Rajeev Venugopal

Aims

• Definition• Classification• Pathophysiology• Special Chemicals• General Management• Local Experience

Definition

• Transfer of potential energy from chemicalreactions, leading to tissue damage.

• The extent of injury is dependent on:– Nature of the agent– Duration of exposure– Concentration

Types of Burn

50%

30%

13%7%

FlameScaldChemicalElectrical

Causes of Burn

79%

4%

17%

AccidentalSelf InflictedAssault

Classification

• Acids: hydrochloric acid, sulfuric acids, chromicacid

• Alkalis: bleach, cement and hydroxidecompounds

• Poison Control Centers have the ability to list thecontents of household and industrial agents.

Pathophysiology

Acids

• Protein injury by hydrolysis

• Thermal injury is made with skin contact

Pathophysiology

Alkali

• Saponification of fat• Hygroscopic effect- dehydrates cells• Dissolves proteins by creation of alkaline

proteinates (hydroxide ions)

Pathophysiology

• Alkalis causes more damage than Acids

• Hydroxide ions causes much deeperpenetration

• Hydrolysis creates a hard eschar whichacts as a barrier

Pathophysiology

• Epidermis

• Dermis– Papillary– Reticular

• Subcutaneous tissue

Management

Prehospital Care

• Remove all clothing• WASH / IRRIGATE/ LAVAGE

– 15 to 20 L– Drain away the effluent– Monitoring pH

• Exception – Powders

Management

• Call The Poison Center to assess theneed for further intervention

• HAZMAT (Hazardous Material)– Contain the materials– Treat the patient

Management

• Neutralization is not recommended– Heat is generated which can potential cause

additional damage.

Management

• All burn patients should be managed astrauma victims.

• ATLS protocol - ABC

Management

Airway and Breathing

• Hydrochloric acid fumes can causepneumonitis

Management

Circulation

• Parklands formula– Percentage of Surface Area Burnt (BSA)– Weight in Kilograms (Wt)

– 4 X BSA X Wt.

Management

80% of assault chemical burns affect thehead and neck

Permanent ocular injury is a real riskIrrigation with normal saline aided with alocal anaestheticAssess corneal injuryOpthalmological consultOphthalmic antibiotic ointments

Management

• Hydrofluoric Acid– Calcium and Magnesium chelation

• Arrhythmias• Pain

– Treatment• 2.5% Calcium gluconate gel• 10% Calcium Gluconate intravenously• Intradermal and intrarterial Calcium gluconate

Management

• Formic Acid– Metabolic acid– Electrolyte disturbance– Haemolysis– Renal Failure– ARDS

Chemical Terrorism

Amyl NitriteSodium Nitrite

HydrogenCyanide

CyanideAgents

AtropineSarinNerveAgents

SupportiveCare

PhosgeneChokingAgents

HydrotherapyMustard gasesBlisteringAgents

Management

Surgical Options

Escharectomy

CoverageSkin graftsFlaps

Local Experience

• Jamaica held the highest incidence ofchemical assault.– Branday et al 1990 reported a 14% incidence.

• A review of admissions between 1999-2004 had a 10% incidence.

• Stricter penalties for assailants waspassed by the courts

Local Experience

• The aim is to disfigure the victim due to afailed relationship

– The burns involved head and neck in mostinstances followed by extremities

– Third of the patients also had ophthalmologicinvolvement

Local Experience

Local Experience

International Experience

• The current highest incidence of chemicalassault is in Uganda (17%).– Used as a weapon in robberies

• Sri Lanka has also a high incidence and issolely against females.

• Most other centers is secondary todomestic accidents

Case Presentation

• 38 year old male who had a dispute withcommon law wife.

• Poured a cleaning agent onto head whileasleep.

• No other significant medical history

• Showered at the scene

Case Presentation

• Transferred to Hospital where he had showeringand irrigation of eyes.

• The injuries affected 18% of Body Surface Area– The entire face including entire cornea bilaterally– The scalp except for the occipital region– The Anterior torso

Case Presentation

Case Presentation

• Noted to have significant renal dysfunction andsevere metabolic acidosis.

• Had escharotomy of the anterior torso and neckwith placement of temporary dialysis catheter.

• Opthamological care– Topical antibiotic– Artificial tears– Corneal chamber

Case Presentation

Case Presentation

• Had staged resurfacing of face and neckwith thick meshed skin grafts.

• Attempt at salvage of cornea with amnioticmembrane.

Case Presentation

Case Presentation

Case Presentation

• Developed ectropions in all four lids whichwas treated with release and full thicknessgrafting.

• The nasal region and scalp where allowedto demarcate.

Case Presentation

Case Presentation

Case Presentation

• Financial Cost

– In Patient Care : > $500000.00

– Productivity Costs

– Disability Costs

Conclusions

• Chemical burns continues to pose aserious problem to our society.

• Penalties must be reinforced

• Public Education