Case 22 – A Bad Burn

Case #22: A Bad Burn
Author: Michael Gottlieb, MD
Peer Reviewer: Michael Christian, MD

A 23 year old male is brought to the ED by paramedics after some industrial grade drain cleaner splashed into his eyes. Immediately after it occurred, he splashed water on his face for 10 minutes and then called for an ambulance. He notes severe pain and significantly decreased vision, as well as pain with eye movement and photophobia. His exam is significant for diffuse ocular erythema, superficial partial thickness chemical burns in the periorbital area, and visual acuity limited to hand motion bilaterally

Vitals: Temp: 98.8, HR: 126, RR: 18, BP: 158/98, O2 Sat: 100% on RA

What is the most likely etiology of this patient’s presentation?
This man suffered a severe chemical burn to the eye and periorbital area. The type of solution (acidic or alkaline) is important for further management. However some household products can be either.

Below is a list of common household solutions:

Acids: Battery fluid, metal and jewelry cleaners, rust remover, drain cleaner, fertilizer, and swimming pool cleaner.

Alkalis: Ammonia, bleach, lye, cement, dishwasher detergent, drain cleaner, toilet bowl cleaner, oven cleaner, denture cleaner, hair relaxer, and swimming pool cleaner.

Note the overlap in many products (emphasizing the importance of pH testing and contacting the Poison Control Center early – see below).

What other clinical symptoms might you expect to see with this patient?
Depending on the mechanism….

Dermal Contact: Pain and erythema
Ocular Contact: Pain, erythema, and decreased visual acuity. Note: with deeper injuries, pain may decrease due to corneal nerve injury.
Ingestion: Vomiting, drooling, stridor, and esophageal/gastric perforation. These patients are also at a significantly increased risk of esophageal strictures and squamous cell cancer in the long-term. Of note, the lack of oropharyngeal burns does not exclude the presence of esophageal injury.
Inhalation: Lung injury and possibly ARDS.

Also note that acids cause coagulative necrosis, which leads to less damage than alkalis, which can penetrate deeper due to liquefactive necrosis.

What is the initial treatment for this patient?
Dermal Contact: Copious irrigation, followed by standard burn care. If the exposure is a powder, brush it off PRIOR TO irrigation.

Ocular Contact: Copious irrigation until tear film pH is 7.5-8.0. For more severe burns and ANY alkali burns, obtain emergent Ophthalmology consult. For some minor acid burns, topical analgesics, and topical antibiotics with close follow up has been advocated and may be sufficient.

Ingestion: Dilute the caustic agent with water, but DO NOT use neutralizing agents as the combination can cause severe thermal reaction. Activated charcoal is also not recommended as it does not adsorb caustic agents and can obscure the view when EGD is performed. EGD should be performed within 24 hours to assist with prognostication, but need not be performed emergently in the ED.

Inhalation: Frequent reassessments and intubation, if needed.

What further work-up is required?
Consider a CBC, BMP, Lactate, and Upright CXR (to look for mediastinal and/or intraperitoneal free air). For dermal/ocular exposure, test the area with pH paper to attempt to determine if the substance is acid or alkali. For symptomatic ingestion, the patient will need an emergent EGD within 24 hours.

And, DON’T FORGET to examine the surrounding areas for additional injuries (including splash and dribble injuries).

Assistance from your poison control center can be very helpful in determining what further testing is needed.

What is the disposition of these patients?
Most ocular injuries (not requiring emergent consultation) can be discharged with close follow up.

Mild to moderate dermal injuries can be irrigated, dressed, and followed up closely. Use the American Burn Association guidelines to determine who will need admission and/or transfer to a burn center (

All symptomatic caustic ingestions require admission.

How would the management change if this were a Hydrofluoric Acid (HF) burn?
Recall that the Fluoride ion in HF chelates Calcium and Magnesium, which can cause significant local and systemic effects. Treatment includes standard management PLUS local Calcium application as follows.

1. Calcium Gel
-Apply to small areas (< 50 cm2) with dilute (< 20%) solutions
-Mix 3.5 g Calcium Gluconate with 150 mL water-soluble surgical lubricant
-Apply to affected area for 10-15 mins (or until pain improves).

2. Intradermal Calcium Injection
-Apply to larger injuries or those refractory to Calcium Gel
-Mix 10% Calcium Gluconate with 0.9 NS in a 1:1 mixture (creating a 5% solution)
-Inject into the surrounding area, injecting NO MORE than 0.5 mL per cm2
-If the nail bed is involved, remove the nail bed.

3. Intraarterial Calcium Gluconate
-Mix 10 mL of 10% Calcium Gluconate with 40 mL of 0.9 NS
-Infuse into one of the proximal arteries over 4 hours.


Turner A, Robinson P. Respiratory and gastrointestinal complications of caustic ingestion in children. Emerg Med J 22: 359, 2005.

Havanond C. Clinical features of corrosive ingestion. J Med Assoc Thai 86: 918, 2003.

Spector J, Fernandez WG. Chemical, thermal, and biological ocular exposures. Emerg Med Clin North Am 26: 125, 2008.

Hall AH, Maibach HI. Water decontamination of chemical skin/eye splashes: a critical review. Cutan Ocul Toxicol 25: 67, 2006.

Kuckelkorn R et al. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmol Scand 80: 4, 2002.

Schiettecatte D et al. Treatment of hydrofluoric acid burns. Acta Chir Belg 103: 375, 2003.

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