Chemical Burns Treatment & Management

Prompt wound irrigation is the most critical aspect in limiting 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. ^[13]

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.

If eye exposures have not been irrigated, then this should be started immediately. Immediate removal of caustic substances in the eye is critical. ^[14]

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. ^{[13, 15, 16, 17]} An analysis of 13 studies showed that diphoterine, a hypertonic, amphoteric, polyvalent, and chelating solution, may be superior to other rinsing solutions for cutaneous and ocular chemical burns, but further study is required. ^[18]

If a question of airway compromise exists, secure the airway.

Large surface burns require the same fluid therapy as that for thermal burns. ^[19] See Emergent Management of Thermal Burns.

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. Cover the area with mineral oil. 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's lamp may aid in detection and removal of retained phosphorus particles. ^[3]

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. ^[20]

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. ^[21] 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. ^[22]

No objective studies comparing intra-arterial calcium to other treatments have been done. 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. ^[23]

Ocular exposures ^[14]

The goal for decontamination should be to achieve a pH (of the eye wash) of at least 7.3, preferably 7.4. If the pH remains below this, check the pH of the irrigating solution. The pH should be rechecked 30 minutes after irrigation has been completed. ^{[24, 25]}

If pH paper is not available, an adequate guideline is decontamination with 2 L of irrigation fluid over 30-60 minutes. A Morgan lens is 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). ^{[26, 27, 28]}

Do not attempt to neutralize the caustic agent. Neutralizing the caustic agent may generate excessive heat from the exothermic reaction of neutralization.

Admission

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.

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.

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. ^{[24, 25]}

Caustic ingestions may require multiple specialties, including gastroenterology, GI surgery, ENT, and pediatric surgery for children.

Consult a psychiatrist for cases of attempted suicide.

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.

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.