Chemical Burns

Chemical Burns –
Epidemiology
• 2.5-4% of all burn admission
• Male >> female, adults
• Industrial chemicals
• Chemical stored in households
• Military injuries
• Criminal assault
 Chemical Burns -
Pathophysiology

• As in thermal burns involves protein

denaturation
• Injury contnues as long as chemical exists
in tissue
• Chemical nature determines damage
• The concentration and time of exposure has
a crutial role
 Chemical Burns –
Mechanisms of Action
• Reduction
• Oxigenation
• Corrosive
• Protoplasmic poison
• Desiccants
• Vesicants
 Chemical Burns - Management

• Tend to be deeper than appear at first

• Usually not very wide (< 10% TBSA)
• Thick eschar
• Heal more slowly- hospital stay +30%
 Chemical Burns –
Emergency Care
• Remove immediately all clothing
• Dilution - copius water irrigation
– Drain first lavage fluid
– Moniter lavage fluid pH (if possible)
• Identify assaulting chemical
• Specific neutralizing solutions
 Chemical Burns –
Emergency Care
• Metabolic monitoring and
support -ABG’s and
electrolytes
• Airway management,
oxygenation amd
ventilation
• Analgesia
• Hypothermia
 Chemical Burns - Management

• Tangential excision + STSG after extent is

obvious
• Excision and primary closure of trickling
• Enzymatic or laser debridement
Chemical Burns - Classes

• Acids
• Bases
• Organic compounds
• Inorganic agents
 Chemical Burns – Acids
• Tungstic, picric, sulfosalycylic, trichloric
– renal and hepatic damage
• Oxalic acid – lethal at 0.5 gr/kg
– Apply Ca salts to site
– Iv Ca-gluconate/chloride if systemic Ca2+
• Sulfuric acid – release heat, black eschar
– Limited yet deep  excision +STSG
 Chemical Burns –
Hydroflouric Acid
• Silica dissolvent, petrollium,
semiconductors
• Dehydration and corrosion as
an acid
• F- entrap Ca2+ and Mg2+
• Concentration dependent
 Chemical Burns –
Hydroflouric Acid
• Local - necrosis and bone decalcification
• PAINFULL
• Systemic – hypocalcemia,
hypomagnesemia, hyperkalemia
• Cardiac arrhythmias – refractory VF
 Chemical Burns –
Hydroflouric Acid
Treatment
• Topical and local injections of Ca-gluconate
• Cardiac monitoring, frequent elctrolyte
evaluation
• Dialysis
 Chemical Burns –
Hydroflouric Acid
Specific injuries
• Hand – radial artery administration Ca-
gluconate
• Eye – immediate NS irrigation, Ca-
gluconate q2-3h
• Inhalation – Ca-gluconate inhalation,
C-PAP, steroids
 Chemical Burns - Alkali
• NaOH, KOH, Lime
• Mechanism
– Fat saponification
– Hygroscopic qualities
– Alkaline proteinates Further reactions
• Rapid dry eschar formation
• Ocular damage – topical anasthesia,
cycloplegia, Abx , cysteine, topical steroids
 Chemical Burns - Cement

• Alkali
• Anterior leg
• Abrasive if mixed with gravel or
sand
• Exothermic
• Hygroscopic
• Painless
 Chemicl Burns - Assault
• Male 70-80 %, 30’s
• Usually sex partner
• Facial and genital injuries
• Cheap household chemicals
(lye, sulfuric acid)
• Almost never adequate
lavage
 Chemical Burns –
Organic Compounds
Petrolium
• superfacial burns, heal spontaniously
• Fluid resuscitation - Parkland
• Acute renal failure –dehydration + direct
tubuloglomerular damage
• Lung injury from petrolium fumes,
surfactant production inhibited
 Chemical Burns –
Organic Compounds
Phenol
• Dermatits, depigmentation, necrosis
• Acts as local anasthetic
• Local treatment - water, PEG, soap, oil
• Albumin bound
• Cardiac arrhythmias, hemolysis
 Chemical Burns-
Chrome Deriviates
• Chromic acid, chromic salts
• Yellow coagulum , blisters, ulceration
• VERY toxic : gastritis, muscle cramps,
vertigo, vascular collapse,nephritis coma
• Acid – buffered phosphate rinse,
demercaprol IM injection
• Salt - 2% hyposulfite or buffer phosphate
 Chemical Burns - Phosphorus
• Military, fireworks, farmers
• Ignites in contact with air
• Painful, necrotic, yellowish, garlic odor
• Water soaked dressing + CuSO4 0.5%
irrigation
• Hypocalcemia, hyperphosphatemia, ECG
changes, arrhythmias
 Chemical Burns - Vesicants
Nitrogen/sulfur mustard, Lewisite
• Immediate – ocular and throat burning
• 4-48 hrs – erythema, blistering, pruritus,
ulcers
• Days – Bone marrow suppression, GI, CNS,
pneumonits, superimposed infection
• Late - Respiratory mucosal injury, recurrent
corneal ulceration and chronic conjunctivits
Chemical Burns - Vesicants
 Chemical Burns – Mustard Gas
• Lipophilic but activated in aqueous
solution
• 12-50% react in the skin
• Alkylation of DNA, targeted at TAC
• Deplition of thiol oxidative stress
• Late hyperpigmentation
• Slowing wound healing process
 Chemical Burns - Vesicants
• Protective garments
• Eye - NS or 1.26% bicarbonate
• Debride blisters + antimicrobial ointment
• Lewisite burns – topical chelator
dimercaprol/DMSA
• Deep ulcers Tx as thermal injury
• Fluid replacement, electrolyte management,
G-CSF
 Chemical Burns - Vesicants
• Topical skin protectants • Post contact
– Perflouroalkylpolyether – Vandillylate
(PFAPE) neropeptide inhibitors
– Polytetrafluoroethylene – Bimoclomol
(PTFE, teflon)
– Chloramide