6. Chemical Burns

General Characteristics, Assessment and Treatment Eye Injury Specific Chemical Injury Chemical burns are commonly seen in the home but especially in the workplace. The most common categories of toxic chemicals will be described. These chemicals can produce local tissue injury and some have potential to be absorbed resulting in body poisoning. Toxic chemicals can be in the form of gases, liquids or solids. The gas form typically causes injury through breathing like smoke exposure. The liquid and solid forms are more likely to cause damage to the skin, with the exception of fuming sulfuric acid, heat or thermal injury play a minor role in chemical burn.

1. Characteristics of Chemical Burns

   - Usually deeper than it looks as the skin is destroyed mainly by chemicals.  Appearance is often brown to gray as opposed to the typical white or char with a flame burn.

   - Continue to get deeper and later appearance is usually worse.

   - Severe persistent pain is often present indicative of ongoing skin damage.                                                                                              

   - Chemical toxins like phenol or hydrocarbons like gasoline may cause only skin irritations, but absorption can lead to systemic poisoning.

2. tREATMENT & assessment

Airway Support airway as fumes can cause swelling
Breathing Fumes or absorption of toxins cause injury to lungs Chemical explosions can cause chest damage Assess and assist breathing
Circulation Assess adequacy of circulation with vital signs, skin color and temperature (Hypovolemic shock is usually not present in the immediate post burn period) Intravenous catheter indicated mainly for administration of medications Local circulation  removal of constricting objects, like jewelry deep chemical burn can produce constriction of local blood flow similar to thermal burn
Disability Absorption of some chemicals can lead to impaired brain function  seizures   Unconscious state Altered consciousness can also be due to head injury (if explosion) Assess and document level of consciousness A-V-P-U Management based on protocol
Expose & Examine Remove clothing and constricting objects
History Once the ABC’s and initial removal of the chemical have been initiated, further details as to history of the event must be obtained Place of exposure (was it enclosed?) Nature of exposure (spill, fall, explosion?) Duration of exposure (how long was the chemical exposure before initial treatment) What is the chemical/chemicals? - acid, alkali, hydrocarbon  specific toxic properties (information usually available if industrial accident) Relevant patient history health status current symptoms
Wound Management Initial management of the chemical burn has a major impact on outcome Continuous water irrigation if the area should be initiated - use of showers in the workplace is optimum - use tepid water if possible, to avoid long exposure to cold or hot water - irrigation for strong acid or alkali exposure is 30-60 minutes - continuous irrigation if eye is exposed to chemicals - do not attempt to neutralized acids with alkali or vice versa, just use copious water Continue irrigation through transport while maintaining body To Solid chemicals should be brushed off first prior to irrigation using safety gloves Cover the patient with clean dry sheet or blanket after irrigation stopped (per protocol
CHEM-TREC - Chemical Transport Emergency Center
This 24-hour service established in 1971 provides information to rescue teams responding to chemical emergencies and can provide direct contact with the chemical company. The phone number for CHEM- TREC is 1-800-424-9300
Pain Management Water irrigation should begin to decrease pain Pain medications (Intravenous administration in small amounts)
Significant Chemical Burns meet Criteria for Transfer to Burn Center
Eye Injury (Prevention & Treatment)
Permanent eye damage con be prevented if copious, continuous irrigation with water, saline or Ringer’s Lactate Remove contact lenses Hold eyelids apart and begin gentle, continuous irrigation Use if IV bag and tubing provides continuous controlled irrigation
Eye Injury from splattered alkali	Alkali burn to eye
Treatment is continuous water irrigation	Delayed treatment resulted in permanent corneal damage

3. Specific Chemical Burns

Strong Acid Burn from Sulfuric Acid
	Note the brownish-gray appearance. Characteristic of a deep skin burn from a strong acid or alkali. Persistent pain is present. Wound usually looks deeper at 24 hours. Treatment is removal of clothing and water irrigation. Burn is Full Thickness.

 

Chemical Burn from Nitric Acid
	Burn is caused by a nitric acid spray. A brown discoloration is characteristic. Persistent pain is present. Treatment is water irrigation.
Deep Lime Powder burn to lower leg
	Lime powder at a construction site entered the patient’s boot. The deep burn was noted when pain developed. Initial treatment is water irrigation.
Full Thickness Sodium Hydroxide Burn to the back (at 24 hours)
	Brownish dry appearance indicates the burn is full thickness. Patient did not seek medical attention for 24 hours.

 

Other Chemical Injuries:

Petroleum (Hydrocarbon) Exposure: These agents carry the risk of not only a skin injury from exposure but the exposed patient is highly flammable. In addition these chemicals can be rapidly absorbed leading to a life threatening poisoning. Agents include: gasoline, fuel, solvents, phenol Protection from any sparks or flame source as these agents make clothes and skin highly flammable Absorption of these toxins can lead to poisoning Initial skin burn from chemical is often superficial Early removal of clothing and copious irrigation needed - A small exposure to water can actually spread the agent and lead to further damage

Hot Tar Burns: Tar in its liquid form is superheated and therefore any direct contact e.g. roofers, will usually lead to a deep burn. Pain may be minimal as the burn is deep, and under estimation of the degree of burn is common. The tar typically remains adherent to the skin. A secondary exposure, e.g. stepping on already poured but still sticky tar, will likely produce a more superficial but still significant burn. Initially cool the tar to decrease retained heat: - use of copious water Do not attempt to remove the tar in the pre-hospital setting - careful removal will further damage the skin burn Cover area with clean, dry sheet or cloth Removal in definitive care can be done using fat emulsifiers - Neosporin ointment - mineral oil  - not flammable solvents

 

Deep Hot Tar Burn to Hand
	Note the white area in the exposed wound, indicating the burn to be very deep. Pain is minimal and injury can be easily underestimated.
Skateboarder versus Poured Asphalt
	The asphalt was still hot upon contact. The burn was partial thickness. Initial management is cooling the tar with water then transport to Burn Center due to facial burn. An eye assessment will be needed.

 

Agent	Pathophysiology	Treatment
General category of Acids	Deep skin burn caused by tissue desiccation and protein denaturation. Injury may extend well below skin with concentrated acids. Acids such as sulfuric, nitric, hypochloric cause local damage. Appearance is tan to gray discoloration with extreme pain, a common finding.	Vigorous water irrigation up to 60 minutes after injury using warm water with extensive exposure to avoid hypothermia. Treatment should be based on the assumption that the burn will be much deeper than initial appearance indicates. Standard fluid resuscitation principles.
Hydrofluoric Acid	Deep skin burn usually on the fingers can be extensive. Systemic effects are due to hypocalcaemia as a result of removal of tissue calcium by the fluoride.	Vigorous water lavage along with local injection of calcium gluconate as well as topical use of 2.5% calcium gluconate gel. Topical zephrin solution is also helpful. Endpoint of local wound calcium is relief of pain.
General category of Alkali	Deep skin burn caused again by tissue and protein desiccation and protein denaturation from chemical reaction of alkali exposed to hydrated tissue. Alkali burns tend to be worse than acid burs, but systemic effects from absorption are not common. Appearance is tan to gray surface discoloration with  characteristic extreme pain.	Vigorous water lavage for at least 60 minutes after injury and longer for lye burns, avoiding hypothermia during the lavage. Treatment should be based on the assumption that the burn will progress in depth. Standard fluid resuscitation principles.
General category Organic Components Gasoline Immersion	Superficial skin injury: erythema Systemic poisoning from absorbed hydrocarbons	Water irrigation plus aggressive maintenance of hydration and pulmonary support.
Phenol	Partial thickness burn: dull tan to gray color Systemic injury from absorption, which is usually rapid with the rate and amount being directly proportional to surface area of exposure	Spray or pour large volumes of water on surface. Do not swab or use small amounts of water, which will only increase surface area exposure. After lavage, use a quick skin wipe with polyethylene or propylene glycol.
Tar	Depends on T° of tar once skin contact occurs. No systemic absorption is present	Removal of tar to allow wound care. Neosporin contains the emulsifier Tween-80 which is useful in dissolving the tar.