Focus on: Burns CareChemical burns: A review
Introduction
Chemicals are present in household substances and used widely in industrial products. There are more than 65,000 chemicals available on the market and an approximate 60,000 new chemicals enter the market each year1 with 25,000 marketed with the capability of producing tissue damage.2 Chemical burns are therefore extremely common and can vary from innocuous burns to life threatening injuries. There is an array of products and varying levels of exposure, therefore each case must be assessed differently and treated according to its merits.
Chemical burns are reported to form up to 10.7% of total burns cases reported3 and account for 2–6% of burns centre admissions. Up to 30% of all death from burns are reported to be due to chemical burns,4 highlighting the importance of prompt and correct management. In 2005, the American Association of Poisons Control centres reported 48,000 burns due to alkali and 26,300 burns due to acid substances. Many present with full thickness burns,3 which demonstrate the high morbidity associated with this type of injury.
Not infrequently, chemicals are used as weapons of assault in the civilian population. World prevalence varies widely. Jamaica has been reported to have the highest cases of chemical burns due to assault5, 6 where chemicals are often used as means of defence against guns by those too poor to afford munitions6 (Fig. 1).
The use of chemicals in warfare has driven us to improve our management of chemical burns out of necessity. Sulphur-containing chemicals have been used as weapons since World War I7, 8 and have been reported up until the Iran–Iraq war (1984–1987).9 The favoured quality of chemical weapons was their ability to incapacitate rather than kill8 thus inflicting a large invalid burden on the recipient side. Wound healing is considerably slower than that for comparability sized thermal burns and patients often require extended hospital treatment.9, 10 The main focus of this article is to cover the most common chemicals encountered in everyday practice. The specific management of injuries from Chemical weapons is beyond the scope of this article and remains the remit of military medical services.
Section snippets
Pathophysiology
The fundamental difference between chemical and thermal burns is that chemical burns continue the destructive processes until the inciting agent is removed.11 Often, the causative chemical is still in contact at presentation. The severity of the burn is dictated by the following:
- 1.
Substances responsible – there is great variation between chemicals as to their deleterious effects. These shall be covered more specifically later in the article.
- 2.
Percentage burn – much like their thermal counterparts,
Management
Like all burns injuries, the patient should be resuscitated according to the Advanced Trauma Life Support (ATLS) protocol. It is important to try and ascertain the chemicals involved as soon as possible as each has special considerations. Certain chemicals such as sulphuric acid, phenol, hydrochloric acid and dry lime are excluded from the general recommendations of lavage, either because the addition of water causes more burning or because they do not mix with water.18 A brief history will
Hydrofluoric acid
Hydrofluoric acid is a highly lipid soluble undissociated acid found both in the anhydrous and aqueous form. It is one of the strongest inorganic acids known to man. It was first used in glass etching in 1670 and has since been widely used in industry. However, it is also present in household products such as rust remover and heavy duty cleaners.
Hydrofluoric acid not only acts as a topical agent but having penetrated into tissues can cause metabolic toxicity. It does so by several mechanisms.
Conclusion
Although chemical burns form a small number of total burns cases, they take up a high proportion of burns admissions and can penetrate deep into tissues. Because of their relatively low occurrence, they are often mismanaged.
There are tens of thousands of chemicals used both in household products and in industry with thousands entering the market every year. The mainstay of managing chemical burns is copious irrigation with saline until the skin pH is back to normal and the chemical is
References (37)
- et al.
Cases of chemical assault worldwide: a literature review
Burns
(2007) - et al.
Chemical burns as assault injuries in Jamaica
Burns
(1996) - et al.
Agents of chemical warfare: sulphur mustard
Ann Emerg Med
(1992) - et al.
Vesicant burns
Br J Plast Surg
(1991) The burn patient: initial care
Curr Probl Surg
(1979)Cement burns
Ann Emerg Med
(1980)- et al.
Epidermal lipids and the natural history of hydrofluoric acid (HF) injury
Burns
(1994) - et al.
Fatal systemic fluorosis due to hydrofluoric acid burns
Ann Emerg Med
(1985) - et al.
Digital hydrofluoric acid burns: treatment with intraarterial calcium infusion
Ann Emerg Med
(1986) Chemical burns
Am J Surg
(1959)
The treatment of chemical burns; specialised diagnostic, therapeutic and prognostic considerations
J Trauma
Going deep into chemical burns
Ann Acad Med Singapore
Chemical burn injury
Exposure to first world war blistering agents
Emerg Med J
Sulphur mustard injuries of the skin. Pathophysiology and management
Toxicol Rev
Chemical burns
J Burn Care Rehabil
Chemical burns: retrospective review
J Burn Care Rehabil
Cited by (13)
Medicolegal evaluation of cases with burn trauma: Accident or physical abuse
2021, BurnsCitation Excerpt :In addition to these burn types, chemical burns should be discussed especially because of their effects on morbidity and mortality. In literature, it has been emphasized that 10% of all burn cases, 2–6% of presentations at burns units, and 30% of burn-related mortalities are of chemical origin [22,23]. In the present study, chemical burns were observed in 15 (1.2%) patients, which was a similar rate to that reported in previous studies which have included chemical burn patients [19].
The biophysical effects of localized electrochemical therapy on porcine skin
2020, Journal of Dermatological ScienceCitation Excerpt :The extent of the pH perturbations is directed by dosimetry and electrode design, which dictate electric field geometry and the chemical gradient. Conventionally, direct exposure of skin to either an acid or base is deleterious [24]. However, with intradermal placement and precise spatial control, the pH effect may be limited to discrete locations.
Hand chemical burns
2015, Journal of Hand SurgeryCitation Excerpt :It has an anesthetic effect, and because exposure is not painful, presentation may be delayed. Its lipophilic nature causes deep penetration and systemic absorption, which may lead to hemolysis and kidney, liver, and central nervous system toxicity.1 Phenol is much more soluble in polyethylene glycol than in water.
THE SILENT THREAT - ALKALI FOOT BURN: A CASE REPORT
2023, Annals of Burns and Fire DisastersPhysicochemical characterization of particulate matter in a cement production plant
2022, Environmental Science: Processes and Impacts