First thing’s first: PPE
You need standard PPE – gloves, apron, mask and eye protection to protect you from direct contact with the acid/ alkali and to protect from splash decontamination when rinsing.
Manage their pain
Get decent analgesia on board straight away – consider intranasal opioid and then further analgesia IV if necessary. Be generous, a spoonful of liquid paracetamol just isn’t going to cut it on its own.
Minimise the damage
The extent of the burn is linked to a number of variables – our priority is to minimise the damage by removing the chemical as quickly as possible.
The exact chemical is rarely identified but knowing whether it is acid or alkali can be helpful. Acid burns cause a coagulative necrosis is where the cells die but maintain their structure for several days so the full damage is only evident days later. They also precipitate tissue protein creating a mechanical barrier limiting further damage tending to be less severe than alkali burns. Hydrofluoric acid is the exception and which rapidly penetrates cell membranes creating deep and extensive burns. Alkalis are known to cause worse burns and this is because they are lipophilic i.e. they dissolve in fat and penetrate through the skin and eye more deeply than acid. Liquefactive necrosis occurs where tissues are liquified and saponification of fatty acids in cell membranes causes more destruction. The damaged tissue secrete proteolytic enzymes as part of an inflammatory response which leads to further damage.
The full extent of the depth of the burn only evolves over several days requiring staged debridement.
It is really, really important to remove all their clothes and jewellery – even underwear as it may have been splashed with the rinsing solution and may be causing further injury without even realising it.
pH of skin is variable, therefore keep rinsing until you get a static pH within normal limits or put a drop of your rinsing solution on a part of the patient’s unaffected skin and then check their skin pH. Eyes are more straightforward and you should aim for a normal pH. However chemical burns may need prolonged rising compared to normal thermal burns.
There are many options for rinsing solutions. Thinking back to basic science, water is freely available and plentiful and it mechanically rinses the skin. It dilutes the chemical which is good but the osmotic pressure of water is less than the skin and eye hence you get a wash in effect taking some of the chemical with it.
A better option is a more hypertonic solutions e.g. Hartmann’s or normal saline which don’t have the same wash in effect.
It appears the best treatment with increasing evidence to support this is now an amphoteric rinsing solution such as Diphoterine. It has previously been used extensively in industrial facilities as an emergency treatment for chemical burns but is now gaining popularity in medical setting.
Diphoterine is amphoteric so is effective on acids or alkalis and neutralises the effects of the chemical far quicker than water alone – so helps to stop the development of the burn. It is chelating and stops the chemical reacting with biological components of the tissues. It is also hypertonic so its osmotic pressure is greater than that of the skin or eyes and therefore limits the penetration of the product into the tissues. By neutralising the pH it also has an analgesic effect, so is particularly useful in gaining control in children as reduces pain. A cost benefit analysis is required before wide spread use can be recommended.
Eye injuries can be severe and stressful.
You can often feel as though you are adding very little and the patient needs an expert review. However, the main treatment acutely is to ensure adequate irrigation occurs which doesn’t require specialist expertise.
The ophthalmology treatment mainly resolves around trying to prevent further damage and trying to promote the best healing possible. They generally prescribe a combination of topical antibiotics, topical steroids, topical and oral ascorbate as well as oral doxycycline and lubricant eye drops to try and stop infection, acute glaucoma, promote re-epithelisation, support repair and control inflammation.
What happens next?
All chemical burns should be referred to a specialist unit. As with all injuries in children then safeguarding must be considered and all of these cases will invariably involve significant safeguarding concerns and should be dealt with according your local policies.