Elsevier

Current Anaesthesia & Critical Care

Volume 19, Issues 5–6, October–December 2008, Pages 282-286
Current Anaesthesia & Critical Care

Focus on: Burns Care
Chemical burns: A review

https://doi.org/10.1016/j.cacc.2008.09.015Get rights and content

Summary

Chemical burns form a significant percentage of mortality from burns and total burns cases reported. There are over 65,000 chemicals available on the market, a large number of which can cause tissue damage. Despite this, they are often mismanaged. The severity of the chemical burn is dictated by the substance responsible, the percentage burn, the concentration, time since exposure, subsequent management and regional skin properties. Burns can be caused by both acids and alkalis. Acid burns cause eschars which limit the extent of the burn. Alkali burns therefore tend to be deeper. Like all burns, the patient should be resuscitated according to the Adult Trauma Life Support guidelines. Copious irrigation forms the mainstay of treatment. Neutralising agents are present for certain chemicals but their use should not delay the irrigation process which may take several hours. We look at the most common chemicals encountered in daily life and explore special considerations when dealing with resulting burns. Chemical burns are often associated with other injuries such as inhalation injury, so it is essential that the patient is considered holistically and all other injuries considered before concentrating all efforts on the chemical burn alone.

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)

  • Edlich RE, Drake BD, Long BW. Chemical burns. Emedicine. <http://www.emedicine.com/plastic/topic492.htm> [accessed June...
  • P.W. Curreri et al.

    The treatment of chemical burns; specialised diagnostic, therapeutic and prognostic considerations

    J Trauma

    (1970)
  • C.Y. Wang et al.

    Going deep into chemical burns

    Ann Acad Med Singapore

    (1992)
  • A. Luterman et al.

    Chemical burn injury

  • H.Q. Le et al.

    Exposure to first world war blistering agents

    Emerg Med J

    (2006)
  • P. Rice

    Sulphur mustard injuries of the skin. Pathophysiology and management

    Toxicol Rev

    (2003)
  • R. Saydjari et al.

    Chemical burns

    J Burn Care Rehabil

    (1986)
  • R.A. Sykes et al.

    Chemical burns: retrospective review

    J Burn Care Rehabil

    (1986)
  • Cited by (13)

    • Medicolegal evaluation of cases with burn trauma: Accident or physical abuse

      2021, Burns
      Citation 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 Science
      Citation 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 Surgery
      Citation 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 Disasters
    View all citing articles on Scopus
    View full text