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CHEMICAL BURNS Chemical burn injuries are uncommon. These are not hyperthermic, but are due to tissue reactions to noxious substances, including oxidizing agents, reducing agents, corrosives, protoplasmic poisons, desiccants, and vesicants. In general, chemical injuries are deeper than they initially look. The key to treatment of most chemical burns is early and continued copious irrigation of the insulted skin surface. Wounds can be most easily irrigated with water, while a balanced saline solution is preferable for irrigation of mucosal surfaces or eyes. Dilution and not neutralization is paramount. Misdirected attempts at neutralization of acid or alkali burns can produce exothermic damage as well. Deep alkali burns should be irrigated for 24 hours. Initial copious hydrotherapy is indicated for all chemical burns except those caused by dry-line, phenol, concentrated sulfuric acid, sodium metal, and muriatic acid; which either are not miscible with water or react with water exothermically. Besides irrigation, 'antidotes' are often helpful for burns from hydrofluoric aced, phenol, and white phosphorous. Hydrofluoric acid (HFA) causes liquefaction necrosis of the subcutaneous tissue and can penetrate to bone. Systemic complications of HFA toxicity include hypocalcemia and pulmonary edema. HFA wounds are covered with a 10% calcium gluconate solution mixed to a slurry with a water soluble ointment, or infiltrated if excruciatingly painful. Phenol is an acidic alcohol which produces local coagulation and systemic toxicity in large doses, including fatal arrhythmias. Acute phenol burns are treated topically with polyethylene glycol solution irrigation. White phosphorus is contained in grenades and anti-personnel mines. Once particles are imbedded in skin, white phosphorus causes burn by both chemical and thermal reactions, as particles are spontaneously ignited with prolonged exposure to air. Patients should be submersed in water until imbedded particles can be surgically debrided. The skin is washed with a solution of 5% sodium bicarbonate, 3% copper sulfate, and 1% hydroxycellulose to blacken the particles and aid earlier identification. Prolonged exposure to copper sulfate solution can induce coagulopathies.
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