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Chemical Burns
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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. |
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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.
- 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.
- tREATMENT & assessment
- Airway
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- Breathing
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Fumes or
absorption of toxins cause injury to lungs
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Chemical
explosions can cause chest damage
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Assess
and assist breathing
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- Circulation
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Assess adequacy of
circulation with vital signs, skin color and temperature
(Hypovolemic shock is usually not present in the immediate
post burn period)
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Intravenous
catheter indicated mainly for administration of
medications
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Local circulation
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removal
of constricting objects, like jewelry
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deep chemical burn can
produce constriction of local blood flow similar to
thermal burn
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- Disability
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- Expose & Examine
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- 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
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Nature of exposure
(spill, fall, explosion?)
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Duration of exposure (how long was the chemical exposure
before initial treatment)
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What is the
chemical/chemicals?
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acid, alkali,
hydrocarbon
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- Wound Management
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Initial management of the chemical burn has a major
impact on outcome
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Continuous
water irrigation if the area should be
initiated
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use of showers in the
workplace is optimum
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use tepid water if
possible, to avoid long exposure to cold or hot water
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irrigation for strong acid
or alkali exposure is 30-60 minutes
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continuous irrigation if
eye is exposed to chemicals
- do not attempt to
neutralized acids with alkali or vice versa, just use
copious water
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Continue irrigation through transport
while maintaining body To
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Solid chemicals should be brushed off
first prior to irrigation using safety gloves
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Cover the patient
with clean dry sheet or blanket after irrigation stopped
(per protocol
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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
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- Significant Chemical Burns meet Criteria for
Transfer to Burn Center
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Eye
Injury (Prevention & Treatment) |
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Permanent eye damage con be prevented if
copious, continuous irrigation with water, saline or
Ringer’s Lactate
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Remove contact lenses
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Hold eyelids apart and begin gentle,
continuous irrigation
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Use if IV bag and tubing provides continuous controlled
irrigation
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Eye Injury
from splattered alkali |
Alkali burn to
eye |
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Treatment is continuous water
irrigation |
Delayed treatment resulted in
permanent corneal damage |
- Specific Chemical Burns
Strong Acid
Burn from Sulfuric Acid |
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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.
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Chemical Burn
from Nitric Acid |
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Burn is caused by a nitric acid spray. A
brown discoloration is characteristic. Persistent pain is
present. Treatment is water irrigation.
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Deep Lime
Powder burn to lower leg |
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Lime powder at a construction
site entered the patient’s boot. The deep burn was noted
when pain developed. Initial treatment is water irrigation.
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Full Thickness
Sodium Hydroxide Burn to the back (at 24 hours) |
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Brownish dry appearance
indicates the burn is full thickness. Patient did not seek
medical attention for 24 hours.
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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.
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Agents include:
gasoline, fuel, solvents, phenol
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Protection from any
sparks or flame source as these agents make clothes and
skin highly flammable
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Absorption of these
toxins can lead to poisoning
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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
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careful removal will further
damage the skin burn
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Cover area with clean, dry
sheet or cloth
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Removal in definitive care
can be done using fat emulsifiers
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Neosporin
ointment
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mineral
oil
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not
flammable solvents
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Deep Hot Tar
Burn to Hand |
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Note the white area in the
exposed wound, indicating the burn to be very deep. Pain is
minimal and injury can be easily underestimated.
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Skateboarder
versus Poured Asphalt |
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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.
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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.
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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
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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
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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. |
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