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Home , Chemical burn, Liquefactive necrosis

CLINICAL

Cutaneous chemical : assessment and early management

Neiraja Gnaneswaran, Eshini Perera, Marlon Perera, Raja Sawhney

Background urns are a common trauma that affects up to 1% of the Australian population and may be associated with Chemical burns are common and may cause significant B significant physical, psychological, social and economic physical, psychological, social and economic burden. Despite burden.1 Chemical burns represents 3–5% of all burns-associated a wide variety of potentially harmful chemicals, important admissions.2 Despite the small proportion, chemical burns general principals may be drawn in the assessment and initial account for 30% of burns-associated ,3,4 most commonly management of such . Early treatment of chemical burns occurring as a result of chemical ingestion. Given the nature is crucial and may reduce the period of resulting morbidity. of , hospitalisation tends to be prolonged and healing is Objective delayed. Many substances that are freely available in the community, This article reviews the assessment and management of either occupational or domestic items, have the potential to cause cutaneous chemical burns. chemical burns. The immediate availability and poor labelling of these substances has accounted for an increase in unintentional Discussion chemical burns. Assault and suicidal attempts account for the remaining cases of chemical burns. The affected population is Assessment of the patient should be rapid and occur in conjunction with early emergency management. Rapid history generally evenly distributed but an increase in paediatric chemical 5 and primary and secondary survey may be required to exclude burns has been previously documented. Areas affected tend systemic side effects of the injury. Depth of assessment to include the face, eyes and extremities. As such, the scope is difficult given that caused by various chemicals of this review is limited to the assessment and management can continue despite cessation of exposure. Early management of cutaneous chemical burns. Ocular burns should be urgently should be conducted with consideration of clinician’s safety, referred to an appropriate ophthalmic service. and appropriate precautions should be taken. Excluding More than 25,000 chemicals are used commonly in industrial specific situations and chemical exposure, copious irrigation and domestic settings. The diversity of harmful chemicals results with water remains the mainstay of early management. in a vast array of clinical sequelae and a short review would not Referral to a centre of higher acuity may be required for expert suitably cover the relevant treatments. The current publication evaluation. is aimed to provide principals in the assessment and general management of chemical burns. Keywords Pathophysiology and types of chemicals burns, chemical; and injuries; skin The pathological end result of chemical burns, regardless of the type of chemical, is consistent with changes occurring during thermal burns. The external toxic stimulus causes denaturation of biological proteins and thus renders them physiologically

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inactive. This inactivation of essential results in disruption of physiological or solid), concentration, quantity, proteins results in . Thermal processes. duration of cutaneous contact, extent burns tend to cause rapid coagulation • Inorganic solutions: cause injury by of penetration and initial emergency of protein due to protein crosslinking. denaturation mechanisms as outlined management.7 By contrast, chemical burns cause above. denaturation of physiological proteins General prinicples of through six different processes including Assessment management reduction, oxidation, , vesication, 1. Personal protection equipment: it is After primary survey and initial rapid dessication and protoplasmic poisoning.6,7 vital that the treating clinician wears assessment, the following care outlines It should be noted that many chemicals protective clothing to prevent injury the general principles for managing acute cause injury through combinations of (eg gloves, safety googles). chemical burns.11 these processes. 2. Primary and secondary survey: as with 1. Removal of the chemical: the duration Chemical agents can also be classified any clinical presentation, the patient of skin contact is the key determinant on the basis of the induced chemical must be stabilised using principals of injury severity.12,13 Thus, prompt reaction that the agent initiates. of primary survey. This should be removal of chemical contact is Such classification may be useful for completed in a rapid and systematic mandatory. consideration of early management approach. a. This should be performed rapidly options. Chemical agents may be a. Airways: ingestion of chemicals, and generally requires removal of classified into one of these categories particularly alkali agents, may contaminated clothing at the scene despite slight variations in the resulting result in upper airways obstruction. of injury.14 Initially, residues or dust clinical sequelae. Stabilisation of airways and urgent should be brushed off the skin. • : act as proton donors in the medical support is required. b. Irrigation should then be performed biological system. injury causes a b. Breathing: special considerations with warm water under a tap with of the superficial during chemical injury include the appropriate drainage to prevent tissue. exclusion of inhalation injuries, further injury. Care should be • Bases: chemicals are proton acceptors particularly for aerosol chemicals or taken to ensure the wash off does and tend to have greater capability smoke.10 Such patients frequently not occur across unaffected skin. of producing injury.7, 8 These agents require ventilatory support and thus Early irrigation dilutes the chemical produce heat via reactions with fats, early referral should be sought prior concentration and has been shown extract water from surrounding tissue to clinical deterioration. to reduce the severity of the and result in liquefactive necrosis c. Circulation: smaller chemical burns and hospital stay.8 No objective (Figure 1). Such necrosis allows infrequently cause cardiovascular measure for appropriate irrigation penetration deep to the superficial collapse. Occasionally, severe has been defined in the literature wound and continues to cause injury metabolic disturbances may result but it is widely accepted that 0.5–2 despite initial removal of the insult.9 from chemical absorption and thus hours may be required to maintain a • Organic solutions: cause injury by monitoring and stabilisation may be cutaneous pH of 5–11.10 dissolving the lipid membrane, which required. c. Neutralisation of chemicals is 3. History: a rapid history should contentious but is generally not be taken simultaneously during indicated because of the risk of primary survey and initial care of further heat production and thus the cutaneous burn. It is vital that continuing injury. Several neutralising such assessment does not delay the agents have shown some benefit,9 initiation of immediate treatment. but irrigation with plain water Information regarding comorbidities remains the most efficacious, and medication may be useful. accessible and cost-effective Information regarding the chemical treatment.12,15–17 injury is important, particularly if the 2. Complete wound evaluation: the patient requires transfer to a higher microcirculation of the wound acuity service. Pertinent information is evaluated by pinprick test for includes: insulting agent (and the pain and capillary return time.18,19 Figure 1. Severe liquefactive necrosis secondary to exposure of alkaline chemical associated mechanism of injury), Assessment regarding the depth phase of the chemical (gas, liquid of the chemical burn is notoriously

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difficult, as burns may be deceptively a. Metabolic disturbances: the most physician, referral to secondary or superficial.11,20 The difference in surface common disturbance is acid- tertiary centres is required for formal temperature between the affected and imbalance. Monitoring blood gases assessment by specialist services. unaffected skin may assist in depth through venous sampling may be Full-thickness chemical burns may assessment.18,19 Re-assessment should necessary to ensure metabolic require admission for surgical be done at regular intervals as this stability.10,22 debridement and grafting of non- may provide information about injury b. Electrolyte disturbances and viable tissue. progression. As a general rule, unless associated sequel: various chemicals b. Ocular chemical injury is beyond the the observer can be absolutely sure, may cause biochemical disturbances. scope of this review, but generally chemical burns should be considered As such, patients may require requires urgent ophthalmic review. deep dermal of full-thickness until biochemical analysis on admission to proven otherwise. higher acuity centres. For example, Specific agents a. Chemicals causing liquefactive hydrofluoric acid (HFA) may cause Management of specific chemical agents necrosis, typically basic solutions, hypocalcaemia and resulting cardiac is complex and is generally advised in may cause continuing necrosis arrhythmia. the emergency department following dispute removal of agent. Caution c. Hypothermia: may occur from early management. Current Australian should be practised in such situations the prolonged duration of wound guidelines have been previously and expert opinion may be required. lavage. Water temperature should published.23 Table 1 outlines common b. Debridement of and non- be maintained as close to body domestic products and the harmful agents viable tissue is advocated as early as temperature as possible.10 they contain, with more comprehensive possible via surgical or non-surgical 4. Referral: Given the difficulty in lists easily accessible online. approaches.7,21 assessing injury extent and depth, • Cement: is a common cause of 3. Systemic toxicity: the insulting caution is generally advised. Chemical chemical burns. The main injury-causing chemical injury or subsequent burns should be treated as full- agent in wet cement is calcium oxide treatment may produce systemic thickness burns until proven otherwise. and resulting hydroxyl ion.15 Cement changes that require assessment and a. Unless full thickness burns can be has multiple mechanisms of action, intervention. explicitly excluded by the treating but predominantly can be classed as an alkali. Injury is insidious, usually presenting several hours after injury.24 Table 1. Common domestic agents and mechanism of injury Copious irrigation and periodic wound assessment should be performed to Domestic item Chemical agent Pathological process exclude the requirement of surgical In the garage debridement.25 • Tar: in liquid form, tar is superheated Batteries (car) • Sulphuric acid Potent acid causing coagulative necrosis and classically causes deep thermal and chemical burns. If not removed In the laundry promptly, tar cools and causes Cleaners • Potent alkali causing oxidization liquefactive necrosis and adheres • Sodium hypochlorite and liquefactive necrosis to skin. Adherent tar should not be Bleach • Sodium hypochlorite As previous removed in the pre-hospital setting and urgent referral is required as surgical Pool cleaner • Sodium hypochlorite As previous debridement may be necessary. Various In the kitchen household items such as baby oil, Oven cleaners • Sodium (or potassium) Potent alkali causing oxidation and mineral oils and butter may aid in tar hydroxide production of heat (exothermic) removal.7,26 In the bathroom • Hydrocholoric and sulphuric acids: burns caused by these agents are among the Toilet cleaner • Precursors of sulohuric acid Potent acids and alkalis as most commonly treated chemical burns. • Hypochlorite previous • Hydrochloric acid Common household goods contain moderate concentrations of such agents Drain cleaner • Sulphuric acid Potent acids and alkalis as or their immediate precursors. On • previous contact, these agents donate protons

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and cause coagulative necrosis of the component is a metabolic toxin affecting Copious irrigation should be performed affected tissue.27,28 Immediate irrigation nerve transmission.33 Haemodialysis and the patient should be transported is recommended. Excision of non-viable and cation exchange resins have been with a wet towel covering the injury. tissue should be considered early in the reported for removal of absorbed Systemic consequences including course of injury.6,10 fluoride.33,34 Copious irrigation and early hypocalcaemia, hyperphosphataemia • HFA: a large proportion of the population referral are essential. Inactivation of and cardiac arrhythmia have been is at risk from HFA given its widespread the fluoride ion is necessary by topical previously reported.35 use in the household setting. HFA preparations (eg quaternary ammonium • Alkali: act as proton acceptors and has the potential to cause significant products or calcium gels) or infiltrative classically cause progressing injury local and systemic effects despite a preparations (eg calcium gluconate). despite the removal of the harmful small contact wound.10 The onset of • Phosphoric acids: such chemicals are agent. As discussed above, alkalis local effects are dependent on the found in fertilisers and explosives, thus cause liquefactive necrosis, allowing concentration of the HFA.29 The injury generally causing injury in the industrial progression to deeper tissues. caused by HFA causes liquefactive setting. White phosphorus ignites in the Initially alkali burns seem superficial, necrosis and causes interruption in the presence of oxygen and thus immediate but may progress to full thickness surrounding cellular physiology. The removal is necessary. Particles may be within 48–72 hours.36 Brushing of injury results in hypocalcaemia and identified with the aid of ultraviolet light residues and irrigation provides early hypophosphataemia30–32 and, potentially, or 0.5% copper sulphate solution and control.10 Referral to a centre of higher cardiac arrhythmia. The fluoride should be removed from the wound. acuity and consideration for wound

Personal protection Primary and secondary --Protective equipment survey including gloves, --Assess airway, breathing, googles circulation

Notify emergency Early management Rapid assessment services --Remove solid debris, --Assess agent --Support compromised carefully brush if (concentration, phase Compromised system until necessary and amount), location of emergency services burn, duration of insult --Copius irrigation 30 to arrive 120 mins as necessary

Systemic evaluation Stable Referral to centre Wound evaluation --Consider metabolic, of higher acuity for electrolyte and further assessment --Assess microcirculation thermostatic disturbances and sensation to gauge as potential sequele of depth injury or treatment --Treat as full thickness --Normal primary, until proven otherwise secondary and systemic evaluation --Wound; full thickness Complete early explicity excluded, management burns <1% of BSA, --Complete early no vital regions management and treat as injured (ie. face, eyes, Figure 2. Algorithm for the outpatient genitalia assessment and early management for acute cutaneous chemical burns

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