Chemical BurnsChemical Burns
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Chemical BurnsChemical Burns
Epidemiology 60,000 patients/yr in US 2-6% of burn unit admissions
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
ClassificationClassification
Alkalis Sodium/potassium/ammonium/lithium/barium/
calcium: hydroxide or carbonate. Oven cleaners,drain cleaners, fertilizer (lime),
industrial cleaners, cement Mechanism:
Liquefactive necrosis & protein denaturization Promotes deeper spread of chemical and more severe
burns
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
ClassificationClassification
Acids: Hydrochloric, Oxalic, Hydrofluoric, Muriatic, Sulfuric
acids Cleaners, rust removers, pool acidifiers, drain cleaners. Mechanism:
Coagulative necrosis and protein precipitation Limits depth of tissue damage (HF acid is an exception)
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
ClassificationClassification
Organic compounds: Phenols, Creosote, petroleum products (gasoline,
diesel, varsol, turpentine) Mechanism:
Saponification of lipids and systemic toxicity due to lipophilicity
Cell membrane solvent action liver and kidney toxicity
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Factors Determining SeverityFactors Determining Severity
Agent Concentration (depth) Volume (TBSA exposed) Duration of contact Mechanism of action of agent
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
TreatmentTreatment
Universal precautions Protect yourself first Gloves, gown, eye protection Remove offending agent
DO NOT ATTEMPT TO NEUTRALIZE pH
ABCDE, Primary and Secondary Surveys Identify active agent
Poison control centre
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
ALKALISALKALIS
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
AlkalisAlkalis
Slippery feel due to saponification of lipids in skin.
Liquefactive necrosis Treatment:
Irrigate copiously Supportive care ABC’s
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Eye Injury Eye Injury
Frequently caused by alkali 2x more common than acid
injury to eye Young adults Occur at home, industrial
workplace, assault Swelling/spasm of eyelid Tx: flush with saline catheter
or Morgan lens until Opthalmologist arrives 10% potassium ascorbate drops Oral Ascorbic acid to ↓
inflammatory cell release and collagenase activityDr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Ammonia (gas or liquid)Ammonia (gas or liquid)
Fertilizer or industrial refrigerant Used in manufacture of illicit methamphetamine Strong base with penetrating odour Signs and symptoms of exposure:
Blistering of skin, pneumonitis, uveitis Eye injuries common
Tx: Copious irrigation with water Optho consult for eye wounds; may need
ventilator support for severe inhalation injuriesDr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Bleach (hypochlorite)Bleach (hypochlorite)
5% Na or Ca hypochlorite Strong base Common in suicidal
attempt May release chlorine gas
when mixed with acid Toxic to mucous
membranes Respiratory compromise
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
CementCement
Contains ~60% Ca02
Reacts with water to release CaOH (alkali)
pH >12 Short contact with irrigation may
cause contact dermatitis Prolonged contacts (2-6 hrs) can
cause full thickness burns May have solidified cement in
woundsDr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Sodium HydroxideSodium Hydroxide
Commonest cause of civilian burns Hydroxyl ion produces saponification & liquefaction
necrosis Insidious, full thickness injury Intense irritation of skin, mucous membranes, glottic
edema and rapid asphyxia; vomiting can cause rupture Tx: immediate copious irrigation with water for 12-24
hours Endpoint: Significant reduction in pain and normal pH
(test with pH paper)Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Sodium, Potassium, Magnesium MetalsSodium, Potassium, Magnesium Metals
Produce chemical and thermal injuries Highly reactive metals when in contact with air or
water Tx: fire extinguisher for flames; cover remaining
particles in oil to prevent water or air contact
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
ACIDSACIDS
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Sulphuric AcidSulphuric Acid
Second commonest cause of chemical burns
Car batteries Very strong acid Severe injury Upper and lower airway
injury possible Irrigate x 2 h Graft when necessary
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Hydrochloric AcidHydrochloric Acid
Immediate discomfort Slower and deeper reaction than sulfuric acid
More severe ulcers Muriatic acid = concentratedHydrochloric acid
Airway edema possible Tx: copious irrigation x 2h; sameas for sulfuric
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Hydrofluoric AcidHydrofluoric Acid
Common in industry glass etching, chrome plating, making Teflon, cleaning semiconductors, rust removers.
Weak acid Fluoride ion ++ toxic Severe pain Variable presentation depending concentration
Low concentration may have delayed pain onset High concentration = immediate pain
Hypocalcemia → DEATHDr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Hydrofluoric AcidHydrofluoric Acid
Mechanism of action: H+ ion causes the acid burn F- ion causes extensive local and systemic necrosis by
chelating positively charged ions (e.g. Ca2+, Mg 2+) Efflux of intracellular Ca2+ with resultant cellular death
F- ion remains active until completely neutralized by the bivalent cations and penetrates bone
F- also inhibits Na-K ATPase and allows K+ efflux Electrolyte shifts at nerve endings thought to cause the
extreme pain associated with these burnsDr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Hydrofluoric AcidHydrofluoric Acid Treatment
Irrigate with water (1 minute) Topical Calcium gel
1 amp Ca gluconate in 100g MukoInvolved hand placed in glove containing Ca
gelDigital block and nail removal if nailbed
involved Injectable CaGluc 10%
0.5 ml/cm2 tissue injected intra/sub dermally Inta-arterial CaGluconate
Start invasive measures immediately if exposure to >40% HF
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Hydrofluoric AcidHydrofluoric Acid
Monitor blood Ca2+, Mg2+ q2h Cardiac monitoring, ECG
Prolonged QT interval Refractory when dysrhythmia develops Important to stay ahead of this with Ca++ infusions
Calcium gluconate intravenous infusion for treatment of hypocalcemia
NEVER USE CaCl- CORRISIVE
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
ORGANICSORGANICS
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Phenol (Carbolic Acid)Phenol (Carbolic Acid)
Acidic alcohol Coagulation necrosis of dermal proteins Paradoxical injury
Dilute penetrates deeper than concentrated DO NOT DILUTE WITH WATER
Copious irrigation with PEG or Etoh Dysrythmias, hepatitis, nephritis, cellular
respiratory inhibition, hypothermia
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Petroleum injuriesPetroleum injuries
Primarily gasoline and diesel Delipidation injury Full thickness injury that appears only partial
thickness Systemic toxicity – liver, kidneys
Develops in 6-24 hours post-exposure Can occur concurrently with lead toxicity if gasoline
contains tetraethyl lead Supportive care, no specific antidotes
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Halogenated hydrocarbonsHalogenated hydrocarbons
Solvent, paint strippers, cleaners Significant liver and kidney toxicity Defatting of skin may cause full thickness burns Methylene chloride metabolized to CO Dysrhythmias common
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Tar BurnsTar Burns
Contact burns Bitumen compound not absorbed and is not toxic Cool molten material with cold water
Stops burning process Cover adherent tar with petroleum-based ointment
to emulsify tar White petroleum jelly Mayonnaise (Dr. Parkhill!)
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Chemical Warfare AgentsChemical Warfare Agents
Vesicants Mustard gas – binds DNA & arrests cell function;
ARDS and bone marrow suppression Tx: clean skin with oil, then water, then SSD Intubate for airway compromise
Lewisite – organic arsenical, similar function to Mustard gas Tx: antidote – British Anti-Lewisite 2
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Chemical Warfare AgentsChemical Warfare Agents
Nerve agents Organophosphate acetylcholinesterase inhibitors
Sarine, Tabun Inactivate enzymes by phosphorylation and cause
excessive ACh production Bronchoconstriction and parasympathetic overactivity Tx: Antidotes
Sarine → Palidoxime Tabun → Obidoxine
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
Chemical Warfare Agents - PhosphorusChemical Warfare Agents - Phosphorus
Used In Weapons Hand Grenades Mortar Bombs Artillery Shells Fireworks
Burns Seen Mainly In Military Personnel Ignites In The Presence Of Air
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
PhosphorusPhosphorus
Burns When In Contact With Skin Progresses Until Agent Is Oxidized Or Starved Of
Oxygen By Bathing In Water Wounds
Extremely Painful Necrotic
Characteristic Smell Garlic
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
PhosphorusPhosphorus
Treatment Remove Clothing Irrigate With Saline or Water Transport To Specialized Unit
Cover Burns In Saline / Water Soaked Gauze
Specific Therapy Irrigate With 0.5% Copper Sulfate
• Forms Cupric Oxide - Impedes Oxidation
• Facilitates Location
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
PhosphorusPhosphorus
Treatment Ultraviolet Light
Fluoresces Embedded Particles
Electrolyte Disturbances Even With Small Burn Hypocalcemia And Hyperphosphatemia Cardiac Arrythmias
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
THANK YOUTHANK YOUBurns Helpline 27793333Burns Helpline 27793333
Dr. Sunil Keswani, National Burns Centre, www.burns-india.com, [email protected]
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