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Hydrofluoric Acid Burns Treatment & Management

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

Prehospital Care

Treatment of hydrofluoric acid burns includes basic life support and appropriate decontamination, followed by neutralization of the acid by use of calcium gluconate or hydrofluoric-specific agent such as Hexafluorine, if available. If exposure occurs at an industrial site, obtain and transport any available treatment literature.

Assess and manage acute life-threatening conditions in the usual manner. Emergency Medical Services (EMS) personnel should use gloves, masks, and gowns, if necessary.

Remove soiled clothing. Initially decontaminate by irrigation with copious amounts of water.

Ice packs on the affected area may alleviate symptoms by retarding diffusion of the ion.

If calcium gluconate gel or specific agent (eg, Hexafluorine) is available, apply liberally to the affected area.

For digital burns, if calcium gluconate gel is not available, the fingers may be soaked in magnesium hydroxide–containing antacid preparations (eg, Mylanta) en route to a medical facility. Retain gel/antacid in a latex glove if practicable, and the gloved hand may be immersed in iced water.

Treat inhalation injuries with oxygen and 2.5% calcium gluconate nebulizer.

Control pain with opioid agents.

Transport the patient to the nearest appropriate medical facility.

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Emergency Department Care

Initial steps

Remove soiled clothing.

Decontaminate by irrigation with copious amounts of water.

Assess and manage life-threatening conditions as with any other cause.

Commence comprehensive monitoring for significant exposures.

With any evidence of hypocalcemia, immediately administer 10% calcium gluconate IV.

Treatment by location of burn

Cutaneous burns

Apply 2.5% calcium gluconate gel to the affected area. If the proprietary gel is not available, constitute by dissolving 10% calcium gluconate solution in 3 times the volume of a water-soluble lubricant (eg, KY gel). For burns to the fingers, retain gel in a latex glove.

If pain persists for more than 30 minutes after application of calcium gluconate gel, further treatment is required. Subcutaneous infiltration of calcium gluconate is recommended at a dose of 0.5 mL of a 5% solution per square centimeter of surface burn extending 0.5 cm beyond the margin of involved tissue (10% calcium gluconate solution can be irritating to the tissue).

Do not use the chloride salt because it is an irritant and may cause tissue damage.

Burns to the digits

Local infiltration of digits is not recommended because of pain, disfigurement, and potential complications. Alternative treatment methods follow.

IV regional calcium gluconate: 10-15 mL of 10% calcium gluconate plus 5000 units of heparin diluted up to 40 mL in 5% dextrose. Use a Bier ischemic arm block technique to infuse the solution intravenously. Release the cuff when any of the following conditions first occur: (1) pain from the digits resolves, (2) the cuff becomes more painful than the burn, or (3) 20 minutes of ischemic time elapses. Treatment can be repeated after 4 hours if needed. Continuous ECG and clinical monitoring are essential during this procedure.

Intra-arterial calcium gluconate: Place an arterial catheter in the radial or brachial artery to perfuse the affected digits. Infuse a solution of 10 mL of 10% calcium gluconate in 40 mL of 5% dextrose over a 4-hour period. Follow with further infusions repeated after 4-8 hours, if necessary. Several treatments may be needed. Exercise great care to ensure that the catheter is appropriately placed intravascularly (ie, by continuous waveform analysis), as tissue necrosis and digit loss have occurred following extravasation of calcium salts. Continuous ECG and clinical monitoring are essential during this procedure.

Digital block with local anesthetics may be an alternative for pain control in patients with delayed presentation after exposure to low concentration HF.

Administer opioids for additional pain control.

Ocular burns

Generously irrigate with sterile water or saline for at least 5 minutes. Local anesthetic may be required. If pain persists, irrigate with a 1% solution of calcium gluconate, which is made by diluting the 10% solution in 10 times the volume of normal saline. Do not use undiluted 10% calcium gluconate.

Calcium salts are very irritating to the eye, and urgent ophthalmologic consultation should be requested prior to the irrigation with 1% calcium gluconate solution.

Inhalation burns

Exposures to the head and neck should arouse suspicion of pulmonary involvement. If any doubt is present, admission for observation is advised. Specific treatment includes the following:

Provide 100% oxygen by mask, 2.5% calcium gluconate by nebulizer with 100% oxygen, continuous pulse oximetry, ECG, and clinical monitoring.

Acute lung injury is treated along conventional lines, as needed.

Oral ingestion

Despite concerns of perforation, consider gastric lavage with calcium chloride (ie, 20 mmol calcium in 1000 mL normal saline solution) early in overdose. In isolated HF exposure, lavage should be performed through a nasogastric tube.

One series of autopsies performed on decedents who had received calcium chloride lavage after hydrofluoric acid ingestion demonstrated hemorrhagic gastritis; however, no evidence of perforation was revealed.

Secure the airway prior to gastric lavage.

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Consultations

Consultation with specialty units may be required depending on individual circumstances.

  • Toxicologist
  • Burn surgeon
  • Intensive care specialist
  • Ophthalmologist
  • Hand surgeon
  • Gastroenterologist (following ingestions)
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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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