Topical chemical burns
- Sangeeta Kaushik, MD
Sangeeta Kaushik, MD
- Attending Physician
- Georgetown University Medical Center
- Steven Bird, MD, FACEP
Steven Bird, MD, FACEP
- Associate Professor of Emergency Medicine
- University of Massachusetts Medical School
- Section Editors
- Stephen J Traub, MD
Stephen J Traub, MD
- Section Editor — Toxicology
- Associate Professor of Emergency Medicine
- Mayo Medical School
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Maria E Moreira, MD
Maria E Moreira, MD
- Section Editor — Adult Trauma
- Associate Professor, Department of Emergency Medicine
- University of Colorado Denver School of Medicine
- Residency Program Director
- Denver Health Residency in Emergency Medicine
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Emergency Medicine (Adult and Pediatric)
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Chemical burns, which are often work-related , are unique injuries that require individualized treatment and management depending upon the causative agent. They account for 4 percent of admissions to burn units in developed countries and up to 14 percent in underdeveloped countries .
A variety of chemicals are manufactured for household, agricultural, industrial, and military use, with an estimated 60,000 new chemicals produced each year . For management of toxic exposures, it is helpful to organize these chemicals into general categories, keeping in mind that some have overlapping properties or incompletely understood pathophysiology.
The evaluation and treatment of common topical chemical burns will be reviewed here with a focus on the basic principles of management. Thermal burns, chemical ingestions, chemical eye injuries, and agents used for chemical warfare are discussed elsewhere. (See "Emergency care of moderate and severe thermal burns in adults" and "Caustic esophageal injury in adults" and "Caustic esophageal injury in children" and "Corneal abrasions and corneal foreign bodies: Clinical manifestations and diagnosis" and "Chemical terrorism: Rapid recognition and initial medical management".)
PRINCIPLES OF MANAGEMENT
General approach — The potency and concentration of the toxic agent and the duration of contact primarily determine the degree of tissue destruction. Therefore, it is critical that treatment be started immediately. In the great majority of cases, the management of topical chemical burns consists of the following general steps:
●Ensure protection of rescuers and health care workers from exposure.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Pruitt VM. Work-related burns. Clin Occup Environ Med 2006; 5:423.
- Eldad A, Weinberg A, Breiterman S, et al. Early nonsurgical removal of chemically injured tissue enhances wound healing in partial thickness burns. Burns 1998; 24:166.
- Edlich RF, Farinholt HM, Winters KL, et al. Modern concepts of treatment and prevention of chemical injuries. J Long Term Eff Med Implants 2005; 15:303.
- Brent J. Water-based solutions are the best decontaminating fluids for dermal corrosive exposures: a mini review. Clin Toxicol (Phila) 2013; 51:731.
- Chemical protective clothing; OSHA Technical Manual. www.osha.gov/dts/osta/otm/otm_viii/otm_viii_1.html (Accessed on January 06, 2009).
- Respiratory protection; OSHA Technical Manual. http://www.osha.gov/dts/osta/otm/otm_viii/otm_viii_2.html (Accessed on January 06, 2009).
- Conclusions regarding personal protective equipment; OSHA Best Practices for Hospital-based First Receivers of Victims from Mass Casualty Incidents Involving the Release of Hazardous Substances. www.osha.gov/dts/osta/bestpractices/html/hospital_firstreceivers.html#t3 (Accessed on January 06, 2009).
- Leonard LG, Scheulen JJ, Munster AM. Chemical burns: effect of prompt first aid. J Trauma 1982; 22:420.
- Harchelroad, F, Rottinghaus, D . Chemical Burns. Emergency Medicine Reports 2008; 29:249.
- Jelenko C 3rd. Chemicals that "burn". J Trauma 1974; 14:65.
- Flammiger A, Maibach H. Sulfuric acid burns (corrosion and acute irritation): evidence-based overview to management. Cutan Ocul Toxicol 2006; 25:55.
- Andrews K, Mowlavi A, Milner SM. The treatment of alkaline burns of the skin by neutralization. Plast Reconstr Surg 2003; 111:1918.
- Spector J, Fernandez WG. Chemical, thermal, and biological ocular exposures. Emerg Med Clin North Am 2008; 26:125.
- Duffy B. Managing chemical eye injuries. Emerg Nurse 2008; 16:25.
- Ikeda N, Hayasaka S, Hayasaka Y, Watanabe K. Alkali burns of the eye: effect of immediate copious irrigation with tap water on their severity. Ophthalmologica 2006; 220:225.
- Fish R, Davidson RS. Management of ocular thermal and chemical injuries, including amniotic membrane therapy. Curr Opin Ophthalmol 2010; 21:317.
- Naradzay J, Barish RA. Approach to ophthalmologic emergencies. Med Clin North Am 2006; 90:305.
- Knoop K, Trott A. Ophthalmologic procedures in the emergency department--Part I: Immediate sight-saving procedures. Acad Emerg Med 1994; 1:408.
- Saari KM, Leinonen J, Aine E. Management of chemical eye injuries with prolonged irrigation. Acta Ophthalmol Suppl 1984; 161:52.
- Cartotto RC, Peters WJ, Neligan PC, et al. Chemical burns. Can J Surg 1996; 39:205.
- Bartlett D. Dermal exposure to hydrofluoric acid causing significant systemic toxicity. J Emerg Nurs 2004; 30:371.
- Wedler V, Guggenheim M, Moron M, et al. Extensive hydrofluoric acid injuries: a serious problem. J Trauma 2005; 58:852.
- Dalamaga M, Karmaniolas K, Nikolaidou A, Papadavid E. Hypocalcemia, hypomagnesemia, and hypokalemia following hydrofluoric acid chemical injury. J Burn Care Res 2008; 29:541.
- Sanz-Gallén P, Nogué S, Munné P, Faraldo A. Hypocalcaemia and hypomagnesaemia due to hydrofluoric acid. Occup Med (Lond) 2001; 51:294.
- Yamaura K, Kao B, Iimori E, et al. Recurrent ventricular tachyarrhythmias associated with QT prolongation following hydrofluoric acid burns. J Toxicol Clin Toxicol 1997; 35:311.
- Bordelon BM, Saffle JR, Morris SE. Systemic fluoride toxicity in a child with hydrofluoric acid burns: case report. J Trauma 1993; 34:437.
- McIvor ME, Cummings CE, Mower MM, et al. Sudden cardiac death from acute fluoride intoxication: the role of potassium. Ann Emerg Med 1987; 16:777.
- Baltazar RF, Mower MM, Reider R, et al. Acute fluoride poisoning leading to fatal hyperkalemia. Chest 1980; 78:660.
- McCulley JP, Whiting DW, Petitt MG, Lauber SE. Hydrofluoric acid burns of the eye. J Occup Med 1983; 25:447.
- Wing JS, Brender JD, Sanderson LM, et al. Acute health effects in a community after a release of hydrofluoric acid. Arch Environ Health 1991; 46:155.
- Roblin I, Urban M, Flicoteau D, et al. Topical treatment of experimental hydrofluoric acid skin burns by 2.5% calcium gluconate. J Burn Care Res 2006; 27:889.
- Höjer J, Personne M, Hultén P, Ludwigs U. Topical treatments for hydrofluoric acid burns: a blind controlled experimental study. J Toxicol Clin Toxicol 2002; 40:861.
- Su, Mark. Hydorfluoric acid and fluorides. In: Goldfrank's Toxicologic Emergencies, 8th edition, McGraw-Hill, New York 2006. p.1417.
- Björnhagen V, Höjer J, Karlson-Stiber C, et al. Hydrofluoric acid-induced burns and life-threatening systemic poisoning--favorable outcome after hemodialysis. J Toxicol Clin Toxicol 2003; 41:855.
- Spiller HA, Quadrani-Kushner DA, Cleveland P. A five year evaluation of acute exposures to phenol disinfectant (26%). J Toxicol Clin Toxicol 1993; 31:307.
- Barillo DJ, Cancio LC, Goodwin CW. Treatment of white phosphorus and other chemical burn injuries at one burn center over a 51-year period. Burns 2004; 30:448.
- Barqouni L, Abu Shaaban N, Elessi K. Interventions for treating phosphorus burns. Cochrane Database Syst Rev 2014; :CD008805.
- Amshel CE, Fealk MH, Phillips BJ, Caruso DM. Anhydrous ammonia burns case report and review of the literature. Burns 2000; 26:493.
- Centers for Disease Control and Prevention (CDC). Anhydrous ammonia thefts and releases associated with illicit methamphetamine production--16 states, January 2000-June 2004. MMWR Morb Mortal Wkly Rep 2005; 54:359.
- Poupon M, Caye N, Duteille F, Pannier M. Cement burns: retrospective study of 18 cases and review of the literature. Burns 2005; 31:910.
- Spoo J, Elsner P. Cement burns: a review 1960-2000. Contact Dermatitis 2001; 45:68.
- Lewis PM, Ennis O, Kashif A, Dickson WA. Wet cement remains a poorly recognised cause of full-thickness skin burns. Injury 2004; 35:982.
- Suhr M, Kreusch T. Burn injuries resulting from (accidental) airbag inflation. J Craniomaxillofac Surg 2004; 32:35.
- Vitello W, Kim M, Johnson RM, Miller S. Full-thickness burn to the hand from an automobile airbag. J Burn Care Rehabil 1999; 20:212.
- Hansbrough JF, Zapata-Sirvent R, Dominic W, et al. Hydrocarbon contact injuries. J Trauma 1985; 25:250.
- Schneider MS, Mani MM, Masters FW. Gasoline-induced contact burns. J Burn Care Rehabil 1991; 12:140.
- Baruchin AM, Schraf S, Rosenberg L, Sagi AA. Hot bitumen burns: 92 hospitalized patients. Burns 1997; 23:438.
- Türegün M, Oztürk S, Selmanpakoğlu N. Sunflower oil in the treatment of hot tar burns. Burns 1997; 23:442.
- Tiernan E, Harris A. Butter in the initial treatment of hot tar burns. Burns 1993; 19:437.
- Juma A. Bitumen burns and the use of baby oil. Burns 1994; 20:363.
- Bozkurt A, O'Dey D, Pallua N. Treatment of hot bitumen-contact-burn injuries. Burns 2008; 34:1053.
- PRINCIPLES OF MANAGEMENT
- General approach
- Protection of providers
- Removal of chemical
- - Basic approach
- - Skin irrigation
- Eye exposure
- Chemicals NOT treated with immediate water irrigation
- Burn assessment
- Systemic toxicity
- Treatment of thermal burns from chemical exposure
- SPECIFIC AGENTS AND TREATMENTS
- - Hydrofluoric acid
- - Management of hydrofluoric acid burns
- - Systemic toxicity from hydrofluoric acid
- - Phenol (carbolic acid) and derivatives
- - White phosphorus
- - Anhydrous ammonia
- - Cement burns
- - Automobile airbag burns
- Tar and asphalt
- ADDITIONAL RESOURCES
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS