Edit concept Question Editor Create issue ticket

Chemical Burn

A chemical burn ensues after contact with or ingestion of a toxic agent. Since chemicals are found in many products used at home and at the workplace, there is significant potential for injury.


Presentation

The common injury sites are the face, eyes, arms, hands, and legs. Many burns are small and require mild treatment in the outpatient setting. Note that the extent of the wounds may not be as apparent visually.

The presentation may be unpredictable and even deceiving. The clinical picture may feature any of the following signs at the site of contact: redness, irritation, burning, pain, numbness, blister formation, or darkened skin. Symptoms may include a cough, dyspnea, or emesis. If the eyes are affected, there is a risk of visual loss.

Patients with severe injuries may experience weakness, dizziness, loss of consciousness, dyspnea, and a cough. Additionally, life-threatening manifestations include hypotension, seizures, and arrhythmias.

Physical exam

The severity is determined by the depth and the percentage of the affected body surface according to charts available to clinicians. For example, in adults, the arm comprises 9% of the body surface.

The classification of burns

The depth of damage is as follows:

First-degree burns are superficial and involve the epidermis. Furthermore, second-degree injuries describe an extension into the dermal layer. This depth may be categorized as superficial or deep depending on the level of damage in the dermis. Finally, third-degree burns encompass the epidermis, dermis, and the underlying fat layer. Additionally, other structures are also affected such as hair follicles, sweat glands, and nerve endings.

All first-degree burns are considered minor. Also, second-degree injuries that involve less than 10% of the body are minor.

Moderate and severe burns are comprised of injuries sustained to the face, hands, feet, or genitals, as well as second-degree burns that affect greater than 10% of the body surface and all third-degree burns.

Toothache
  • The patient used internet search engines to seek a toothache remedy and did not identify any reports of this complication.[ncbi.nlm.nih.gov]
Corneal Edema
  • At presentation, both had total corneal erosion, corneal edema, and limbal ischemia. After 12 to 15 days, a stromal line was apparent by both slit-lamp examination and anterior segment optical coherence tomography.[ncbi.nlm.nih.gov]
Ankle Pain
  • We describe a case of a child who sustained a full-thickness burn after an application of a coal ash poultice for ankle pain.[ncbi.nlm.nih.gov]
Blister
  • […] roundup.jpg 2 606 2 525; 1,93 MB Blister-arm.jpg 350 235; 7 KB Blister-back.jpg 379 224; 9 KB Charakteristische Brandwunde von Wasserstoffperoxid H2O2.jpg 864 864; 123 KB Chemical burn injury..jpg 300 226; 56 KB Chemical burns follwong Israeli bombings[commons.wikimedia.org]
  • "She has blisters from her finger to her elbow and is in so much pain."[thesun.co.uk]
  • Bullous pemphigoid is a blistering disorder characterized by antibody deposition in the lamina lucida of the basement membrane zone.[ncbi.nlm.nih.gov]
  • If the burn has blistered or has removed the top layer of skin, you have a second-degree chemical burn.[healthfully.com]
  • Concentrations of 35% or more will cause immediate blistering.[emedicine.com]
Eczema
  • An invisible spot on the thin-layer chromatography plate gave a test eczema and was further investigated with gas chromatography-mass spectrometry. DPGDA was detected in the spot.[ncbi.nlm.nih.gov]
  • In some cases, contact urticaria can be demonstrated only on damaged or previously eczematous skin, and it can be part of the mechanism responsible for maintenance of chronic eczemas ‏ الصفحة 416 - Loveless SE, Ladies GS, Gerberick GF, et al. (1996) Further[books.google.com]

Workup

Clinical evaluation includes the history of exposure, identification of the offending agent, a physical exam, and investigations.

Laboratory tests

Note that the studies are selected based on the severity and causes of the chemical burn.

In severe injuries, the clinician should obtain electrolytes, complete blood count (CBC), creatinine, blood urea nitrogen (BUN), glucose, urinalysis creatine phosphokinase, and a coagulation profile.

If caustics are consumed, then hemoglobin and hematocrit measurements are warranted. Additionally, if there is respiratory involvement, this necessitates arterial blood gas (ABG) or other measures.

Calcium, magnesium, and potassium levels are obtained in hydrofluoric acid burns while creatinine and BUN are warranted in chromic acid injuries. Additionally, oxalic acid burns require calcium measurement.

Furthermore, electrolytes, CBC, creatinine levels, liver function tests (LFTs), and urinalysis are performed in patients with phenol injuries. Finally, electrolytes and ABG tests are indicated in monofluoroacetic acid burns.

Imaging procedures

Esophagoscopy and gastroscopy are indicated in cases suggestive of oral intake. For example, these studies are performed in patients with symptomatic ingestions and those who are asymptomatic but have previously ingested harmful substances [1] [2].

In patients with evidence of esophageal burns, the injury is described according to the layers it involves: superficial, transmucosal, or transmural.

Note that only 2% to 15% of patients with esophageal damages have oral burns.

Staphylococcus Aureus
  • She had a benign-looking erythema on her neck which, over the next several days, became a second-degree chemical burn infected with Staphylococcus aureus.[ncbi.nlm.nih.gov]

Treatment

The treatment should be prompt. First aid should be applied immediately or as soon as possible. In fact, the chemical should be rinsed under running water for a duration of 10 to 20 minutes [7]. Likewise, if there is eye exposure, it should be rinsed for a minimum of 20 minutes prior to seeking emergency therapy. Also, all contaminated clothing or material on the body should be removed quickly.

Additionally, the burned area should be loosely wrapped in a sterile and dry dressing or cloth.

With regards to pain, superficial injuries can be treated with over-the-counter analgesics. However, significant burns require emergent care and stronger pain medications.

The patient must go to the nearest emergency room if the following signs are exhibited [8]:

  • Shallow breathing
  • Signs of shock
  • Measurement of the burn is greater than 3 inches
  • Injury involves the eyes, hands, feet, groin, buttocks, or major joint
  • Over- the-counter analgesics do not achieve pain control

Management

Wound care therapy may include debridement, use of antibiotics and anti-itching medications, skin grafting, intravenous fluids, and specialized dressings.

Note that there are contraindications such as gastric emptying. For example, measures such as charcoal use or dilution with milk or water should be avoided. Anything that may compromise the airway or the endoscopic procedure is not permitted.

The clinician should be cautious of adding water to products that contain sulfuric acid or sodium hydroxide since the resultant reactions will produce heat. Hence, this heat formation can be limited if diluting with 250-500ml of fluid [9].

Prognosis

The outcomes of dermal burns are related to the degree of involvement. For example, first-degree and mild second-degree burns will typically recover in days to weeks. These do not usually produce scars. However, deep second-degree and mild third-degree require weeks to heal and are associated with scar formation. Also, skin grafting is commonly indicated with these injuries.

With regards to prognosis, there is a high risk of mortality with burns that affect greater than 90% of the body. In fact, in more advanced ages, greater than 60% may result in death.

As for specific manifestations, it depends on the location of the injuries. Caustic burns will produce scarring especially in certain areas of the body. Also, eye injuries may lead to blindness while esophageal and gastric burns may result in the formation of a stricture. Note that patients with full thickness esophageal burns are predisposed to stricture formation.

Etiology

There is a broad spectrum of industrial and commercial products that are composed of toxic levels of acids, bases, and other substances that cause burn injuries [1] [2].

Acids

There are multiple forms of an acid such as sulfuric acid, hydrofluoric acid, hydrochloric acid, phosphoric acid, acetic acid, formic acid, chloroacetic acid, phenols, and cresols.

Frequently found in drain cleaners, battery fluid, and fertilizer production is sulfuric acid. Some products contain 8% acid while others are made up of nearly 100% acid. Additionally, hydrofluoric acid is often present in tire cleaners, rust removers, tanning, petroleum refining and other products.

Another type, hydrochloric acid, is used in metal cleaners, dye manufacturing, swimming pool cleaners, and laboratory chemicals. The levels are anywhere from 5% to 44%. Furthermore, phosphoric acid is added in disinfectants, metal cleaners, and fertilizer products while acetic acid constitutes disinfectants and dyes. Also, formic acid is used in tanning and cellulose manufacturing.

Mono, di, and trichloroacetic acid are key ingredients in the manufacturing chemicals. Additionally, mono chloroacetic acid leads to systemic toxicity since it disrupts cellular respiration.

Other acids such as phenol are used in plastics, drugs, and disinfectants while cresol is used in wood preservatives and degreasing products.

Bases

Some of the most common bases are sodium hydroxide, calcium oxide, sodium and calcium hypochlorite, ammonia, phosphates, sodium carbonate, and lithium hydride. These are found in a variety of products. For example, sodium hydroxide is an ingredient in drain and denture cleaners while ammonia, sodium carbonate and phosphates are constituents in detergents.

Calcium oxide is the corrosive component in cement that causes burns if diluted with water. Meanwhile, bleach contains sodium and calcium hypochlorite. Along with sodium hydroxide, hypochlorite is also found in pool chlorinating mixes, which are caustic.

The space industry utilizes lithium hydride to absorb carbon dioxide. The reactions that occur with water produce hydrogen and lithium hydroxide which cause thermal and alkaline injuries.

Oxidants

Oxidants include bleach, peroxides, and chromates. Peroxides are key elements in hair dyes while chromates are components of industrial chemicals in tanning, painting, and printing. In fact, chromates cause significant skin injuries and systemic toxicity such as kidney failure.

Other

Phosphorous is present in fireworks, munitions, and fertilizer. Moreover, when these products explode, phosphorous residue remains on the skin and smolder [3]. Other potentially hazardous materials are hair dyes [4] as they may burn the scalp.

Chemical warfare products such as sulfur and nitrogen mustards are blistering agents.

Epidemiology

The emergency department frequently treats chemical injuries, and almost 5% of patients are admitted [5]. While the number of burns previously declined, it has been constantly steady since 2000.

Corrosive substances are used worldwide in aggressive situations. Furthermore, the likely victims of chemical assaults are women [6].

Sex distribution
Age distribution

Pathophysiology

The pathogenic mechanisms differ in accordance to the type of offending substance.

Acids

This chemical causes coagulation necrosis through the denaturation of proteins. Furthermore, this injury develops a coagulum that restricts the penetration of the agent.

One exception is hydrofluoric acid, which produces a liquefaction necrosis.

Bases

These agents lead to liquefaction necrosis, which is a more significant injury. In addition to protein denaturation, fat saponification occurs as well. Moreover, penetration of tissue is permitted.

Factors related to severity

The pH, concentration, and volume of the chemical, as well as the duration of exposure, play a role in the degree of severity of the burn. Additionally, the site and method of contact, the type of chemical, and length of time to washing also influence the damage. For example, the consumption of solid form of alkaline products leads to increased length of contact time in the gastrointestinal tract. This is correlated with serious destruction. Similarly, concentrated products that are diluted or neutralized will develop heat and yield thermal and caustic damage.

Prevention

Preventive measures include wearing protective clothing on the body and eyes when handling chemicals. Additionally, everyone should follow safety precautions and directions. Finally, all chemical agents should be secured out of the reach of children.

Summary

A burn is a damage or an injury to the human tissue that occurs due to electricity, chemicals, heat, friction or various other factors. Chemical burns can result from various irritants such as acids, bases, and oxidants, all of which can be found in home products as well as products used in workplaces such as manufacturing plants. Since cleaners, disinfectants, fertilizers, laboratory products, and bleach all contain toxic substances, there is potential for accidental injuries.

The overall clinical picture of the burn depends on the chemical to which the exposure occurred. Furthermore, the factors that determine the extent of the tissue damage are the pH, concentration, and volume of the agent as well as the duration and method of contact. While some burns are minor, others may be so severe that systemic toxicity ensues.

The clinician should perform a thorough physical exam to identify the amount of body surface that is harmed as well as the depth of the tissue destruction. Also, the medical team should ascertain what the offending agent is if possible as this can guide the appropriate workup and treatment. If the chemical was ingested, then an esophagoscopy and a gastroscopy are warranted.

Regarding the first aid response, immediate removal of the contaminated clothing and washing of the affected sites are essential. Critically ill patients will need immediate medical attention and stabilization. Also, wound care, pain management, and other treatments may be indicated.

Regarding prevention, precautionary measures include following proper guidelines and wearing protective clothing when handling chemicals.

Patient Information

When a chemical comes in contact with the skin or eyes, this may cause a burn. These types of injuries may occur through accidental exposures with toxic products at home or in the workplace. Examples of the latter include chemical plants, pool maintenance, mining, fertilizer manufacturing, and the aerospace industry since all use heavy chemical and toxins. Therefore, employees in these professions are at risk for accidents and injuries.

The following toxic agents are used in various products:

  • Bleach
  • Ammonia
  • Silver nitrate
  • Hydrochloric acid
  • Sulfuric acid
  • Phosphoric acid
  • Acetic acid
  • Calcium hydroxide
  • Sulfur mustard
  • Vesicants

Skin burns exhibit the following:

In seriousness cases, the symptoms are:

How are burns diagnosed?

The medical team will evaluate the extent and depth of the burns. In severe cases, the team will need to stabilize the patient. Also, they will obtain blood tests. If the chemical was ingested, then an esophagoscopy and gastroscopy are performed.

The symptoms depend on the chemical, the amount, the concentration, how long the skin was exposed to it, and whether the exposure was through skin contact or ingestion.

The burn is classified as a first, second, or third-degree depending on which layers of the skin are involved. Also important is the percentage of the body surface affected by the burn.

What is the treatment?

The treatment consists of pain management which can be achieved with over-the-counter analgesics such as acetaminophen. Also, antibiotics may be necessary. In severe cases, the patient may need skin grafting and other appropriate care and management.

How can burns be prevented?

All products and chemicals should be placed out of the reach of children. Additionally, everyone should follow the instructions when using these products. Finally, protective clothing and eye gear should be worn when handling chemical substances.

References

Article

  1. Ramasamy K, Gumaste VV. Corrosive ingestion in adults. J Clin Gastroenterol. 2003; 37(2):119-24.
  2. Gorman RL, Khin-Maung-Gyi MT, Klein-Schwartz W, et al. Initial symptoms as predictors of esophageal injury in alkaline corrosive ingestions. Am J Emerg Med 1992; 10(3):189-94.
  3. Barillo DJ, Cancio LC, Goodwin CW. Treatment of white phosphorus and other chemical burn injuries at one burn center over a 51-year period. Burns. 2004; 30(5):448-52.
  4. Maguina P, Shah-Khan M, An G, et al. Chemical scalp burns after hair highlights. J Burn Care Res. 2007; 28(2):361-3.
  5. Taira BR, Singer AJ, Thode HC, et al. Burns in the Emergency Department: A National Perspective. J Emerg Med. 2010; 39(1):1-5.
  6. Mannan A, Ghani S, Clarke A, et al. Cases of chemical assault worldwide: a literature review. Burns. 2007; 33(2):149-54.
  7. Leonard LG, Scheulen JJ, Munster AM. Chemical burns: effect of prompt first aid. J Trauma. 1982; 22(5):420-3.
  8. Bertolini JC. Hydrofluoric acid: a review of toxicity. J Emerg Med. 1992; 10(2): 163-8.
  9. Friedman EM, Lovejoy FH. The emergency management of caustic ingestions. Emerg Med Clin North Am. 1984; 2(1):77-86.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2019-07-11 22:11