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Burns, Chemical: Treatment & Medication

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
Contributor Information and Disclosures

Updated: Jan 10, 2008

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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