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Hydrofluoric Acid Burns

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

Background

Hydrofluoric (HF) acid, one of the strongest inorganic acids, is used mainly for industrial purposes (eg, glass etching, metal cleaning, electronics manufacturing). Hydrofluoric acid also may be found in home rust removers. Exposure usually is unintentional and often is due to inadequate use of protective measures.

Hydrofluoric acid burns are a unique clinical entity. Dilute solutions deeply penetrate before dissociating, thus causing delayed injury and symptoms. Burns to the fingers and nail beds may leave the overlying nails intact, and pain may be severe with little surface abnormality.

Severe burns occur after exposure of concentrated (ie, 50% or stronger solution) hydrofluoric acid to 1% or more body surface area (BSA), exposure to hydrofluoric acid of any concentration to 5% or more BSA, or inhalation of hydrofluoric acid fumes from a 60% or stronger solution. The vast majority of cases involve only small areas of exposure, usually on the digits.

A unique feature of HF exposure is its ability to cause significant systemic toxicity due to fluoride poisoning.

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Pathophysiology

The two mechanisms that cause tissue damage are corrosive burn from the free hydrogen ions and chemical burn from tissue penetration of the fluoride ions.

Fluoride ions penetrate and form insoluble salts with calcium and magnesium. Soluble salts also are formed with other cations but dissociate rapidly. Consequently, fluoride ions release, and further tissue destruction occurs.

Systemic toxicity occurs secondary to depletion of total body stores of calcium and magnesium, resulting in enzymatic and cellular dysfunction, and ultimately in cell death. Majority of deaths are resulting from cardiac arrhythmias that were precipitated by hypocalcaemia and consequent hyperkalemia.[1]

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Epidemiology

US frequency

More than 1000 cases of hydrofluoric acid exposure are reported annually. Actual incidence rate is unknown.

In a review of 15 years' experience with hydrofluoric acid burns at one center, hydrofluoric acid burns accounted for 35 (17%) patients out of 205 who were admitted for chemical burns; all of these patients were men.[2]

Sex

Males are affected more commonly by hydrofluoric acid burns, which reflects occupational patterns.

Age

The majority of hydrofluoric acid exposures occurs in adults.

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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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