This is the third in a series of articles focused on the best practices for burn care from the perspective of the EMS provider. This work will address burn injuries caused by chemical sources and their associated acute care. (The previous articles in this series include “Thermal Burn Care,” “A Review of Best Practices1” and “Blast Injuries and Burn Care.2”)
Chemical burns are produced when the skin is exposed to a corrosive material, such as an acidic or an alkaline substance. Exposure to a variety of common substances can lead to an injury; this article will cover several of the more common chemicals that pose risk to the patient. Caustic substances that have capacity to cause burns can range from non-lethal capsaicin-based sprays used by law enforcement to commonly available chemicals found in households, industrial settings and construction work sites. One critical aspect to always consider when responding to a patient with a known or suspected chemical burn is the risk of exposure to the responder by the same causative agent.
Several of the agents most closely associated with war and terrorism are caustic chemicals that result in burn injury. The prevention and management of chemical burns are prominent features in current efforts to curtail the impact of weapons of mass destruction (WMD).3–6 In the aftermath of the 9/11 attacks,7 WMD became and remain a central focus of the U.S. Department of Homeland Security (DHS) in its efforts to coordinate and develop overall disaster preparedness and planning. For medical disaster planning and preparedness, the U.S. Department of Health and Human Services’ (DHHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) and its Hospital Preparedness Program (HPP)3,5,8–10 have also developed a focus on chemicals in the context of WMD to include weaponized chemical agents. Due to the widespread use of chemicals in households and industry,11,12 and the capacity for their purposeful use of chemical agents intended to injure or instill fear,13–16 exposure to caustic chemicals and the burns they create is an ongoing danger.17
Clinically, chemicals damage the body in much the same manner as poisons. For the purpose of this work, the focus will include chemicals that can lead to burn injuries through the creation of exothermic reactions that generate heat and thereby produce either superficial blisters or deep penetrating burns.
Many chemical agents are organic compounds, meaning they dissolve in lipids and have a solvent action on cell membranes that can be particularly dangerous. Chemicals can cause injury to the body through one or a combination of three primary methods of exposure: absorption, inhalation or ingestion. Absorption occurs by direct contact of a chemical with either the skin or a mucous membrane. Injurious agents can also enter the body through the inhalation of gaseous chemical gases or aerosolized particles and through interaction with the gastrointestinal tract if swallowed (ingested).
The first steps of the assessment are to limit ongoing injury and determine the extent of exposure. These steps can be simplified to: strip, flush and cover the area. If it appears clothing is adhering to the injury site, then flush the area with water; wetting the clothing will facilitate its release from the wound.
It is critical to determine the extent of the area that has been exposed to chemical injury. While there may be an obvious initial area of involvement, it is essential to complete a head-to-toe assessment to identify if there has been either primary chemical exposure to other areas of the body or indirect exposure created by runoff from maneuvers performed to dilute the initial chemical exposure site.
Indirect injury can readily result from chemical agent collection in physically constrained areas covered by clothing such as the beltline, socks and shoes.
Triage and Factors Contributing to Injury Severity
A key triage feature of a patient with a chemical burn includes scene size-up and assessment to determine if there is an ongoing threat to the responders. While some commonly used systems for triage may lead to over-triage, systems such as START18 and Smart19 Triage remain good options that are applicable to chemical injuries and burns. As with all events, scene safety is first evaluated and immediately followed by patient assessment. This includes assessing responsiveness, airway patency and respiratory effort. Pay particular attention to the nose and mouth for signs of inhalation injury, or for evidence of inhalation/ingestion of a chemical or caustic agent. Is there unusual mucus or saliva? Are there noticeable sounds associated with respiratory effort or efforts to talk, such as stridor, rales (crackles), wheezing, dysphonia (hoarseness) or aphonia (inability to speak)? Is the respiratory rate too fast or too slow? Is the pulse rate too fast (tachycardia) or too slow (bradycardia)? Are there signs of shock and are there concomitant traumatic injuries such as could be sustained following a fall?
If the chemical agent is still on the patient, or if you are unsure, the first step in gross decontamination is to remove clothing while being careful to not contaminate other areas of the patient or nearby responders. Gross decontamination can be easily and quickly accomplished simply by clothing removal, physical relocation from the at-risk environment, and rinsing off the exposed areas of the body. The recommended sequence is Strip, Flush and Cover.
Triage remains a dynamic process requiring evaluation and periodic reevaluation for patients in the treatment area. While the obvious or distracting injury may be the chemical burn, also quickly assess the patient for concomitant traumatic injury to include a search for both internal and external hemorrhage.
The severity of a chemical burn injury is typically determined by the physical properties of a particular chemical or compound, its concentration, the route of exposure, the rate and duration of contact, and the temperature of the involved chemical or compound. The varying nature of chemicals and mixtures of compounds can produce a wide-ranging injury pattern over a period of time and it is essential to repeatedly reassess the patient for dynamic changes in the clinical condition.
While it is important to identify the type and nature of the chemical exposure, it is also important to quickly and effectively decontaminate the patient while protecting rescuers and bystanders. In any situation, be certain that the patient and rescuers are no longer exposed to the vapors associated with the chemical and that both are in a well-ventilated area. Minimum personal protective equipment (PPE) for this type of response should include gloves, eye protection and a method to mitigate splash exposure. It is always important to remember that whatever may have injured the patient can also injure rescuers and hospital personnel.
Remove all sources of the caustic agent. Brush away powder residue or any remaining solid materials and quickly initiate the application of copious amounts of water to thoroughly irrigate the affected area. Continue to care for and assess the patient to include a comprehensive search for concomitant injuries such as inhalation exposure. Administer supplemental oxygen to isolate the airway when an inhalation is identified or suspected, and assess for associated stridor, which is an indicator of a more serious inhalation injury. Continue to apply copious amounts of water and irrigate affected areas to dilute the chemical as completely as possible while being attentive to minimize secondary injury from the irrigant, (particularly if the irrigant is hypotonic). If the patient is standing or seated and the water being used to irrigate the chemical burn area is draining to dependent areas, look for collection points where the water and chemical may pool and transfer sufficient amounts of the chemical to cause additional burns remote from the actual site of the injury.
For chemicals that are determined to be acidic in nature, the irrigation should continue for up to 30 minutes. For alkali (base) burns, irrigation should continue until reaching the hospital and should continue there until a pH assessment can be conducted to determine if the alkali has been neutralized.
Depending on the concentration, an alkali exposure may require irrigation for hours to reach a mitigation point in the decontamination process. An alkali agent will feel slippery or soapy; this is due to the saponification (reaction between an alkali and a fatty acid) of the fatty substances on the surface of the skin. If there is uncertainty as to whether the chemical burn is either an alkali or an acid, it is best to continue the irrigation process until reaching definitive care where the pH can be determined.
Furthermore, all alkali burns should be evaluated by a physician. It should be noted, while “alkali” and “base” are generally considered to be interchangeable in the context of chemistry, they are not identical terms. For this paper the term used and focus will be an “alkali.”
Although helpful for determining the pH of affected tissue for treatment purposes, the use of pH-sensitive paper to determine the pH of the chemical causing the injury is not recommended. At best it is difficult to gain an accurate reading and at worst it may offer misleading and inaccurate information. The most reliable way to determine the original pH of the chemical causing the injury is to attain that information from the container or source of the chemical.
With only rare exceptions, irrigation with water is a critical step in managing any patient with a chemical burn. Irrigation, as discussed in this article, implies the use of copious amounts of clean water that can commonly be obtained from a household faucet. It is not necessary to use sterile water or saline solution. The temperature of the water used should be similar to normal body temperature. Avoid excessive use of water that is either cold (<70 degrees Fahrenheit or 21.1 degrees Celsius) or hot (>110 degrees Fahrenheit or 43.3 Celsius). It should be noted that several chemicals are either non-water soluble or could be activated by moisture. Nevertheless, using large volumes of warm water will either be of significant benefit or at worse, cause minimal or no harm beyond that which has already occurred. Several of the exceptions are discussed later in this article.
General Patient Care Considerations
The generally accepted clinical axioms associated with management of burn injury apply in this setting as well. If an advanced airway is indicated, endotracheal intubation is preferred over a blind airway insertion device (BAID). Closely monitor the respiratory effort and continue to evaluate for inhalation injuries. Evaluate vital signs and if there is evidence of shock, such as hypotension, tachycardia and diaphoresis, manage accordingly but reevaluate for concomitant trauma that could have produced a hemorrhagic injury. Fluid resuscitation should include lactated ringers (LR) solution or normal saline if LR is not available. The infusion rate can range from 125 to 1000 milliliters per hour (ml/hr) based on the size of patient and the total body surface area (TBSA) of the burn injury. For any burn, stop the burning process with water. For chemical burns this requires more liberal use of water than with thermal burns.
While typical analgesics such as morphine sulfate can be used to manage pain, there may be specific situations (discussed later) where pain management is better accomplished with a specific treatment such as calcium gluconate (if available) for a hydrofluoric acid burn. Once the burning process has been stopped and the wound sufficiently irrigated, a loose dry dressing can be applied.
Chemical burns can be considered minor injuries under the following conditions: isolated injury where there is no blistering or charred appearance; no suspected alkali involvement; or the injury does not include inhalation, ingestion, or ocular or mucous membrane contact. If the triage and assessment indicates the injury is minor, the patient can be managed outside the hospital environment with wound management and appropriate follow-up as needed.
Common Chemical Burns for EMS Patients
The following sections will cover several of the more frequent chemical agents faced by EMS responders. Regardless of cause, management for all chemical burns includes ensuring the patient is no longer exposed to the agent, supplemental oxygen for inhalation injury and management as a thermal burn for contact injury (chemical burn). Additional treatment considerations beyond those initially covered in the General Treatment section are noted with each of the specific chemicals discussed.
Hydrofluoric acid (HF) can cause deep tissue damage and deplete circulating calcium and magnesium resulting in lethal dysrhythmias. HF is a colorless, highly corrosive, weak inorganic acid that is commonly found in tire rim cleaners, rust removers and cleaning solutions. HF’s mechanism of injury includes deep tissue damage through liquefactive necrosis whereby highly lipophilic fluoride ions penetrate tissue and alter cellular metabolism.
As a result, the clinical presentation of HF burns often includes substantial pain without an obvious burn. The treatment will often include the topical application of 10% calcium gluconate gel. HF exposure can lead to pronounced hypocalcemia, and the electrocardiogram (ECG) should be monitored for conduction abnormalities—the condition may mimic a calcium channel blocker overdose. Symptomatic prolongation of the QT interval or bradycardia may require intravenous infusion of calcium gluconate or calcium chloride (CaCl).
Hydrochloric acid (HCl) is a clear and colorless solution that is commonly used in household cleaning products and when significantly diluted can be used as a food additive. HCl is one of the more commonly used compounds found in many household cleaners which contain acid as an active ingredient.
Depending on the brand, some drain cleaners contain an acid, while others use an alkali as their active ingredient. It is advisable while on site to read and review the label (if available) to determine the active ingredient. Common alkalis include sodium hydroxide (NaOH, also known as lye or caustic soda) and potassium hydroxide (KOH). The collective term for the alkali drain cleaners is lye. Acidic drain openers often contain sulfuric acid as the active ingredient. In either situation, inhalation of concentrated vapors may lead to lung irritation and direct skin or mucous membrane contact can cause chemical burns.26-29
Sulfuric acid (H2SO4) is a major ingredient in acidic drain cleaners and is a highly corrosive mineral acid. Also known as the “oil of vitriol” and commonly used in the industrial environment, H2SO4 can be very dangerous if absorbed, inhaled or splashed in the eyes.
The household version of ammonia is a solution of NH3 dissolved in water. Ammonia is a common household cleaner used on floors and bathroom fixtures such as toilet bowls. While not as concentrated, human and animal urine also contain ammonia. When adverse exposures occur, the extent of associated injury will be related to the concentration of the ammonia, the route and duration of exposure. Ammonia is colorless with a highly irritating gas; the odor is distinct and suffocating.
Bleach is used to disinfect household items and surfaces, and is commonly used for swimming pool and hot tub sanitation. “Bleach” is a general term that describes a host of chemical products, all of which perform their intended functions with varying degrees of success accompanied by varying levels of risk. While not all oxidizing bleaching agents include chlorine (Cl) (such as hydrogen peroxide and sodium percarbonate), most bleach formulas include Cl. The term “bleach” most commonly refers to the compound sodium hypochlorite (NaClO). Bleach as a source of chemical injury is most often associated either with an inhalation injury or a direct contact injury involving liquid chlorine compounds used to treat swimming pools.30,31
Individually, ammonia and chlorine-based cleaners work well in isolation. However, the greatest risk occurs when a chloride product is combined with ammonia, producing volatile ammonium chloride. Mixing of these chemicals can produce an exothermic reaction (heat producing) that can explode and/or produce a purple-colored gas that can be deadly if inhaled in significant concentrations.
Anhydrous ammonia (NH3) is the most common fertilizing chemical used in the farming environment that can pose significant risk of injury. The word anhydrous means “without water,” meaning this compound is stored as a colorless gas (although this gas does produce a pronounced pungent odor). It should also be noted that anhydrous ammonia is a critical component for a crudely made but powerful bomb (commonly mixed with diesel fuel). Anhydrous ammonia is also a common ingredient in methamphetamine production.32–34
Paving and Construction Environment
Tar and asphalt (bitumen) is most commonly found in roofing applications and the paving or patching of highways. Although chemically similar, tar and asphalt are different substances. Nevertheless, initial care is the same. Due to the extreme heat needed to prepare the product, these materials are typically used only in when the ambient temperature is above 60 degrees Fahrenheit (15.5 degrees Celsius). Tar or asphalt can be transported in large tankers that may also include circulating heating sources to maintain the materials in their molten forms. Exposure to hot tar and asphalt can cause deep thermal injuries.35,36 When caring for these injuries, it is critical to cool the affected area and to continue those cooling measures throughout the care of the patient. If it is necessary to remove adherent tar or asphalt from the skin, use Vaseline, mineral oil, vegetable oil or white petroleum to dissolve it. Do not use gasoline, diesel fuel, fuel oil or other potential petroleum-based solvents to dissolve the tar or asphalt.
Calcium oxide (CaO), also known as quicklime, is a key building ingredient, a potent alkali and is commonly found in cement. When water is added to CaO, an exothermic reaction occurs. Chemical burns from exposure to CaO dust particles can occur when dust collects at the top of socks, boots or the wristlet around gloves, and the CaO is then activated by perspiration. In these concentrated locations, what may initially appear to be simply reddened and painful superficial injuries may actually develop into partial or full-thickness thermal burns.37 Inhalation injury can occur when the CaO dust particles are inhaled and activated by the moisture in the respiratory system. Concrete burns can produce significant complications with an extended recovery for both inhalation and contact burns.
Hydrofluoric acid (HF), in addition to household use, is also used in industry for oil refining, semi-conductor production, as well as the manufacturing of Teflon, Freon and other organofluorine compounds. HF in low concentrations can cause delayed yet severe pain while higher concentrations can result in immediate pain and significant associated tissue damage.
The likelihood of a highly concentrated HF exposure in the industrial setting is rare but dangerous to both the patient and the rescuer. If suspected, PPE is essential and it is essential to the clinician and rescuers to avoid cross contamination. Attempt to determine the concentration and evaluate the location, size and duration of exposure to HF. Inhalation injury should be suspected if the HF concentration is greater than 50%, exposure affects the head and neck or greater than 5% TBSA, or where clothing is deeply soaked or there is a substantive temporal delay in removing involved clothing.38
Industrial HF treatment includes liberal use of topical calcium gluconate gel applied directly to the affected area. If unavailable, a treatment solution can be made by mixing 25 ml of 10% calcium gluconate injectable with 75 ml of water-soluble jelly (such as K-Y jelly). Topical application to the wound site will reduce pain; while other medications can be used to manage central pain perception, calcium gluconate reduces pain by stopping the burning process.
Exposure to a high concentration of HF is a true emergency and death has been reported with even seemingly small burns (3–5% TBSA).39 Pain relief following the administration of calcium gluconate is a reliable indicator for the effectiveness of therapy.40 Injection of calcium gluconate, either subcutaneously in the immediate area at the site of the wound or intravenously, can at times be effective. Although calcium gluconate may be given inter-arterially, most likely this administration route will only occur in a fixed facility setting.
If a high concentration of HF is inhaled, protect the airway and initiate treatment for an inhalation burn including 100% humidified oxygen and potentially the use of 3% nebulized calcium gluconate. If HF is ingested, treatment also includes airway protection. To limit additional injury, do not induce emesis, but encourage the ingestion of water to dilute the HF. Gastric lavage with calcium gluconate solution may be of benefit, but will most likely take place in a fixed facility or in a controlled environment if indicated.38 In all cases, appropriate monitoring includes ECG and oxygen saturation with close attention being paid to the ECG waveform changes that would suggest the need for further evaluation of potential hypocalcemia or hypercalcemia.
While previously discussed, anhydrous ammonia (refrigerants) and sodium hypochlorite (water treatment) in high concentrations are also commonly used in industrial settings. An accidental release of these agents can readily produce death and disability in the impacted area. An example of the scope of damage that can be caused with such an event is the train crash that occurred in 2004 in Graniteville, S.C.41-43
Sulfuric acid (H2SO4) is commonly found in lead acid batteries and various cleaning agents. It is also used in fertilizer manufacturing, wastewater processing and oil refining. To a lesser extent, it is also found in insecticides, pharmaceuticals, detergents, antifreeze and drain cleaners.
Hydrochloric acid (HCl) is a clear and colorless solution dissolved in water. HCl has broad and wide-ranging utility in the industrial setting, ranging from rust removal to creating vinyl chloride and dichlorethane for the manufacture of polyvinyl chloride (PVC) plastic pipe and other PVC products. HCl is also one of the more commonly used compounds found in industrial cleaners where an acid is employed as the active ingredient.
Many of the same chemicals used in household and farm settings are also used in industry. It should be noted that these chemicals or compounds are typically stored and used in higher concentrations in the industrial setting, which increases the risk associated with exposure. A report from one international major medical center indicated a clear majority of its patients admitted with chemical burns44 resulted from industrial chemical exposures.
It should also be noted that alkalis in the industrial environment are similar but typically of higher concentrations to those discussed in the Household Environment section of this paper as well. In addition to cleaning products, alkali examples from industry include their use to produce lubricants, alloys for aircraft and railroad bearings. The most common alkali metals found naturally include sodium (Na), potassium (K), lithium (Li) and cesium (Cs). While sodium and potassium are commonly found in the home and workplace (and others are essential elements for human life), lithium and cesium are less common in household exposures. Lithium is commonly found in batteries. Cesium has medical, petroleum exploration and electrical power uses, but is somewhat rare and not typically found either in the environment or the workplace.
The appropriate care for an alkali exposure includes copious and ongoing irrigation. As previously discussed, irrigation for an alkali exposure should be of greater duration than for acids (more than 30 minutes).
Great risk and potential for injury is present when dealing with chemical burns. The very same event that injured a patient can similarly place the responder at risk. Appropriate PPE is essential in any response to a 9-1-1 alarm for “chemical burns.” For many chemical burns, the exothermic reaction associated with an exposure will also produce an associated thermal burn; the combined effects may lead to organ failure, pulmonary edema, and even cardiac arrest from hypocalcemia or hypomagnesemia-associated dysrhythmias. A common initial treatment strategy is dilution of the causative agent with copious amounts of applied water. However, it should also be noted that not all chemicals, such as hydrocarbon based solutions, are water-soluble. Nevertheless, the use of water even for chemicals that are not water-soluble can indirectly aid in dissipating the irritating chemical and provide symptomatic relief.
This article reviewed treatment concepts for many of the more commonly encountered chemical agent exposures that a responder may encounter, but given the thousands of compounds present in our environment, no review can be 100% complete and comprehensive. Nevertheless, many of the initial treatment concepts and actions presented here are generalizable as first interventions. The majority of serious injuries that result from chemical burns should be managed with dilution, exposure control, a search for associated injuries, treatment of thermal injuries when identified, establishment of IV access, administration of supplemental oxygen and non-invasive monitoring (e.g., ECG, SpO2, EtCO2).
Additionally, where indicated, care may also include unique solutions for special considerations such as the administration of atropine for OP, 2-PAM and atropine for nerve agents, and calcium for HF exposure.
All care guidelines discussed in this article are based on the current science and literature reviewed by the authors. Nevertheless, EMS clinicians should always defer to local protocol and local medical control should there be uncertainty or a variance in treatment practices.
National Oceanic and Atmospheric Administration (NOAA), Office of Response and Restoration, Database of Hazardous Materials, CAMEO Chemicals: http://cameochemicals.noaa.gov/. CAMEO Chemicals contains a library with thousands of datasheets containing response-related information and recommendations for hazardous materials that are commonly transported, used, or stored in the U.S. CAMEO is a reactivity prediction tool, which can be used to predict potential reactive hazards between chemicals. So long as there is a working Internet connection, this program works great through a smartphone: http://m.cameochemicals.noaa.gov/search/simple
Wireless Information System for Emergency Responders (WISER) is a system designed to assist first responders in hazardous material incidents. WISER provides a wide range of information on hazardous substances, including substance identification support, physical characteristics, human health information, and containment and suppression advice. http://wiser.nlm.nih.gov/
There are WISER applications that are free and can be downloaded to most smartphones. Download options include the iOS for the iPad and iPhone, any Android device, BlackBerry Palm OS PDAs and Windows Mobile Devices.
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