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Chemical Burns
INTRODUCTION

Background: Chemical burns are divided primarily into 2 groups: acid and alkali. In addition to the occupational hazards associated with industrial strength product use in the work place, a plethora of products are available and used by the general public. As with most environmental or toxicological exposures, knowing the specifics of the offending agent is key. Appropriate evaluation requires a complete assessment of the offending agent (composition, acid or alkali, concentration), type of exposure (inhalation, cutaneous, ocular, gastrointestinal), duration of exposure, and other events or injuries associated with the burn (explosion, fall, trauma).

Pathophysiology: Acids and alkalis cause injury via different mechanisms.

Acids produce coagulation necrosis by denaturing proteins upon tissue contact. An area of coagulation is formed and limits extension of injury. An exception is hydrofluoric acid, which produces a liquefaction necrosis similar to alkalis.

Alkalis cause a liquefaction necrosis, and are potentially much more dangerous than acid burns. Alkali agents liquefy tissue by denaturation of proteins and saponification of fats. In contrast to acids, whose tissue penetration is limited by the formation of a coagulum, alkalis can continue to penetrate very deeply into tissue.

Frequency:
 

  • In the US: Accurate statistics are lacking. However, approximately 25,000-100,000 chemical burns are reported every year.

Mortality/Morbidity:

  • Chemical burns result in approximately 20 deaths per year, with a mortality rate of less than 1%.
  • Morbidity, defined as severe toxicity, occurs in less than 1% of those exposed.
  • Bleach is associated with severe toxicity in less than 1% of cases. Death is rare, although anecdotal reports of fatalities exist.

     
  • Alkali exposures are high risk.

     
  • Drain cleaners are associated with severe toxicity in 1-2% of cases, with a mortality rate of less than 0.1%.

     
  • Caustic ingestions are high risk and may result in airway compromise.

     
  • Ocular exposures are high risk.

Age:

  • Children and adults have similar exposure rates.
  • Younger children tend to be exposed accidentally because of inadequate childproofing.
  • Older children and young adults may be exposed because of impetuous behavior or experimentation.

CLINICAL
History:

  • Although a careful physical examination is important, a thorough history usually helps determine how a patient should be treated.

     

  • Type of exposure
    • Determine the offending substance. It is not enough to rely solely on patient history. Obtain the substance's container, call the manufacturer, use a computerized poison index, and/or call your regional poison center.
    • Determine whether the substance is acid, alkali, or chemical in composition, and ascertain the concentration.
    • Determine whether the exposure was cutaneous, oral, gastrointestinal, ocular, or inhalation.
  • Time and duration of exposure
  • Symptoms immediately after the injury (pain, burning, numbness, change in level of consciousness, respiratory distress, vital signs, oral discomfort or swelling, ocular discomfort, change in vision)
  • Decontamination or life-saving measures provided at the scene
  • Other injuries possibly resulting from a fall, explosion, or fire
  • Preexisting medical conditions

Physical:

  • Airway
    • Patients with oral or inhalation injury may experience significant edema or difficulty maintaining their airway and often require intubation.

       

    • Particular attention should be paid to the presence of stridor, hoarseness, and oral swelling.
  • Breathing: Patients may develop wheezing and labored breathing as a result of inhalation. Symptoms may range from discomfort and mild wheezing to respiratory failure requiring artificial ventilation.
  • Circulation
    • Assess circulation by determining perfusion to end organs—level of consciousness, skin color and temperature, capillary refill, and urinary output.

       

    • Assess heart rate for appropriate rate and regularity.
  • Disability: Perform a thorough neurologic evaluation to determine the presence and degree of deficit. Serial examinations are necessary to evaluate symptom progression or resolution.
  • Environmental

     

    • As with many environmental injuries, patients may be at risk for becoming hypothermic, with associated increased morbidity and mortality. Attention should be paid to maintaining normal temperature.

       

    • Preventing further injury is also important. Wet or contaminated clothing should be removed, and the patient maintained warm and dry.
  • Extremities: Close inspection of all extremities should be performed to rule out any other associated injuries.
  • Special considerations
    • Patients with oral or inhalation injury may experience significant swelling or difficulty maintaining their airway. Particular attention should be paid to the presence of drooling, stridor, hoarseness, and oral swelling. Intubation may be necessary.
    • Seek, and document, the presence, size, and depth of cutaneous burns.
    • Depths of burn classifications are superficial partial thickness, deep partial thickness, and full thickness. Depth determination involves describing the affected area's color, texture, and sensation.

       

      • First-degree burn: Redness without change in texture and intact sensation denotes a superficial injury.

         

      • Second-degree burn: Blister formation with or without denuding and pink to mildly pale tissue with intact sensation denotes deeper partial-thickness injury.

         

      • Third-degree burn: Areas that are white, leathery, and insensate denote full-thickness injury.
    • Determining extent of involvement requires an estimate of the affected body surface area. Special attention also is paid to injuries of the face, hands, feet, and genitalia. Circumferential injury should also be noted.

       

    • Body surface area can be estimated by using a standard chart with the Rule of 9's. However, the Lund and Browder Chart provides a more accurate estimate in children.

       

    • Most small injuries can be approximated using the size of the patient's palm. The entire palm, including the fingers, represents approximately 1% of total body surface area (TBSA).
  • Oral or gastrointestinal
    • Oral or gastrointestinal exposure may cause severe burns, particularly if the exposure is to a strong alkali.

       

    • Early injury may be represented by redness, swelling, and pain. Patients breathe through an open mouth, drool, speak with a hoarse voice, or have stridor.

       

    • Remember that alkali compounds result in liquefaction necrosis—with potential for ongoing deep tissue penetration. Severe precipitous airway edema or obstruction may result.

       

    • Children refusing to swallow their own saliva should be given particular attention. Risk of esophageal perforation and stricture is very real (although these are later complications and usually are not present when the patient is in the emergency department.
  • Ocular
    • Patients with ocular exposure or complaints require detailed ophthalmologic evaluation. However, initial examination is deferred until adequate decontamination has occurred with copious amounts of saline (minimum of 0.5 h).

       

    • Complete evaluation includes general appearance of the globe, conjunctiva, anterior chamber, and cornea with attention to redness, pallor, or opacification.

       

    • Examine the eye for presence of foreign bodies.

       

    • Verify pupillary and extraocular muscle function.

       

    • pH testing should be performed before and after each set of irrigations and should be continued until the pH returns to the normal range (7-8).

       

    • Stain with fluorescein to look for areas of increased uptake signifying corneal abrasion.

       

    • A slit lamp examination may be useful. It allows for a more detailed examination of the cornea and anterior chamber, including the presence of a hyphema or hypopyon.

       

    • Document the visual acuity of patients with ocular exposure or complaints. Documentation should include right eye and left eye individually, then vision with both eyes.

Causes:

  • Inadequate child-proofing
    • Cleaning or caustic products are not stored out of reach of young children.

       

    • Cleaning solutions or agents are stored in bottles other than the original container (eg, a potentially caustic solution in a soda pop bottle).
    • Directions are not regarded or supplies are inappropriately mixed (eg, mixing bleach and ammonia products creates a noxious gas, which can precipitate acute bronchospasm and respiratory distress).
    • Unintended exposures are caused by something breaking, exploding, or being squirted or sprayed.
  • Common sources of acids
    • Toilet bowl or drain cleaners may contain sulfuric or hydrochloric acid. They also may contain alkali.
    • Automotive tire or metal cleaners and rust removers may contain hydrofluoric, sulfuric, or phosphoric acid.
    • Engraving solution may contain hydrofluoric or nitric acid.
    • Tile cleaners or glass etching may contain hydrofluoric acid.
    • Battery fluid may contain sulfuric acid.
  • Common sources of alkalis (bases)
    • Drain or oven cleaners may contain sodium or potassium hydroxide.
    • Cleaners and detergents may contain ammonia or any of the sodium or potassium polyphosphates.
    • Household bleach or pool chlorination system or tablets may contain sodium or calcium hypochlorite.
    • Cement, mortar, or plaster may contain calcium hydroxide or oxide.
    • Denture cleaners or Clinitest tablets may contain sodium or potassium hydroxide.
    • Dishwashing or clothing detergents may contain silicates or sodium carbonate.
    • Toilet cleaners (lye) may contain potassium hydroxide or other strong alkali.
WORKUP
Lab Studies:
  • Mild burns: In most patients, no laboratory studies are indicated.
  • Severe burns: Consider basic screening with a computerized blood count, serum electrolytes, quantitative creatine kinase (CK), and coagulation studies.
  • Hydrofluoric or oxalic acid burns: Screening levels of calcium, magnesium, and phosphorus often are ordered and may be useful. However, the degree to which these levels contribute to patient treatment is uncertain.

Imaging Studies:
 

  • A chest radiograph is indicated for patients with inhalation injury or respiratory distress.
  • When evaluating for edema or perforation of the soft tissues of the neck, direct visualization with endoscopy is preferred. Radiographs of this area have limited value.
  • When evaluating for perforation of the abdomen, direct visualization with endoscopy is preferred, although radiographs have some value.
  • CT scan of the head is indicated for patients with altered mental status, history of explosion, or closed head injury.
  • CT scan of the abdomen with oral and intravenous contrast has limited utility in evaluating for perforation. Direct visualization with endoscopy is preferred.

Other Tests:

  • Direct visualization (endoscopy) of the posterior pharynx, airway, esophagus, and gastrointestinal tract is the method of choice for evaluation of injury.

Procedures:

  • Intubation and mechanical ventilation may be required for oral and inhalation exposures.
  • Intravenous access and possibly central venous access may be indicated, depending on the severity of the injury.
  • A Foley catheter (to monitor fluid status via continuous measurement of urine output) is indicated for the patient with severe burns.
  • Fasciotomies and escharotomies generally are not necessary.

TREATMENT
Medical Care:

  • Medical care begins with removal of the patient from the source of the injury (while maintaining the safety of rescuers and caregivers).

     

  • All products should be handled as potentially hazardous material. Decontamination should be provided at the scene of contact. To avoid spreading the material to the transport vehicle or urgency department, the patient should have as much of the offending substance removed as possible prior to transportation.

     

  • Airway

     

    • Removal of the patient from the offending gas is essential.

       

    • No method of lung decontamination exists.

       

    • Maintain airway patency. Oral and upper airway involvement may cause progressive edema and stridor, heralding the need for intubation. Patients with oral or inhalational exposures should be given continuous pulse oximetry monitoring and receive supplemental oxygen as indicated.

       

    • If there is any question about ongoing edema and airway patency, secure the airway with a prompt, semielective intubation.

     

  • Breathing

     

    • Maintain adequate ventilation and oxygenation. Patients may require artificial ventilation.

       

    • Patients with inhalation injuries may experience acute bronchospasm. Beta-agonist bronchodilators (eg, albuterol) are indicated for patients with wheezing.

     

  • Circulation

     

    • Maintain adequate perfusion to the tissues.

       

    • Patients should be treated as if they have a burn; however, most are of relatively small magnitude and usually do not require massive volume resuscitation.

     

  • Disability

     

    • After obtaining a baseline neurological examination, prevent any further injury.

       

    • If there is any potential for a cervical spine or back injury, the patient should be immobilized completely, pending radiographic studies.

     

  • Exposure

     

    • Patients need to be completely undressed for a thorough examination; however, they need to remain euthermic. Patients should be covered and kept clean and dry.

       

    • External warming devices should be used early in the course of care if indicated because hypothermia has particularly deleterious effects on burn victims.
  • Pain management

     

    • Most, if not all, patients require medication for pain control. Although oral agents may be an option for mild burns, it is usually preferable to use the IV route to allow for exact titration of pain and reversal if necessary.

       

    • Morphine sulfate is the drug of choice (0.1 mg/kg).

     

  • Tetanus

     

    • Burns are considered tetanus prone, and all patients should be immunized.

       

    • If there is a question about the need for tetanus, it should be given.

     

  • Decontamination basics

     

    • Dilution is the solution to decontamination.

       

    • Never attempt to neutralize the offending agent because it may result in an exothermic reaction that could worsen the burn or cause explosion.
  • Cutaneous exposure

     

    • If the agent is a powder, brush off as much as possible before moving the patient. After brushing as much of the powder from the patient as possible, rinse the affected area. Remember that rinsing creates a dilute solution of the offending substance. Make certain that the solution is not soaking the clothing and the patient no longer has contact with it.

       

    • If the substance is a liquid and has saturated the clothing, remove the clothing and rinse the affected area thoroughly. Use copious amounts of fluid to dilute the substance. Ensure that the patient no longer has contact with the remaining fluid, and provide dry covering to maintain patient euthermia.
  • Oral and gastrointestinal

     

    • The mouth should be rinsed as much as possible. Do not attempt neutralization.

       

    • Maintain the airway, and instruct the patient to have nothing by mouth (NPO).

       

    • Do not attempt gastric emptying. Do not lavage and do not give ipecac syrup.
  • Ocular

     

    • The solution is dilution.

       

    • Affected eyes should be rinsed with copious amounts of isotonic sodium chloride solution for a minimum of 0.5 hour at a time.

       

    • Anesthetic drops should be provided for pain relief; however, these usually provide only partial relief, and parental pain relief with morphine often is required.

       

    • A specialized ocular irrigation cup, or Morgan lens, may be used after adequate analgesia is provided (ocular and parenteral pain control).

       

    • The pH of the eye should be checked after each 0.5 hour of irrigation and continued until the pH has normalized (pH is 7-8).
  • Inhalation

     

    • Hydrofluoric acid burns

       

      • Calcium is used to treat hydrofluoric acid burns.

         

      • The hand is the body part most commonly exposed to hydrofluoric acid.

         

      • A glove containing a mixture of calcium chloride, KY jelly, and hydrocellulose is placed on the patient’s hand to provide continuous and complete exposure to the calcium.

         

      • Another option is an intradermal or intra-arterial injection of calcium.

         

      • Bier-type block and IV calcium also are used.

Surgical Care:

  • Vascular access may be necessary.
  • Fasciotomies and escharotomies are rarely necessary.

Consultations:

  • Always consult with the regional poison control center. The center has accurate statistics on exposures, can aid in substance identification, and has up-to-date information on burn management.
  • Consultation with a toxicologist also may be indicated, depending on the type and degree of exposure.
  • Chemical burns are treated similarly to thermal burns and require consultation with a burn specialist.
  • All but the most trivial of ocular injuries require consultation with an ophthalmologist.

MEDICATION
Drug Category: Analgesic agents -- Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.

Drug Name
 		 Morphine sulfate -- DOC and provides immediate pain relief. IV administration provides rapid and effective pain relief that is titratable and reversible.
Adult Dose 2-4 mg IV q2-4h prn
Pediatric Dose 0.1 mg/kg IV; not to exceed 2 mg/dose; initially may repeat q5-10 min prn; then prn q2-4h
Contraindications Documented hypersensitivity; hypotension; potentially compromised airway when establishing rapid airway control would be difficult
Interactions If given with a sedative (eg, benzodiazepines), the dose of each should be reduced by 25%; phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, or other CNS depressants may potentiate adverse effects of morphine; CYP2D6 substrate, clearance may decrease with CYP2D6 inhibitors (eg, cimetidine, ranitidine, fluvoxamine)
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Pregnancy category D if prolonged use or high doses; may cause respiratory depression and hypotension (may be reversed with naloxone and IV fluids); gradually titrate dose upward to effect
May cause a characteristic urticarial rash shortly after administration as a result of histamine release; this is not a true allergic reaction and usually resolves without any further treatment; if severe, the underlying cause (massive histamine release) is treated in the standard fashion with diphenhydramine, corticosteroids, and epinephrine
Chest wall rigidity may occur (may be reversed with naloxone); if severe rigidity occurs, use succinylcholine; however, succinylcholine causes paralysis and requires at least temporary ventilatory support

Drug Category: Vaccines -- Active immunization increases resistance to infection. Vaccines consist of microorganisms or cellular components, which act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.

Drug Name
 		 Tetanus toxoid -- Burns are considered tetanus-prone and require adequate prophylaxis. The immunizing agents of choice for most adults and children >7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Adult Dose 0.5 mL IM
Pediatric Dose Administer as in adults
Contraindications Documented hypersensitivity; a history of any type of neurological symptoms or signs following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Interactions Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization because of poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol because it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude its concurrent use)
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Do not use to treat actual tetanus infections or for immediate prophylaxis of unimmunized individuals (use tetanus antitoxin instead, preferably human tetanus immune globulin) diminished antibody response to active immunization may be observed in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended

Drug Category: Topical antibiotic cream -- Topical agents, such as silver sulfadiazine, are used to cover cutaneous burns. The agent acts as a protective barrier and has some bactericidal properties. It also may provide relief of pain by covering the denuded highly sensate skin.

Drug Name
 		 Silver sulfadiazine (Silvadene) -- DOC for topical covering of most cutaneous burns. Not recommended for burns involving the face because the silver component has been reported to cause staining of the skin. Facial burns should be covered with bacitracin ointment. Useful in prevention of infections from second- or third-degree burns. Has bactericidal activity against many gram-positive and gram-negative bacteria, including yeast.
Adult Dose Apply a thin layer (1/16-in thickness) over the entire burn qd/bid
Pediatric Dose <2 years: Not recommended
>2 years: Administer as in adults
Contraindications Documented hypersensitivity; age <2 years
Interactions Effect of proteolytic enzymes is reduced when used concomitantly with this product
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Use with caution in patients with G-6-PD deficiency or renal insufficiency; may cause silver staining of skin
Drug Name
 		 Bacitracin ointment (Baciguent) -- DOC for facial burns.
Adult Dose Applied in thin layer over affected area tid/qid
Pediatric Dose Administer as in adults
Contraindications Documented hypersensitivity
Interactions None reported
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions Prolonged use may result in growth of nonsusceptible organisms; rare topical sensitization has occurred

FOLLOW-UP
Further Inpatient Care:
 

  • Provide adequate pain management
  • Administer IV fluids (lactated Ringer solution) to maintain adequate urine output of at least 1 mL/kg/h.
  • Hypothermia has particularly deleterious side effects. Maintain temperature homeostasis.
  • Patients with hydrofluoric acid burns require continual calcium therapy until pain free.

Further Outpatient Care:
 

  • Pain control
  • Referral to burn or toxicology specialist

In/Out Patient Meds:
 

  • Pain control

     

    • Initial treatment should include parenteral pain control with morphine sulfate.

       

    • The patient may be switched to oral agents once stabilized. These may include oral narcotics (eg, codeine, hydrocodone-containing compounds) or nonsteroidal agents (eg, ibuprofen, naproxen).
  • Antibiotics and steroids
    • Antibiotic creams, such as silver sulfadiazine, may be used for covering cutaneous burns to all parts of the body with the exception of the face. Bacitracin ointment may be used safely on the face.

       

    • Prophylactic oral antibiotics are not indicated. Oral antibiotics should be used only in patients with documented infection.
    • Steroids are not indicated.

Transfer:

  • Patients with burns involving the hand, face, eye, or genitals should be transferred to a burn center.
  • Patients with severe burns (full thickness or >30% body surface area) also should be transferred once stabilized.
  • Transfer should take place only after the patient has been thoroughly decontaminated and stabilized.

Deterrence/Prevention:

  • Childproof the house. Keep dangerous substances out of reach of children.
  • Do not store cleaning or caustic agents in bottles other than what they were intended to carry.
  • Read and follow directions. Do not mix agents.
  • Teach children safe habits. Lead by example.
  • Remember that even commonly used products have the capacity to cause serious injury.

Complications:

  • Oral and gastrointestinal complications include airway obstruction, stricture formation, and perforation.
  • Ocular complications opacification, scarring, perforation, and blindness.
  • Inhalation complications include bronchospasm, severe respiratory distress, and respiratory failure.
  • Dermal complications include burn and occasionally severe scarring.
  • Infection may occur.

Prognosis:

  • Prognosis depends on the extent of injury and the nature of the exposure. Except for strong alkali exposure, the usual patient with limited injury has a favorable prognosis if care is provided promptly.
  • Strong alkali substances have the worse prognosis, particularly with ocular exposures.

Patient Education:

  • Educate the family on childproofing the environment.
  • Provide the family with the telephone number of regional poison control centers.
  • Inform the family of the real potential for serious injury and the importance of prevention.

MISCELLANEOUS
 Medical/Legal Pitfalls:

  • Failure to decontaminate the area
  • Failure to appreciate the severity of the injury
  • Failure to obtain appropriate consultation or transfer
  • Failure to provide adequate fluid resuscitation and maintain perfusion
  • Failure to recognize associated injuries
 

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