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Hydrofluoric Acid Burns Clinical Presentation

  • Author: Garry Wilkes, MBBS, FACEM; Chief Editor: Joe Alcock, MD, MS  more...
 
Updated: Mar 07, 2016
 

History

Time of exposure to onset of symptoms is related to the concentration of the hydrofluoric acid, as follows:

  • Solutions of 14.5% and higher concentrations immediately produce symptoms.
  • Solutions of 12% may take up to an hour to produce symptoms.
  • Solutions of less than 7% may take several hours before onset of symptoms, resulting in delayed presentation, deeper penetration of the undissociated HF acid, and a more severe burn.
  • Concentrated solutions cause immediate pain and produce surface burns similar to those produced by other common acids (eg, erythema, blistering, necrosis).

Pain typically is described as deep, burning, or throbbing. Pain often is disproportionate to apparent skin involvement.

Obtain a history of potential exposure to cleaning solutions within the last 24 hours, to include the following:

  • Duration and type of exposure - Skin, ophthalmic, gastrointestinal (vomiting, abdominal pain), and pulmonary (throat burning, dyspnea)
  • Concentration of acid
  • Use of protective measures
  • Other agents in the solution
  • Symptoms of hypocalcemia - Tetany, Chvostek sign, Trousseau sign
  • Cardiac arrhythmias
  • Additionally, obtain history of medications and intercurrent illness that predispose patient to hypocalcemia or hypomagnesemia.
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Physical

Weaker solutions penetrate before dissociating. Surface involvement in these cases is minimal and may be absent.

Three categories of appearance include the following:

  • Grade 1 - A white burn mark and/or erythema and pain; a grade 1 burn is shown in the photo below
    Grade 1 hydrofluoric (HF) acid burns of the fingerGrade 1 hydrofluoric (HF) acid burns of the fingertips. The patient has severe pain (maximum middle digit) with only minimal redness of the nail beds.
  • Grade 2 - A white burn mark and/or erythema and pain, plus edema and blistering
  • Grade 3 - A white burn mark and/or erythema and pain, edema, and blistering, plus necrosis; a grade 3 burn is shown in the photo below
    Grade 3 hydrofluoric (HF) acid burns of the fingerGrade 3 hydrofluoric (HF) acid burns of the fingertips. Note how the nailbed and tip of the fingers have severely been injured, but the nails show no damage.

Patients with inhalation burns may develop acute lung injury presenting with the following:

  • Hypoxemia
  • Stridor
  • Wheezing
  • Rhonchi

Ocular burns may present with severe pain.

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Contributor Information and Disclosures
Author

Garry Wilkes, MBBS, FACEM Director of Clinical Training (Simulation), Fiona Stanley Hospital; Clinical Associate Professor, University of Western Australia; Adjunct Associate Professor, Edith Cowan University, Western Australia

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.

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians, 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

Edward A Michelson, MD Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Thank you to those clinicians who have shared their experience with this uncommon, clinically distinct and sometimes challenging condition to treat.

References
  1. McIvor ME. Delayed fatal hyperkalemia in a patient with acute fluoride intoxication. Ann Emerg Med. 1987 Oct. 16(10):1165-7. [Medline].

  2. Stuke LE, Arnoldo BD, Hunt JL, Purdue GF. Hydrofluoric acid burns: a 15-year experience. J Burn Care Res. 2008 Nov-Dec. 29(6):893-6. [Medline].

  3. Dalamaga M, Karmaniolas K, Nikolaidou A, Papadavid E. Hypocalcemia, hypomagnesemia, and hypokalemia following hydrofluoric acid chemical injury. J Burn Care Res. 2008 May-Jun. 29(3):541-3. [Medline].

  4. Songur MK, Akdemir O, Lineaweaver WC, Cavusoglu T, Ozsarac M, Aktug H, et al. Comparison of skin effects of immediate treatment modalities in experimentally induced hydrofluoric acid skin burns. Int Wound J. 2014 Jan 29. [Medline].

  5. Burgher F, Mathieu L, Lati E, et al. Experimental 70% hydrofluoric acid burns: histological observations in an established human skin explants ex vivo model. Cutan Ocul Toxicol. 2011 Jun. 30(2):100-7. [Medline]. [Full Text].

  6. Wilkes GJ. Intravenous regional calcium gluconate for hydrofluoric acid burns of the digits. Emerg Med (Aust). 1993. 5:155-8.

  7. Wilkes GJ, Morel DG. Hydrofluoric acid burns of the hands. In: Abstracts of the 6th International Conference on Emergency Medicine. Sydney. 1996.

  8. Wu ML, Deng JF, Fan JS. Survival after hypocalcemia, hypomagnesemia, hypokalemia and cardiac arrest following mild hydrofluoric acid burn. Clin Toxicol (Phila). 2010 Nov. 48(9):953-5. [Medline].

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Grade 1 hydrofluoric (HF) acid burns of the fingertips. The patient has severe pain (maximum middle digit) with only minimal redness of the nail beds.
Grade 3 hydrofluoric (HF) acid burns of the fingertips. Note how the nailbed and tip of the fingers have severely been injured, but the nails show no damage.
 
 
 
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