monochloroacetic acid is used in the production of carboxymethylcellulose, phenoxyacetates, pigments, and some drugs. It has significant systemic toxicity because it enters and blocks the tricarboxylic acid cycle, inhibiting cellular respiration. It is highly corrosive.
  - Dichloroacetic acid is used in manufacturing chemicals. It is a weaker acid than trichloroacetic acid, and it does not inhibit cellular respiration.
- Trichloroacetic acid is used in laboratories and in chemical manufacturing. It is highly corrosive and "fixes" tissues it contacts. It does not inhibit cellular respiration.
- Phenol and cresols
  - Phenol, also known as carbolic acid, is a weak organic acid used in the manufacture of resins, plastics, pharmaceuticals, and disinfectants.
  - Cresols are dihydroxybenzenes that are used as wood preservatives, degreasing agents, and chemical intermediates. These substances are very irritating to the skin and can be absorbed through the skin to produce systemic toxicity.
Bases
- Sodium hydroxide and potassium hydroxide are used in drain cleaners, oven cleaners, Clinitest tablets, and denture cleaners. They are extremely corrosive. Clinitest tablets contain 45-50% sodium hydroxide (NaOH) or potassium hydroxide (KOH). Solid or concentrated NaOH or KOH is denser than water and generates significant heat when diluted. Both the heat generated and the alkalinity contribute to burns.
- Calcium hydroxide also is known as slaked lime. It is used in mortar, plaster, and cement. It is not as caustic as NaOH, KOH, or calcium oxide.
- Sodium and calcium hypochlorite are common ingredients in household bleach and pool chlorinating solution. Pool chlorinators also contain NaOH and have a pH around 13.5, making them very caustic. Household bleach has a pH around 11 and is much less corrosive.
- Calcium oxide, also known as lime, is the caustic ingredient in cement. It generates heat when diluted with water and can produce a thermal or caustic burn.
- Ammonia is used in cleaners and detergents. The dilute form is not highly corrosive. Gaseous anhydrous ammonia is used in a number of industrial applications, particularly in fertilizer manufacturing. It is very hygroscopic (has a high affinity for water). It produces injury by desiccation and heat of dilution in addition to causing a chemical burn. It can cause severe skin burns as well as pulmonary injury.
- Phosphates commonly are used in many types of household detergents and cleaners. Substances include tribasic potassium phosphate, trisodium phosphate, and sodium tripolyphosphates.
- Silicates include sodium silicate and sodium metasilicate. They are used to replace phosphates in detergents. Dishwashing detergents are alkaline, primarily to builders such as silicates and carbonates. They are moderately corrosive.
- Sodium carbonate is used in detergents. It is moderately alkaline, depending on the concentration.
- Lithium hydride is used to absorb carbon dioxide in space technology applications. It vigorously reacts with water to generate hydrogen and lithium hydroxide. It can produce thermal and alkaline burns.
Oxidants
- Bleaches: Chlorates are the primary chemicals used as bleaches in the United States. Household bleach is alkaline with a pH of 11-12, but it is dilute enough that it is minimally irritating to the skin. More concentrated, industrial strength chlorates may be more damaging to the skin.
- Peroxides: Household-grade hydrogen peroxide (3%) produces minimal-to-no skin irritation. Concentrations of 10% may cause paresthesias and blanching of the skin. Concentrations of 35% or more will cause immediate blistering.
- Chromates: Potassium dichromate and chromic acid are common industrial chemicals used in tanning, waterproofing fabrics, corrosion inhibitor, painting, and printing, and they are also used as an oxidizing agent in chemical reactions. Chromates can result in severe skin burns and subsequent systemic toxicity, including renal failure.
- Manganates: Potassium permanganate is a strong oxidizing agent that is used in dilute solutions as a disinfectant or sanitizing agent. In dilute solutions, it is minimally irritating to the skin. In concentrated form or pure crystals, it can cause severe burns, ulcerations, and systemic toxicity.
Other substances
- White phosphorus: This chemical is used as an incendiary in the manufacture of munitions, fireworks, and fertilizer. White phosphorus is spontaneously oxidized in air to phosphorus pentoxide, giving off a yellow flame and a dense white smoke with a garlic odor. After explosions of munitions or fireworks, small particles of phosphorus can become embedded in the skin and continue to smolder.²
- Metals: Elemental lithium, sodium, potassium, and magnesium react violently with water, including water on the skin.
- Hair coloring agents contain persulfates and concentrated solutions of peroxides. Straightening agents may contain concentrated alkali. Chemical burns can result if these are not diluted properly or have a prolonged contact time with the scalp. Burns with various products have been reported in the literature.⁴
Vesicants: These agents are primarily chemical warfare agents and are also known as blister agents. They include sulfur and nitrogen mustards, arsenicals, and phosgene oxime. For more information see CBRNE – Vesicants, Mustard: Hd, Hn1-3, H and CBRNE – Vesicants, Organic Arsenicals: L, ED, MD, PD, HL.

Differential Diagnoses

Burns, Ocular	CBRNE - Vesicants, Mustard: Hd, Hn1-3, H
CBRNE - Chemical Decontamination	CBRNE - Vesicants, Organic Arsenicals: L, ED, MD, PD, HL
CBRNE - Chemical Warfare Agents	Hazmat
CBRNE - Incendiary Agents, Magnesium and Thermite	Toxicity, Caustic Ingestions
CBRNE - Incendiary Agents, White Phosphorus

Workup

Laboratory Studies

Lab studies depend on the burn type and extent of exposure.
Severe burns
- Electrolytes
- Creatinine
- BUN
- Glucose
- Urinalysis
- CBC
- Creatine phosphokinase
- Coagulation profile
Localized burns - Usually no lab tests required
Hydrofluoric acid burns
- Calcium
- Magnesium
- Potassium
Ingestions of caustics
- Hemoglobin/hematocrit
- Pulse-oximetry or ABG if respiratory symptoms
Oxalic acid burns
- Calcium
Chromic acid
- BUN
- Creatinine
Monofluoroacetic acid burns
- Electrolytes
- ABG
Phenol
- Electrolytes
- CBC
- Urinalysis
- Creatinine
- Liver function tests

Imaging Studies

Ingestions
- Chest radiography if any respiratory symptoms
- Abdominal radiography (flat and upright) if signs of peritonitis are present

Other Tests

Endoscopy for ingestions
- Perform esophagoscopy and gastroscopy on all patients with symptomatic ingestions and on patients who are asymptomatic but have a history of a significant ingestion of a substance with the potential to cause major injury.^5,6
- Findings on esophagoscopy do not correlate well with physical signs and symptoms. Of patients with esophageal injuries, 2-15% have no oral burns.
- Burn findings are classified as superficial, transmucosal, or transmural.
- Esophagoscopy findings are used to guide further treatment. The presence of full-thickness or circumferential burns is associated with future stricture formation.
- The issue of whether to extend the endoscopic examination past the first site of injury is controversial.

Procedures

Endotracheal intubation is required for severe respiratory symptoms. Direct visualization is recommended to assess the degree of injury.

Treatment

Prehospital Care

Prompt wound irrigation is the most critical aspect in preventing the extent of dermal burns from exposure to caustic substances. Animal studies have shown that irrigation of both acid exposures and alkaline exposures within several minutes decreases the pH change in the skin and the extent of dermal injury. A burn center case series found that patients who received irrigation within 10 minutes had a 5-fold decrease in full-thickness injury and a 2-fold decrease in length of hospital stay.⁷

Prevent contaminated irrigation solution from running onto unaffected skin.
Remove contaminated clothes.
Special situations
- If contamination with metallic lithium, sodium, potassium, or magnesium has occurred, irrigation with water can result in a chemical reaction that causes burns to worsen. In these situations, the area should be covered with mineral oil and the metallic pieces should be removed with forceps and placed in mineral oil. If forceps are not available, soak the area with mineral oil and cover it with gauze soaked in mineral oil.
- If contamination with white phosphorus has occurred, thoroughly irrigate the area with water then cover the area with water-soaked gauze. Keep the area moist at all times. The area can also be covered with petroleum jelly.

Emergency Department Care

The first priority in treatment is to ensure complete removal of the offending agent. Thorough decontamination is key. Adequate irrigation is difficult to define and depends on the amount of exposure and the agent involved. Using litmus paper to measure the pH of the affected area or the irrigating solution is helpful. Complete removal and neutralization of concentrated acids and alkalis may require several hours of irrigation. Tap water is adequate for irrigation. Low-pressure irrigation is desired; high pressures may exacerbate the tissue injury.^7,8,9,10

If a question of airway compromise exists, secure the airway.
Large surface burns require the same fluid therapy as that for thermal burns. See Burns, Thermal.
After initial decontamination, the full extent of the injury must be ascertained and the patient must be treated as a typical burn patient. Based on the degree of injury, ensure adequate fluid resuscitation and take precautions to prevent complications (eg, hypothermia, infection, rhabdomyolysis).
Special situations
- Elemental metals: The elemental forms of lithium, potassium, sodium, and magnesium react with water. If these metals are thought to be on the skin of a patient, do not irrigate with water. The metallic pieces should be removed manually with forceps and placed in a container of mineral oil.
- White phosphorus: Keep the area immersed in water and manually remove any phosphorus particles seen. Visualization under a Wood lamp may aid in detection and removal of retained phosphorus particles.²
- Phenol: Polyethylene glycol 300 or 400 and isopropyl alcohol have been recommended for the removal of phenols and cresols. If skin damage has already occurred, isopropyl alcohol may be very irritating. Polyethylene glycol should be diluted with water to form a 50:50 ratio prior to using. One study showed polyethylene glycol no more efficacious than copious water irrigation for phenol exposures.¹¹
- Vesicants: See CBRNE – Vesicants, Mustard: Hd, Hn1-3, H and CBRNE – Vesicants, Organic Arsenicals: L, ED, MD, PD, HL for emergency department care.
- Hydrofluoric acid burns
  - These burns require special consideration. They should initially be treated as any other burn, with thorough irrigation. However, due to the penetrating power of the fluoride ion, specific neutralization procedures are indicated. Fluoride can be neutralized by either calcium or magnesium. For small superficial burns, topical calcium or magnesium gels can be applied. Deeper burns usually require subcutaneous injections of calcium gluconate. Hand burns can be difficult to manage; these burns can be treated with subcutaneous injections of calcium, intra-arterial calcium infusions, or intravenous infusions of magnesium. Keeping the hand warm and adequately treating pain will help to increase local circulation and the body's natural supply of calcium and magnesium.¹²
  - No objective comparative studies on these different treatments are underway. Studies on animals demonstrated that intravenous magnesium is as effective or more effective than subcutaneous injections of calcium in treating local hydrofluoric acid burns. When local treatment of hydrofluoric acid burns is not possible, this treatment is safe and should be considered.¹³
- Ocular exposures
  - The goal for decontamination should be to achieve a pH (of the eye wash) of at least 7.2, preferably 7.4.
  - If pH paper is not available, an adequate guideline is decontamination with 1-2 L of irrigation fluid over 30-60 minutes. A Morgan lens is contaminated with recommended for irrigation. Use a topical anesthetic prior to use.
- Caustic ingestions
  - Gastric emptying is contraindicated. Activated charcoal is not useful and may interfere with subsequent endoscopy. Dilution with milk or water is contraindicated if any degree of airway compromise is present. Milk may interfere with subsequent endoscopy. Water is benign. Some substances, such as drain cleaners containing sulfuric acid or sodium hydroxide, generate heat when diluted with water. Local areas of heat generation can be minimized by diluting with a moderate quantity of fluid (250-500 mL).^14,15,16
  - Do not attempt to neutralize the caustic agent. Neutralizing the caustic agent may generate excessive heat from the exothermic reaction of neutralization.

Consultations

For severe dermal burns, consult a general surgeon or a burn service. Burns to the hands, face, or perineum may require the appropriate specialties.
Ophthalmologic consultation is recommended for patients with ocular burns from acids or bases if there is any significant degree of corneal or scleral injury.
Caustic ingestions may require multiple specialties, including gastroenterology, GI surgery, ENT, and pediatric surgery for children.
Consult a psychiatrist for cases of attempted suicide.

Medication

Medications have a limited role in the treatment of most chemical burns. Topical antibiotic therapy is usually recommended for dermal and ocular burns. Calcium or magnesium salts are used for hydrofluoric acid burns. Pain medications are important for subsequent burn care.

Steroid therapy is controversial for caustic ingestions but may be helpful for treating upper airway inflammation. No evidence indicates that steroid therapy decreases incidence of stricture formation. Steroids may predispose the patient to infection and may mask signs of perforation. There has been some use of aloe products on mild burns; however, currently, no definitive information on their use for chemical burns is available.^17,15

Nonsteroidal anti-inflammatory agents do provide some degree of pain relief for mild burns by inhibition of prostaglandin mediators. These have not been evaluated for chemical burns and should be avoided in all cases of GI burns from ingestions.

After decontamination is performed on patients with chemical burns affecting a significant portion of the body, administer standard IV fluid and narcotic therapy as used for thermal burns. For additional information, see the Burns, Thermal article.

Antibiotics

Topical and ophthalmic antibiotics are routinely used for dermal and ocular burns, respectively. The injured tissues lose many of their protective mechanisms and are at increased risk of infection.

Silver sulfadiazine (Silvadene)

Used topically for dermal burns and useful in the prevention of infections from second- or third-degree burns. Has bactericidal activity against many gram-positive and gram-negative bacteria, including yeast.

Dosing

Adult

Apply qd/bid to a thickness of 1/16th inch; continually cover burned area; remove all previous medication before applying each new dose

Pediatric

<2 years: Do not administer
>2 years: Apply topically as in adults

Interactions

Reduces effectiveness of proteolytic enzymes

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Patients with G-6-PD deficiency and renal insufficiency

Erythromycin ophthalmic ointment 0.5% (E-Mycin)

Use prophylactically to prevent infections following ocular burns. Ointment has a very low incidence of allergic reactions. Other possible agents include polymyxin B, bacitracin, and ciprofloxacin solutions.

Dosing

Adult

Apply to affected eye topically tid/qid

Pediatric

Apply as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; viral, mycobacterial, and fungal infections of the eye; patients using steroid combinations after uncomplicated removal of a foreign body from the cornea

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Do not use topical antibiotics to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to a secondary infection (take appropriate measures if superinfection occurs)

Bacitracin, neomycin, and polymyxin B (Neosporin Topical)

Used topically for dermal burns and useful in prevention of infections from second- or third-degree burns. Has bactericidal activity against many gram-positive and gram-negative bacteria, including yeast. Preferable for face and visible areas.

Dosing

Adult

Apply 1/16th-inch thickness bid/tid; continually cover burned area; remove all previous medication before applying each new dose

Pediatric

Apply as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity; epithelial herpes simplex keratitis, mycobacterial, and fungal infections

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in treating extensive burns (>20% body surface area) because absorption of neomycin is possible and may cause nephrotoxicity and ototoxicity; prolonged use may result in overgrowth of nonsusceptible organisms

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained injuries to the eye.

Morphine is recommended in the ED. For outpatient treatment, combinations of hydrocodone or oxycodone and acetaminophen are usually sufficient. Codeine is not recommended.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are most commonly used for the relief of mild to moderate pain. Although effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Morphine sulfate administered IV may be dosed in a number of ways and is commonly titrated until the desired effect is obtained.
During the ED treatment of the acute burn, use IV (preferred) or IM for moderate or severe pain.

Dosing

Adult

5-10 mg IV as loading dose; followed by 4-6 mg IV q10-15min prn

Pediatric

0.05-0.2 mg/kg IV/IM q2-4h; may need to titrate as in adults

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine

Contraindications

Documented hypersensitivity; hypotension; respiratory depression; potentially compromised airway with uncertain rapid airway control; nausea; emesis; constipation; urinary retention

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate

Acetaminophen with oxycodone (Tylox, Percocet)

Drug combination indicated for the relief of moderate to severe pain. DOC for aspirin-hypersensitive patients.
Formulations of oxycodone/acetaminophen are available as follows:
Tylox-5/500
Percocet-5/325
Percocet-7.5/500
Percocet-10/650

Dosing

Adult

1-2 tab or cap PO q4-6h prn pain
Products containing more than 500 mg of acetaminophen/tab should only be prescribed one tab per dose

Pediatric

0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone q4-6h prn

Interactions

Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly persons; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4,000 mg/d of acetaminophen; higher doses may cause liver toxicity

Acetaminophen with hydrocodone (Vicodin, Lorcet, Lortab, Norco)

Drug combination for outpatient use and indicated for the relief of moderate-to-severe pain.
Formulations of hydrocodone/acetaminophen are available as follows: Vicodin-5/500, ES-7.5/750, HP-10/600 Lorcet-10/650, Plus-7.5/650 Lortab-2.5/500, 5/500, 7.5/500, 10/500 Norco-10/325.
Typical elixirs contain 2.5 mg hydrocodone and 167 mg/mL acetaminophen.

Dosing

Adult

1-2 tab or cap PO q4-6h prn for pain
Products containing more than 500 mg of acetaminophen/tab should only be prescribed one tab per dose

Pediatric

0.3 mL/kg q4h provides 10 mg/kg of acetaminophen and 0.15 mg/kg of hydrocodone
0.5 mL/kg q4h provides 16 mg/kg of acetaminophen and 0.25 mg/kg of hydrocodone

Interactions

Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants

Contraindications

Documented hypersensitivity; elevated intracranial pressure

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Withhold for drowsiness; hepatic toxicity may occur in overdose; use Norco or a product that does not contain acetaminophen in patients with a history of severe hepatic disease; may cause constipation and stomach upset; caution in severe renal or hepatic dysfunction

Ibuprofen (Ibuprin, Advil, Motrin)

Usually the DOC for the treatment of mild to moderate pain, if no contraindications exist.
Inhibits inflammatory reactions and pain by decreasing activity of the enzyme cyclooxygenase, resulting in the inhibition of prostaglandin synthesis.
Useful for outpatient oral use where nonsedating drugs are preferred. Also has the advantage of an anti-inflammatory effect.

Dosing

Adult

400-600-800 mg PO, approximately 100 mg/h (eg, 400 mg PO q4h, 600 mg q6h)

Pediatric

5-10 mg/kg PO q4-6h

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Ketoprofen (Oruvail, Orudis, Actron)

Used for the relief of mild to moderate pain and inflammation.
Initially administer small dosages to patients with a small body size, the elderly, and those with renal or liver disease.
When administering this medication, doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 14 years: 0.1–1 mg/kg PO q6-8h
>14 years: Administer as in adults

Interactions

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, resulting in a decrease of prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Decontaminants

These agents can help remove offending substances from the skin and minimize their caustic effects.

Polyethylene glycol

Used as an aid in removing phenol or cresols. Desired agent is PEG 400 mixed 50:50 in water. Most hospitals are not likely to have this product. If not available, use bowel-cleansing products containing PEG.

Dosing

Adult

Use liberally to remove phenol or cresols; may need to wipe off with gauze soaked in PEG solution

Pediatric

Apply as in adults

Interactions

None reported for this indication

Contraindications

Documented hypersensitivity to PEG

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Be cautious on large surface areas of denuded skin; may cause metabolic acidosis or hypocalcemia; phenol may also cause metabolic acidosis if large surface area is involved

Follow-up

Further Inpatient Care

Admission is recommended for large surface area or circumferential dermal burns, for burns by substances with systemic toxicity, or for pain control.
Following caustic ingestions, admission is recommended for any patient with oral burns; any patient who is symptomatic; or any patient who ingested a strong acid, or base, hydrofluoric acid, or other highly caustic substance.

Further Outpatient Care

Dermal burns treated on an outpatient basis should be rechecked every 2-3 days.
Any ocular burns treated as on an outpatient basis should be rechecked in 24 hours.
Endoscopic examination of all transmucosal or transmural esophageal burns should be repeated in 2-3 weeks.

Inpatient & Outpatient Medications

Significant dermal burns require adequate IV fluid resuscitation and analgesics (eg, morphine sulphate). Consider the use of patient-controlled analgesia pumps.

Transfer

Transfer all significant dermal burns that cannot be handled locally to a regional burn center. Always decontaminate the burn area, initiate fluid resuscitation, and administer analgesic agents prior to transfer.
Patients with any significant scleral or corneal injury should be transferred to a facility where ophthalmologic care is available. Always irrigate the eyes prior to transfer.
If endoscopy is not available and the patient is symptomatic, has oral burns, or has ingested a potentially caustic substance, transfer the patient to a facility that can perform endoscopy. Since endoscopy does not need to be performed on an emergent basis, observation of asymptomatic patients is acceptable.

Deterrence/Prevention

For cases of pediatric exposure, counsel the family on keeping dangerous substances out of the reach of children.
For suicide attempts, consult a psychiatrist.
In many states, the Occupational Safety and Health Administration (OSHA) requires reporting of industrial injuries. Employers should provide the necessary training and protective equipment for employees working with potentially hazardous materials.

Complications

Scarring, infection, and poor healing may occur with dermal burns. Skin grafting may be required.
Ocular burns, especially from alkali substances and hydrofluoric acid, can result in cataract formation and/or complete vision loss.
Perforation and/or bleeding and respiratory compromise from upper airway edema are the short-term complications of caustic ingestions. Stricture formation is the main long-term complication associated with caustic burns to the esophagus.

Prognosis

The prognosis depends entirely on the extent of tissue injury. Small lesions heal well, whether dermal or esophageal. Larger dermal burns can produce significant scarring. Extensive esophageal lesions can result in future stricture formation. Hydrofluoric acid burns can cause progressive tissue injury and may result in loss of digits.
Even moderate corneal burns can result in scarring and loss of vision. Sometimes this can be remedied by corneal transplantation.

Patient Education

For cases of occupational exposure, educate the patient on the proper safety precautions that should be taken when working with hazardous materials. All industries are required to inform employees of any dangerous materials they may come into contact with in the workplace and must provide them with adequate training and protective equipment.
When children experience chemical burns, counsel the parents on how to keep medications and chemicals out of the reach of children. Parents may not think that something like automatic dishwashing detergent can be a danger to children. Inform them of the various substances in the home that are potentially dangerous. Consultation with the local social services agency may be indicated to evaluate the child's home situation.
For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient education articles Chemical Burns and Thermal (Heat or Fire) Burns.

Miscellaneous

Medicolegal Pitfalls

Failure to further evaluate a patient with a caustic ingestion because no oropharyngeal lesions are seen
Failure to evaluate and treat a burn
Failure to obtain psychiatric evaluation in a suicide attempt
Treatment of a hydrofluoric acid burn as a general acid burn
Failure to adequately irrigate a chemical exposure
Delay in irrigating a chemical exposure (particularly important when giving prehospital instructions)
Irrigating metallic sodium, potassium, lithium, or magnesium with water

References

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Keywords

acid burns, base burns, corrosive ingestion, caustic burn, caustic chemical burn, esophageal burn, sulfuric acid, nitric acid, hydrofluoric acid, hydrochloric acid, muriatic acid, phosphoric acid, acetic acid, formic acid, chloroacetic acid, monochloroacetic acid, dichloroacetic acid, trichloroacetic acid, phenol, cresol, sodium hydroxide, potassium hydroxide, calcium hydroxide, calcium oxide, lime, ammonia, phosphate, chlorate, white phosphorus, vesicants, chromate, potassium dichromate, chromic acid, peroxides, hydrogen peroxide, bleach, potassium permanganate

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 and American College of Medical Toxicology
Disclosure: Nothing to disclose.

Medical Editor

Jerry Balentine, DO, Professor of Emergency Medicine, New York College of Osteopathic Medicine; Senior Vice President, Chief Medical Officer, Medical Director, Attending Physician in Department of Emergency Medicine, Saint Barnabas Hospital
Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

John T VanDeVoort, PharmD, ABAT, Director of Pharmacy, Sacred Heart Hospital
John T VanDeVoort, PharmD, ABAT is a member of the following medical societies: American Academy of Clinical Toxicology and American Society of Health-System Pharmacists
Disclosure: Nothing to disclose.

Managing Editor

Jon Mark Hirshon, MD, MPH, Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine
Jon Mark Hirshon, MD, MPH 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, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: eMedicine.com, Inc. Consulting fee Consulting

Further Reading