AUTHOR AND EDITOR INFORMATION

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INTRODUCTION

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Background

Chemical burns are primarily divided into 2 groups: acid and alkali. In addition to the occupational hazards associated with industrial strength product use in the work place, a plethora of products are available and used by the general public. As with most environmental or toxicological exposures, knowing the specifics of the offending agent is key. Appropriate evaluation of chemical burns requires a complete assessment of the offending agent (composition, acid or alkali, concentration), type of exposure (inhalation, cutaneous, ocular, GI), duration of exposure, and other events or injuries associated with the chemical burn (explosion, fall, trauma).

Pathophysiology

Acids and alkalis cause injury via different mechanisms.

Acids produce coagulation necrosis by denaturing proteins upon tissue contact. An area of coagulation is formed and limits extension of injury. An exception is hydrofluoric acid, which produces a liquefaction necrosis similar to alkalis. Hydrofluoric acid is also unique in that it may rapidly penetrate the skin to the vasculature, allowing for rapid fluoride ion dissemination.^{1, 2} The fluoride may then precipitate with calcium, causing life-threatening hypocalcemia and metastatic calcification.

Alkalis cause a liquefaction necrosis and are potentially much more dangerous than acid burns. Alkali agents liquefy tissue by denaturation of proteins and saponification of fats. In contrast to acids burns, in which tissue penetration is limited by the formation of a coagulum, alkali burns can continue to penetrate very deeply into tissue.

Frequency

United States

Accurate statistics are lacking. However, approximately 25,000-100,000 chemical burns are reported every year.

Mortality/Morbidity

• Chemical burns result in approximately 20 deaths per year, with a mortality rate of less than 1%.
• Morbidity, defined as severe toxicity, occurs in less than 1% of those exposed.
• Bleach is associated with severe toxicity in less than 1% of cases. Death is rare, although reports of fatalities have been anecdotally reported.
• Alkali exposures are high risk.
• Drain cleaners are associated with severe toxicity in 1-2% of cases, with a mortality rate of less than 0.1%.
• Caustic ingestions are high risk and may result in airway compromise.
• Ocular exposures are high risk.

Age

• Children and adults have similar exposure rates.
• Younger children tend to be accidentally exposed because of inadequate childproofing.
• Older children and young adults may be exposed because of impetuous behavior or experimentation.

CLINICAL

Section 3 of 11  

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History

In patients with chemical burns, a careful physical examination is important; however, a thorough history usually helps determine how a patient should be treated.

• Type of exposure
• • Determine the offending substance. Relying solely on patient history is insufficient. Obtain the substance's container, call the manufacturer, use a computerized poison index, and/or call your regional poison center.
  • Determine whether the substance is acid, alkali, or chemical in composition, and ascertain the concentration.
  • Determine whether the exposure was cutaneous, oral, GI, ocular, or inhalation.
• Time and duration of exposure
• Symptoms immediately after the injury (pain, burning, numbness, change in level of consciousness, respiratory distress, vital signs, oral discomfort or swelling, ocular discomfort, change in vision)
• Decontamination or life-saving measures provided at the scene
• Other injuries possibly resulting from a fall, explosion, or fire
• Preexisting medical conditions

Physical

• Airway
• • Patients with oral or inhalation injury may experience significant edema or difficulty maintaining their airway and often require intubation.
  • Particular attention should be paid to the presence of stridor, hoarseness, and oral swelling.
• Breathing: Patients may develop wheezing and labored breathing as a result of inhalation. Symptoms may range from discomfort and mild wheezing to respiratory failure requiring artificial ventilation.
• Circulation
• • Assess circulation by determining perfusion to end organs, level of consciousness, skin color and temperature, capillary refill, and urinary output.
  • Assess heart rate for appropriate rate and regularity.
• Disability: Perform a thorough neurologic evaluation to determine the presence and degree of deficit. Serial examinations are necessary to evaluate symptom progression or resolution.
• Environmental
• • As with many environmental injuries, patients with chemical burns may be at risk for becoming hypothermic, with associated increased morbidity and mortality. Attention should be paid to maintaining normal temperature.
  • Preventing further injury is also important. Wet or contaminated clothing should be removed, and the patient maintained warm and dry.
• Extremities: Close inspection of all extremities should be performed to rule out any other associated injuries.
• Special considerations
• • Patients with oral or inhalation injury may experience significant swelling or difficulty maintaining their airway. Particular attention should be paid to the presence of drooling, stridor, hoarseness, and oral swelling. Intubation may be necessary.
  • Oral burns are an underreported problem and may lead to severe contracture. Oral contractures can be divided into anterior, posterior, and total. Posterior oral contractures result from caustic ingestion and involve the posterior buccal mucosa, posterior tongue, retro-molar area and oro-pharynx. Total oral contractures typically result from caustic lye ingestion and involve the lips, tongue, oral cavity, and oro-pharyngeal mucosa.
  • Seek, and document, the presence, size, and depth of cutaneous burns.
  • Depths of burn classifications are superficial partial thickness, deep partial thickness, and full thickness. Depth determination involves describing the affected area's color, texture, and sensation.
  • • First-degree burn: Redness without change in texture and intact sensation denotes a superficial injury.
    • Second-degree burn: Blister formation with or without denuding and pink to mildly pale tissue with intact sensation denotes deeper partial-thickness injury.
    • Third-degree burn: Areas that are white, leathery, and insensate denote full-thickness injury.
  • Determining extent of involvement requires an estimate of the affected body surface area. Special attention is also paid to injuries of the face, hands, feet, and genitalia. Circumferential injury should also be noted.
  • Body surface area can be estimated by using a standard chart with the Rule of 9's. However, the Lund and Browder Chart provides a more accurate estimate in children.
  • Most small injuries can be approximated using the size of the patient's palm. The entire palm, including the fingers, represents approximately 1% of total body surface area (TBSA).
• Oral or GI
• • Oral or GI exposure may cause severe burns, particularly if the exposure is to a strong alkali.
  • Early injury may be represented by redness, swelling, and pain. Patients breathe through an open mouth, drool, speak with a hoarse voice, or have stridor.
  • Remember that alkali compounds result in liquefaction necrosis, with potential for ongoing deep tissue penetration. Severe precipitous airway edema or obstruction may result.
  • Children who refuse to swallow their own saliva should be given particular attention. Risk of esophageal perforation and stricture is very real (although these are later complications and are not usually present when the patient is in the emergency department.)
• Ocular
• • Patients with ocular exposure or complaints require detailed ophthalmologic evaluation. However, initial examination is deferred until adequate decontamination has occurred with copious amounts of saline (minimum of 0.5 h).
  • Complete evaluation includes general appearance of the globe, conjunctiva, anterior chamber, and cornea with attention to redness, pallor, or opacification.
  • Examine the eye for presence of foreign bodies.
  • Verify pupillary and extraocular muscle function.
  • pH testing should be performed before and after each set of irrigations and should be continued until the pH returns to the normal range (7-8).
  • Stain with fluorescein to look for areas of increased uptake signifying corneal abrasion.
  • A slit lamp examination may be useful. It allows for a more detailed examination of the cornea and anterior chamber, including the presence of a hyphema or hypopyon.
  • Document the visual acuity of patients with ocular exposure or complaints. Documentation should include right eye and left eye individually, then vision with both eyes.

Causes

• Inadequate child-proofing
• • Cleaning or caustic products are not stored out of reach of young children.
  • Cleaning solutions or agents are stored in bottles other than the original container (eg, a potentially caustic solution in a soda pop bottle).
  • Directions are not regarded or supplies are inappropriately mixed (eg, mixing bleach and ammonia products creates a noxious gas, which can precipitate acute bronchospasm and respiratory distress).
  • Unintended exposures are caused by something breaking, exploding, or being squirted or sprayed.
• Common sources of acids
• • Toilet bowl or drain cleaners may contain sulfuric or hydrochloric acid. They may also contain alkali.
  • Automotive tire or metal cleaners and rust removers may contain hydrofluoric, sulfuric, or phosphoric acid.
  • Engraving solution may contain hydrofluoric or nitric acid.
  • Tile cleaners or glass etching may contain hydrofluoric acid.
  • Battery fluid may contain sulfuric acid.
• Common sources of alkalis (bases)
• • Drain or oven cleaners may contain sodium or potassium hydroxide.
  • Cleaners and detergents may contain ammonia or any of the sodium or potassium polyphosphates.
  • Household bleach or pool chlorination system or tablets may contain sodium or calcium hypochlorite.
  • Cement, mortar, or plaster may contain calcium hydroxide or oxide.
  • Denture cleaners or Clinitest tablets may contain sodium or potassium hydroxide.
  • Dishwashing or clothing detergents may contain silicates or sodium carbonate.
  • Toilet cleaners (lye) may contain potassium hydroxide or other strong alkali.

DIFFERENTIALS

Section 4 of 11  

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WORKUP

Section 5 of 11  

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Lab Studies

• Mild chemical burns: In most patients, no laboratory studies are indicated.
• Severe chemical burns: Consider basic screening with a computerized CBC count, serum electrolyte assessment, quantitative creatine kinase (CK) assessment, and coagulation studies.
• Hydrofluoric or oxalic acid burns: Screening levels of calcium, magnesium, and phosphorus are often performed and may be useful. An EKG should also be considered to monitor for prolonged QT intervals, especially if physical signs of hypocalcemia (tetany, Trousseau or Chvostek sign) are present. However, the degree to which these levels contribute to patient treatment is uncertain.

Imaging Studies

• Chest radiography is indicated for patients with inhalation injury or respiratory distress.
• When evaluating for edema or perforation of the soft tissues of the neck, direct visualization with endoscopy is preferred. Radiographs of this area have limited value.
• When evaluating for perforation of the abdomen, direct visualization with endoscopy is preferred, although radiographs have some value.
• Head CT scanning is indicated for patients with altered mental status, history of explosion, or closed head injury.
• Abdominal CT scanning with oral and intravenous contrast has limited use in evaluating for perforation. Direct visualization with endoscopy is preferred.

Other Tests

• Direct visualization (endoscopy) of the posterior pharynx, airway, esophagus, and GI tract is the method of choice for evaluation of injury.

Procedures

• Intubation and mechanical ventilation may be required for oral and inhalation exposures.
• Intravenous access and possibly central venous access may be indicated, depending on the severity of the injury.
• A Foley catheter (to monitor fluid status via continuous measurement of urine output) is indicated for patients with severe chemical burns.
• Fasciotomies and escharotomies are generally not necessary.

TREATMENT

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Medical Care

Medical care of chemical burns begins with removal of the patient from the source of the injury (while maintaining the safety of rescuers and caregivers). All products should be handled as potentially hazardous material. Decontamination should be provided at the scene of contact. To avoid spreading the material to the transport vehicle or emergency department, the patient should have as much of the offending substance removed as possible prior to transportation. Contaminated clothes should be immediately removed.

• Airway
• • Removal of the patient from the offending gas is essential.
  • No method of lung decontamination is available.
  • Maintain airway patency. Oral and upper airway involvement may cause progressive edema and stridor, heralding the need for intubation. Patients with oral or inhalational exposures should be given continuous pulse oximetry monitoring and receive supplemental oxygen as indicated.
  • If ongoing edema and airway patency are concerns, secure the airway with a prompt, semielective intubation.
• Breathing
• • Maintain adequate ventilation and oxygenation. Patients may require artificial ventilation.
  • Patients with inhalation injuries may experience acute bronchospasm. Beta-agonist bronchodilators (eg, albuterol) are indicated for patients with wheezing.
• Circulation
• • Maintain adequate perfusion to the tissues.
  • Patients should be volume resuscitated; however, most chemical burns are of relatively small magnitude and usually do not require massive volume resuscitation.
• Disability
• • After obtaining a baseline neurological examination, prevent any further injury.
  • If a cervical spine or back injury is possible, the patient should be immobilized completely, pending radiographic findings.
• Exposure
• • Patients need to be completely undressed for a thorough examination; however, they need to remain euthermic. Tepid water should be used for irrigation to avoid iatrogenic hypothermia. Afterward, patients should be covered and kept clean and dry.
  • External warming devices should be used early in the course of care if indicated because hypothermia has particularly deleterious effects on individuals with chemical burns.
• Pain management
• • Most, if not all, patients with chemical burns require medication for pain control; however, removing all pain that results from burns is nearly impossible. Although oral agents may be an option for mild burns, using the intravenous route is usually preferable to allow for exact titration of pain and reversal if necessary.
  • Morphine sulfate is the drug of choice (0.1 mg/kg).
• Tetanus
• • Burns are considered tetanus prone, and all patients should be immunized.
  • If the status of tetanus immunization is unknown, the vaccine should be administered.
• Decontamination basics
• • Dilution is the solution to decontamination.
  • Never attempt to neutralize the offending agent because it may result in an exothermic reaction that could superimpose thermal injury or cause explosion.
• Cutaneous exposure
• • If the agent is a powder, brush off as much as possible before moving the patient. After brushing as much of the powder from the patient as possible, rinse the affected area (tepid tap water is fine, if saline or other irrigant is unavailable in the field). Remember that rinsing creates a dilute solution of the offending substance. Make certain that the solution is not soaking the clothing and the patient no longer has contact with it.
  • If the substance is a liquid and has saturated the clothing, remove the clothing and rinse the affected area thoroughly. Use copious amounts of fluid to dilute the substance. Ensure that the patient no longer has contact with the remaining fluid, and provide dry covering to maintain patient euthermia.
• Oral and GI 
• • The mouth should be rinsed as much as possible. Do not attempt neutralization.
  • Maintain the airway and instruct the patient to have nothing by mouth (NPO).
  • Do not attempt gastric emptying. Do not lavage and do not give ipecac syrup.
  • The use of corticosteroids for prevention of esophageal stricture has been advocated in the past. However, supportive evidence for its use is scant at best and cannot be advocated as standard practice.³
• Ocular
• • The solution is dilution.
  • Affected eyes should be rinsed with copious amounts of an ocular irrigation solution for a minimum of 0.5 hour at a time. The pH of an irrigant solution plays a significant role in its tolerability, because nonneutral solutions cause pain and discomfort.
  • Currently, the irrigation solution of choice for most pediatric emergency ocular decontaminations is normal saline (NS), which has a pH range between 4.5 and 6.0. Other solutions available include lactated Ringer solution (LR), which has a pH range between 6.2 and 7.5, buffered NS with pH adjusted to 7.4 with sodium bicarbonate, and balanced salt solution (BSS) plus, which has a pH of 7.4.
  • The use of more pH-neutral solutions, such as LR, NS with bicarbonate buffer, or BSS plus, may decrease the discomfort associated with copious irrigation and may improve the tolerance of irrigation of the eye by the pediatric patient.
  • Anesthetic drops should be provided for pain relief; however, these usually provide only partial relief, and parental pain relief with morphine is often required.
  • A specialized ocular irrigation cup, or Morgan lens, may be used after adequate analgesia is provided (ocular and parenteral pain control).
  • The pH of the eye should be checked after each 0.5 hour of irrigation and continued until the pH has normalized (pH is 7-8).
• Hydrofluoric acid burns
• • Calcium is used to treat hydrofluoric acid burns. The hand is the body part most commonly exposed to hydrofluoric acid.
  • A glove containing a mixture of calcium chloride, KY jelly, and hydrocellulose is placed on the patient's hand to provide continuous and complete exposure to the calcium; 2.5% topical calcium gluconate gel may also be applied topically to the site of contact.
  • Another option is an intradermal or intra-arterial injection of calcium gluconate.
  • Bier-type block and intravenous calcium are also used.
  • Hemodialysis may be considered for cases refractory to standard treatment.

Surgical Care

• Vascular access may be necessary.
• Fasciotomies and escharotomies are rarely necessary.
• Eyelid reconstruction with acellular dermal allograft in patients with eyelid defects after chemical burns and thermal burns may be considered to improve cosmesis and function.
• Amniotic membrane transplantation (AMT) has been performed in acute ocular burns for reduction of pain and promotion of early epithelialization with moderate burns. However, no definite advantage to AMT over medical therapy alone is apparent in terms of restoring visual acuity, appearance of symblepharon, corneal vascularization, and results of tear function tests on short-term follow-up.
• Oral burns lead to stenosis and contracture, complications that prove refractory to fitting splints, injecting steroids, local surgical procedures, and the use of dynamic appliances to maintain mouth opening. Further investigation of early use of injected antiproliferative agents to prevent scarring, more aggressive surgery, and long-term physiotherapy appliance use may improve treatment outcome.

Consultations

• Always consult with the regional poison control center. The center has accurate statistics on exposures, can aid in substance identification, and has up-to-date information on burn management.
• Consultation with a toxicologist may also be indicated, depending on the type and degree of exposure.
• Chemical burns are treated similarly to thermal burns and require consultation with a burn specialist.
• All but the most trivial of ocular injuries require consultation with an ophthalmologist.

MEDICATION

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Drug Category: Analgesic agents

Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who have sustained trauma or injuries.

Drug Category: Vaccines

Active immunization increases resistance to infection. Vaccines consist of microorganisms or cellular components, which act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.

Drug Category: Topical antibiotic cream

Topical agents, such as silver sulfadiazine, are used to cover cutaneous burns. The agent acts as a protective barrier and has some bactericidal properties. It may also provide relief of pain by covering the denuded highly sensate skin.

Drug Category: Miscellaneous pharmacologic antidotes

The major pharmacologic intervention is calcium gluconate. It may be used in a gel, intravenously, or intra-arterially.

FOLLOW-UP

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Further Inpatient Care

• Provide adequate pain management for individuals with chemical burns.
• Administer intravenous fluids (lactated Ringer solution) to maintain adequate urine output of at least 1 mL/kg/h.
• Hypothermia has particularly deleterious side effects. Maintain temperature homeostasis.
• Patients with hydrofluoric acid burns require continual calcium therapy until pain free. Monitor serum calcium levels and QT interval.

Further Outpatient Care

• Pain control is essential.
• Referral to burn or toxicology specialist may be necessary.
• Tremendous psychosocial impact may accompany disfiguring burns. Individuals may show high levels of anxiety and depression, especially those who are assaulted by members of their own family.

In/Out Patient Meds

• Pain control
• • Initial treatment should include parenteral pain control with morphine sulfate.
  • The patient may be switched to oral agents once stabilized. These may include oral narcotics (eg, codeine, hydrocodone-containing compounds) or nonsteroidal agents (eg, ibuprofen, naproxen).
• Antibiotics and steroids
• • Antibiotic creams, such as silver sulfadiazine, may be used for covering cutaneous burns to all parts of the body with the exception of the face. Bacitracin ointment may be safely used on the face.
  • Prophylactic oral antibiotics are not indicated. Oral antibiotics should only be used in patients with documented infection.
  • Steroids are not indicated.

Transfer

• Patients with burns involving the hand, face, eye, or genitals should be transferred to a burn center.
• Patients with severe burns (full thickness or >30% body surface area) should also be transferred once stabilized.
• Transfer should take place only after the patient has been thoroughly decontaminated and stabilized.

Deterrence/Prevention

• Childproof the house. Keep dangerous substances out of reach of children.
• Do not store cleaning or caustic agents in bottles other than what they were intended to carry.
• Read and follow directions. Do not mix agents.
• Teach children safe habits. Lead by example.
• Remember that even commonly used products have the capacity to cause serious injury.

Complications

• Oral and GI complications include airway obstruction, stricture formation, and perforation.
• Ocular complications opacification, scarring, perforation, and blindness.
• Inhalation complications include bronchospasm, severe respiratory distress, and respiratory failure.
• Dermal complications include the burn itself and, occasionally, severe scarring.
• Infection may occur.

Prognosis

• Prognosis depends on the extent of injury and the nature of the exposure. Except for strong alkali exposure, patients with limited injury usually have a favorable prognosis if care is promptly provided.
• Strong alkali substances have a worse prognosis, particularly with ocular exposures.

Patient Education

• Educate the family on childproofing the environment.
• Provide the family with the telephone number of regional poison control centers.
• Inform the family of the real potential for serious injury and the importance of prevention.
• For excellent patient education resources, visit eMedicine's Burns Center. Also, see eMedicine's patient education articles Chemical Burns and Thermal (Heat or Fire) Burns.

MISCELLANEOUS

Section 9 of 11  

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Medical/Legal Pitfalls

• Failure to decontaminate the area
• Failure to appreciate the severity of the injury
• Failure to obtain appropriate consultation or transfer
• Failure to provide adequate fluid resuscitation and maintain perfusion
• Failure to recognize associated injuries

MULTIMEDIA

Section 10 of 11  

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Media file 1:  Caustic oral burns.
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Media file 2:  Caustic burns of tongue.
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REFERENCES

Section 11 of 11

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Article Last Updated: Aug 11, 2008