To avoid personal contact with the chemical and further complications, the health care provider or decontamination team members must wear gloves, eye, and protective clothing (PPE), or military Mission-Oriented Protective Posture, MOPP (gear) level - 4
Wound Care:
Following copiously irrigating the wound with water, burns should be debrided gently. Burn wound care is similar to that of other burns. The appearance of the burn is superficial, but the extent of tissue destruction becomes evident several hours or days later.
Severity of a chemical injury is related to:
• Agent (type of chemical)
• Concentration
• Volume
• Duration of exposure
Contact with strong acids or bases:
There are several common household and/or industrial cleaning chemicals (bleach and ammonia). Preventing upper airway irritation or edema that may cause respiratory complications is also important.
Remember:
• The victim may be unaware
• Sometimes the wounds may appear superficial
• Progressive damage occurs until the agent is removed
(avoid delays in care)
• Remove all clothing from the patient when is and prevent • Avoid personal contact with the chemical, use PPE.
Acidic chemicals are generally less destructive than bases.
• Usually has a pH < 2.0
• Causes coagulation (cell death) necrosis
• Dark leathery skin texture (full thickness)
• Damage will continue until neutralized
• Should be irrigated with running water to dilute the chemicals to skin pH of 7.0 (use pH [pHydrion] paper, if pH paper is not available and when in doubt irrigate continuously for at least 1 - 4 hours)
• May take several hours to have a skin pH of 7.0 or until pain or burning has decreased
Formic Acid:
• Organic acid used in industry and agriculture, can cause full-thickness chemical bums, systemic toxicity, this acid will cause acidosis
• Copious water irrigation is effective in removing surface accumulations.
Hydrochloric Acid: (HCl)
• Industrial corrosive acid at contact; forms a white or gray-brown eschar.
• Vapor stage can cause airway irritation, edema • Burns should be copiously irrigated with water.
Hydrofluoric Acid: (HF)
• Found in computer chips, solvents, paint remover
• Cause airway edema and respiratory distress
• Can cause ventricular fibrillation, tachycardia and cardiac death!
• Rapid Absorption through skin toxicity resulting in protein coagulation and tissue destruction
• Fluoride ion binds to the tissue components • Fluoride activity ceases when combined with calcium or magnesium to produce an insoluble salt
• Progressive tissue destruction with deep pain and edema can damage tendons if in direct contact.
Recommended Treatment: (Hydrofluoric Acid)
1st - Copious irrigation with water
2nd - Topical Calcium Gluconate gel apply to affected area (2.5 gm in 100 ml water-soluble lubricant, K-Y jelly)
3rd - Dermal injection of 10% Calcium Gluconate solution to affected area, use #27-30 gage needle)
4th - Intravenous 10 ml of 10% Calcium Gluconate diluted 40 ml D5W over 4 hours.
5th - Evacuate patient to a Burn Center. Successful treatment = no pain!
Nitric Acid:
• Industrial acid highly corrosive and causes a yellow eschar.
• Burns should be copiously irrigated with water.
Oxalic Acid:
• Skin and mucosa may show white painful lesions
• Calcium Gluconate should injected (locally and IV)
• Burns must be copiously irrigated with water.
Phenol:
• Highly corrosive acid that causes coagulation necrosis (cell death) and forms a firm thickened light gray or light brown eschar.
• The wound surface appears dry with well define borders.
• Flushing with small amounts of water can increase tissue destruction, it is recommended to flush with copious amounts of water until the smell of Phenol on the wound disappears.
• Cresol is common in several household cleaning products may produce some toxic effects of Phenol.
• Burns must be copiously irrigated with water. Toxic affects: (Phenol)
• Depression of CNS, seizures and coma may occurs within minutes may be delayed up to 18 hours after exposure.
• Hypothermia
• Acute tubular necrosis
• Cardiac arrythmias and pulmonary edema
Sulfuric Acid:
• Is a strong dehydrating acid that produces severe pain due to the extensive heat when in contact with water and the amount used. It extends into subcutaneous tissue and causes a deep dry black or brown eschar.
• Burns must be copiously irrigated with water.
Alkaline (basic) chemicals bind to tissue and are difficult to remove, in general, they cause more severe damage than acids. Liquefaction necrosis occurs due to the heat produced and this can cause further damage of the deeper tissues. Burns may appear superficial in early stages, and the depth of burn is sometimes underestimated. Third degree burns in the early stage are invasive and require long periods of water irrigation (several hours).
- Usually has a pH > 11.0.
- Edema is very noticeable
- Prone for wound sepsis
Ammonia:
• Ammonia dissolved in water forming ammonia hydroxide an alkaline corrosive solution
• Ammonia is common in several industrial and household-cleaning products used daily. It is an irritant gas, which will produce airway edema and some toxic effects and may cause death by laryngospasm, respiratory distress, and asphyxia
Irrigation
• Water or Saline irrigation is the treatment of choice
• Must be irrigated with copious running water to dilute the chemicals to skin pH of 7.0. use pH (pHydrion) paper. If pH paper is not available and when in doubt irrigate continuously for at least 4 to5 hours).
• May take up to 12 hours to have a skin pH of 7.0 or until pain or burning has decreased.
OTHER CHEMICALS BURNS:
Cement:
• Wet cement will cause a chemical burn.
• pH of cement is >12
• Injuries are not recognized many hours later
Hydrocarbons: (Not flames burns)
• Gasoline bums caused by motor vehicle accidents and/or spills, is evident within 4-6 hours
• Cause chemical pneumonitis and bronchitis, tetraethyl lead in gasoline can cause liver disease
• May cause renal and hepatic failure.
Tar:
• Bums caused by hot liquid tar 400–500 ºF, it sticks to the skin
• Hot tar causes thermal deep injury, 2nd & 3rd degree burns
• Removing hot tar may increase the severity of the injury. Treatment: (Tar)
• Rapid cooling of the area
• Removal of the tar by Petroleum-based ointment to solubilize it making easily removal (use of mineral oil is recommended, mayonnaise could be use if mineral oil is NOT available).
White Phosphorus:
Commonly used in incendiary military munitions, fireworks and in agricultures fertilizers.
• When spontaneous oxidations occurs, the phosphorus ignites a yellow flame and white smoke given a classic garlic smell.
• Particles in the clothing may ignite/explosive causing large burns. Recommended Treatment: (White Phosphorus)
• Brushing off the powder first
• Irrigate with copious running water (it will prevent aggravation of the burn caused by the heat produced by lime/water contact)
• Covering the wound with water or saline-soaked dressings.
• Phosphorus is fluorescent and visible under ultraviolet light (wood’s light).
Ocular Injuries:
• Immediate and copious lavage of chemically injured eyes with water or saline solution (Morgan catheter placed over the eye for irrigation)
• Irrigation by everting the eyelids is recommended
• Alkaline injuries often cause scar formation on the cornea
CHEMICAL WARFARE
As the intensity of combat operations varies, including acts of terrorism health care personnel should be prepared for: triage, initial medical care, and the evacuation to a burn center must be planned for the thousands of burned and injured patients.
Precautions and Protective Devices:
• Special precautions should be taken by chemical Hazmat team
• When initial decontamination of the patient is in process the attendants should wear a military MOPP-4 and a butyl rubber gloves and apron.
VESICANTS: Mustard is an oily liquid colorless (pure) to dark brown colored. That smells like garlic, mustard, or horseradish. The hazard form from mustard vapor or liquid depends on the degree of contamination. There is no pain at initial contact.
• ABC’s are the PRIORITY!!
• Decontaminate with the M291 SDK
• Maintain a patent and open airway at all times
• Remove all contaminated clothing
• If M291 SDK is not available may use 0.5 chlorine solution for decontamination of skin and scalp (within 3-4 minutes)
• The therapy and treatment is similar as for the thermal burns.
• Examine the cornea for possible lesions with fluorescein solution, carefully irrigate with a 0.9% sterile saline solution (Morgan catheter may be placed over the glove for irrigation)
Water/Soap Wash:
Both fresh water and sea water have the capacity to remove chemical agents
Lewisite: Blister Agent
• Immediate deep skin burns and blisters within 12 hours with pain and itching lasting 2-3 days.
• Severe Edema of the burned extremities
• Lung edema, nasal secretions and sneezing.
• Systemic poison causing restlessness, weakness, subnormal temperature, and low blood pressure. Recommended Treatment: (Blister Agent) Protective Gloves: military MOPP-4, Butyl Rubber gloves and apron • The primary mode for decontamination of chemical agents is the M291 SDK (skin decontaminating kit)
• Soap and water.
• 0.5% Hypochlorite solution can be used.
Nuclear Radiation:
• The effects are due to radiation, blast (trauma), and thermal burn injuries. • Extremely high temperatures are produced by nuclear explosion.
• The energy released travels at the speed of light causing severe burns at large distances. During initial triage after a traumatic mass casualty event (military war operations, civilian crises, or acts of terrorism) a Burn Center should be contacted to coordinate initial care and adequate fluid resuscitation to prevent complications during transport and aeromedical evacuation of the patients (see evacuation/ burn initial assessment chapters) These patients will have high morbidity and mortality due to under fluid resuscitation, respiratory distress, primary infection, possible leukopenia, and complications due to chemical warfare.