General Approach

The goal of treatment is to minimize any area of irreversible injury and maximize salvage of the zone of reversible damage. With few exceptions, hydrotherapy is the cornerstone of initial treatment for chemical burns. Chemical agents may continue to damage tissue until they are removed or inactivated. The first priority is to stop the burning process. Immediate removal from the offending chemical, removal of garments, and counteraction of the chemical remaining on the body by dilution, debridement, or neutralization are important measures. Dry chemical particles such as lime should be brushed away before irrigation. Initially sodium metal and related compounds should be covered with mineral oil or excised, since water can cause a severe exothermic reaction. Dilution of phenol (carbolic acid) with water may enhance penetration. For the most part, however, use of water or saline to irrigate a chemical burn should not be delayed while searching for a neutralizing agent and should begin at the scene of the accident. In general, the earlier the irrigation, the better is the prognosis.

The amount of elapsed time to initiate dilution or removal of chemical agents relates to the depth and degree of injury. Wounds irrigated 3 min after contact with some chemicals have a twofold greater chance of becoming full-thickness burns than wounds irrigated within 1 min of chemical contact. When using agents to neutralize a chemical burn, additional tissue injury may occur through heat production. In some cases, heat of dilution may be produced using water irrigation, but copious amounts will decrease the rate and amount of chemical reaction and dissipate the heat. Irrigation should be maintained at a gentle flow to avoid driving the chemical deeper into tissue or splashing chemical into the victim's or rescuer's eyes. The time required for irrigation varies; irrigation may need to be continued for hours in the case of alkali burns. Use of pH litmus paper may help determine continued presence of alkali or acid in burn wounds. A more accurate pH result will be obtained if the test is performed 10 to 15 min after completion of irrigation. This will allow residual chemical in the deeper areas to diffuse to the surface.

After irrigation and debridement of remaining particles and devitalized tissue, topical antimicrobial agents should be used and tetanus immunization should be updated as needed. Other than measures specific for a particular chemical burn, treatment following initial therapy is basically the same as for thermal burns. Patients sustaining chemical burns require the same aggressive fluid replacement as those with thermal burns. Analgesics may be needed, and, in the case of allergic responses to chemicals, antihistamines, steroids, and epinephrine may be required. Hemodialysis may be required in cases of severe systemic toxicity and renal failure. Autografts, heterografts, homografts, or synthetic material may be necessary for full-thickness burns. Hyperbaric oxygen may be utilized to assist healing of resistant burn wounds.

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