Chapter 10: Managing Effects of Corrosives

Corrosives such as acids and alkalis are widely used in industry.

The spectrum of these agents encountered in industry include

- Acids

- Alkalis

Examples: hydrofluoric acid, anhydrous ammonia, cement, phenol, white phosphorus, nitrates,
hydrocarbons and tar which could potentially cause chemical burns.

In exposures to corrosives chemicals, management generally involves

- Prompt wound irrigation and initial stabilization

- resuscitation of burns/corrosive injuries

- supportive care

Antidotes are generally not available for most corrosives except for a few, like hydrofluoric acid (HF).

Prehospital management

• Prompt wound irrigation is the most critical aspect in limiting the extent of dermal burns from
exposure to caustic substances. Studies have shown that irrigation of both acid exposures and
alkaline exposures within 10 minutes minutes decreases the pH change in the skin and the extent of
dermal injury.

• Remove contaminated clothes.

• Prevent and minimise contaminated irrigation solution from running onto unaffected skin.

• Special situations:

◦ Alkali metals: If contamination with metallic lithium, sodium, potassium, or magnesium has
occurred, irrigation with water may cause burns to worsen. In these situations, the area should be
covered with mineral oil and the metallic pieces should be removed with forceps and placed in
mineral oil. If forceps are not available, soak the area with mineral oil and cover it with gauze soaked
in mineral oil.

◦ White phosphorous: If contamination with white phosphorus has occurred, thoroughly irrigate the
area with water then cover the area with water-soaked gauze. Keep the area moist at all times. The
area can also be covered with petroleum jelly.

◦Phenol: Polyethylene glycol 300 or 400 and isopropyl alcohol have been recommended for the
removal of phenols and cresols. If skin damage has already occurred, isopropyl alcohol may be very
irritating. Polyethylene glycol should be diluted with water to form a 50:50 ratio prior to using.
However some studies showed that polyethylene glycol no more efficacious than copious water
irrigation for phenol exposures.
◦If eye exposures have not been irrigated, then this should be started immediately. Immediate
removal of caustic substances in the eye is critical.

Emergency Department Management

Thorough decontamination is key. The first priority in treatment is to ensure complete removal of
the offending agent.

If litmus paper is available, it can be used to check adequacy of irrigation by assessing the pH of the
affected area or the irrigating solution.

Complete removal and neutralization of concentrated acids and alkalis may require several hours of
irrigation. Tap water is adequate for irrigation. Low-pressure irrigation is desired; high pressures may
exacerbate the tissue injury.

• If a question of airway compromise exists, secure the airway.

•Large surface burns require the same fluid therapy as that for thermal burns and managed.

• After initial decontamination, the full extent of the injury must be ascertained and the patient
must be treated as a typical burn patient. Based on the degree of injury, ensure adequate fluid
resuscitation and take precautions to prevent acute complications (eg, hypothermia, rhabdomyolysis
and hyperkalaemia). Appropriate burns care to prevent secondary infection and tetanus prophylaxis
must be initiated post resuscitation.

• For severe dermal burns, consult a plastic surgeon or a burn service. Burns to the hands, face, or
perineum may require the appropriate specialties.

Special situations

In addition to the above prehospital section:

◦Hydrofluoric (HF) acid burns

 Pain may be out of proportion in hyodrofluoric acid skin burn lesions and may be
experienced in the lips, mucosa or throat if HF were inhaled or ingested.
 Airway obstruction, irritative airway symptoms or bronchospasm may occur in inhalation
injury.
 Moderate and severe HF burns are more likely to result in systemic toxicity and hence
identification of these casualties is critical in order to expedite decontamination and
administer antidotes promptly.
 Electrocardiogram (ECG) showing prolonged QT interval especially if not known to be pre-
existing in the patient’s old ECG record is highly suggestive of severe poisoning and require
intravenous calcium therapy and close cardiac monitoring.
 Initial management is similar with thorough irrigation and antidote administered.
 Antidote: Calcium Gluconate 10mls 10% solution
o Dose and administration: Calcium gluconate can be administered via the dermal,
oral, intravenous and inhalational route and this is largely determined by the route
of exposure as follows:
 Dermal exposures
 a. Calcium gluconate gel is available commercially but in situations
where it may be unavailable it can be prepared by mixing calcium gluconate
solution with a water soluble gel.
 b. Intradermal infiltration into the burns site.
 c. Intravenous (regional) and intra-arterial injection into the region of
the affected site.
o Inhalational exposure: Calcium gluconate can be nebulized by reconstituting 1 ml of
10% solution with 3 mls of normal saline.
o Oral ingestion: Calcium chewable tables, Antacids which are rich in calcium and
magnesium, Milk or dilution by drinking water can help reduce the toxicity of HF.
o If systemic toxicity is present or likely then intravenous calcium gluconate or calcium
chloride should be used and titrated to reduce the effects of hypocalcaemia and
hypomagnesaemia.
 Hand burns can be treated with subcutaneous injections of calcium, intra-arterial calcium
infusions, or intravenous infusions of magnesium. Keeping the hand warm and adequately
treating pain will help to increase local circulation and the body's natural supply of calcium
and magnesium. May need to refer to appropriate subspecialty for consultation.

Caustic ingestions

Gastric emptying is contraindicated. Activated charcoal is not useful and may interfere with
subsequent endoscopy. Dilution with milk or water is contraindicated if any degree of airway
compromise is present. Milk may interfere with subsequent endoscopy. Water is benign. Some
substances, such as drain cleaners containing sulfuric acid or sodium hydroxide, generate heat when
diluted with water. Local areas of heat generation can be minimized by diluting with a moderate
quantity of fluid (250-500 mL).

 Do not attempt to neutralize the caustic agent. Neutralizing the caustic agent may generate
excessive heat from the exothermic reaction of neutralization.
 Ophthalmologic consultation is recommended for patients with ocular burns from acids or
bases if there is any significant degree of corneal or scleral injury.
 Caustic ingestions may require multiple specialties, including gastroenterology, GI surgery,
ENT, and pediatric surgery for children.

• Consult a psychiatrist for cases of attempted suicide.

Vesicants: Mustard: Hd, Hn1-3, H

Mustard converts to a cyclic compound within minutes of absorption into the body and reacts
rapidly with blood and tissue components. There is increased tissue destruction in the wound,
causing increased risk of wound infection and delayed healing by destroying the immune and healing
responses normally mediated by white blood cells, fibroblasts and other cells involved in wound
repair. Delayed pain out of proportion to the severity of the wound suggests the presence of
mustard in the open wound.
Initial management of vesicants and other chemical warfare agents should be similar to that of
industrial exposures. However vesicants (nitrogen mustard) present a hazard from wound
contamination.

Providers attending contaminated patients should have protective masks, butyl rubber gloves (latex
gloves are NOT adequate), and chemical protective overgarments. Unless carried out within 1-2
minutes, decontamination of victims exposed to mustard agents does not prevent subsequent
blistering. After that brief window, decontamination still should be carried out to prevent secondary
contamination.

Initial treatment consists of irrigating such wounds copiously and liberally, with adequate pain
control. Sodium hypochlorite (0.5%) has a role in irrigation but it is not easily available in large
quantities, whereas water or saline is more easily available and is equally efficacious in large
quantities when used for irrigation. The eyes should be flushed with water or buffered normal saline.

Treatment is supportive as there are no antidotes.