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Difference between revisions of "Hydrofluoric acid"
From WikEM
(→Hyperkalemia and Hypocalcemia) |
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**Glass etching, chrome and other metal cleaning, petroleum processing | **Glass etching, chrome and other metal cleaning, petroleum processing | ||
*Oral ingestion has very high mortality rate | *Oral ingestion has very high mortality rate | ||
| + | *Onset and severity of symptoms correlated with concentration | ||
| + | **Dilute solutions (<20%) may have delayed onset up to 24hr post-exposure | ||
| + | **Moderate solutions (20-50%) develop symptoms within 1-8hr | ||
| + | **Concentrated solutions (>50%) develop symptoms immediately | ||
| + | ***These patients are at highest risk for systemic toxicity/death | ||
| + | ***Pain immediately (even if wound appears minor) implies severe injury | ||
| + | *Burn itself may appear relatively minor | ||
| + | *Toxicity caused by binding of calcium | ||
==Clinical Features== | ==Clinical Features== | ||
[[File:Hydrofluoric_acid_burn.png|thumb|Hydrofluoric acid burn]] | [[File:Hydrofluoric_acid_burn.png|thumb|Hydrofluoric acid burn]] | ||
| − | *Skin | + | *Skin exposure |
**[[Burns]] | **[[Burns]] | ||
| − | *Ophthalmic | + | *Ophthalmic exposure |
**[[Eye pain]] | **[[Eye pain]] | ||
**Erythema | **Erythema | ||
| Line 20: | Line 28: | ||
*Signs/symptoms of [[hypocalcemia]] and [[hypomagnesemia]] | *Signs/symptoms of [[hypocalcemia]] and [[hypomagnesemia]] | ||
**Can lead to QTc interval prolongation and cardiac arrhythmias, the primary cause of death in HF burns | **Can lead to QTc interval prolongation and cardiac arrhythmias, the primary cause of death in HF burns | ||
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| − | |||
| − | |||
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 33: | Line 33: | ||
==Evaluation== | ==Evaluation== | ||
| − | *Trend calcium and potassium levels | + | *Clinical diagnosis |
| − | ** | + | *Trend calcium, magnesium, and potassium levels |
| − | + | **Hydrofluoric acid chelates calcium and poisons the Na+/K+ pump | |
**Expect [[hypocalcemia]] and [[hyperkalemia]] | **Expect [[hypocalcemia]] and [[hyperkalemia]] | ||
| − | * | + | *Monitor EKG for signs of electrolyte abnormality |
| − | + | ||
==Management== | ==Management== | ||
| − | * | + | *Decontamination: remove soiled clothing and irrigate thoroughly. |
| + | *Mainstay of treatment is application of calcium to affected area. | ||
| + | |||
===Cutaneous Burns=== | ===Cutaneous Burns=== | ||
====Minor injuries (<50 cm2 from dilute solutions <20%)==== | ====Minor injuries (<50 cm2 from dilute solutions <20%)==== | ||
| Line 65: | Line 66: | ||
===Ocular burns=== | ===Ocular burns=== | ||
*Irrigate with saline for at least 5 min | *Irrigate with saline for at least 5 min | ||
| − | + | *If persistent pain administer 1% calcium gluconate to eye (dilute 10% calcium gluconate with normal saline) | |
| − | *If persistent pain administer 1% calcium gluconate to eye | + | |
**Consult ophthalmology due to irritation effect of calcium salts to eye | **Consult ophthalmology due to irritation effect of calcium salts to eye | ||
| − | |||
===Ingestion=== | ===Ingestion=== | ||
| − | *If <1hr of ingestion | + | *If <1hr of ingestion, may consider NG tube for suction and gastric lavage |
**Follow lavage by 300mL 10% Ca gluconate down NGT | **Follow lavage by 300mL 10% Ca gluconate down NGT | ||
| − | + | *Consider intubation for airway protection | |
| − | + | ||
===Inhalation=== | ===Inhalation=== | ||
| − | * | + | *Oxygen via NRB |
| − | * | + | *Nebulized 2.5% calcium gluconate |
| − | + | ||
| − | + | ||
===Systemic toxicity=== | ===Systemic toxicity=== | ||
| − | |||
*Administer calcium gluconate 100mg IV (10 mL of a 10 percent solution) over 2-3 minutes | *Administer calcium gluconate 100mg IV (10 mL of a 10 percent solution) over 2-3 minutes | ||
*May also need to replete magnesium (4g IV over 20 minutes) | *May also need to replete magnesium (4g IV over 20 minutes) | ||
| + | *May see QTc prolongation, cardiac arrhythmia, or obvious systemic illness | ||
*Treat [[hyperkalemia]] as needed | *Treat [[hyperkalemia]] as needed | ||
| Line 98: | Line 94: | ||
==References== | ==References== | ||
<references/> | <references/> | ||
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[[Category:Toxicology]] | [[Category:Toxicology]] | ||
Latest revision as of 21:31, 9 May 2017
Contents
Background
- Used in both commercial and home setting
- Rust remover (most common home use)
- Glass etching, chrome and other metal cleaning, petroleum processing
- Oral ingestion has very high mortality rate
- Onset and severity of symptoms correlated with concentration
- Dilute solutions (<20%) may have delayed onset up to 24hr post-exposure
- Moderate solutions (20-50%) develop symptoms within 1-8hr
- Concentrated solutions (>50%) develop symptoms immediately
- These patients are at highest risk for systemic toxicity/death
- Pain immediately (even if wound appears minor) implies severe injury
- Burn itself may appear relatively minor
- Toxicity caused by binding of calcium
Clinical Features
- Skin exposure
- Ophthalmic exposure
- Eye pain
- Erythema
- Ingestion
- Inhalation
- Shortness of breath
- Throat pain/burning
- Signs/symptoms of hypocalcemia and hypomagnesemia
- Can lead to QTc interval prolongation and cardiac arrhythmias, the primary cause of death in HF burns
Differential Diagnosis
Caustic Burns
- Caustic ingestion
- Caustic eye exposure (Caustic keratoconjunctivitis)
- Caustic dermal burn
- Airbag-related burns
- Hydrofluoric acid
- Tar burn
- Cement burn
Evaluation
- Clinical diagnosis
- Trend calcium, magnesium, and potassium levels
- Hydrofluoric acid chelates calcium and poisons the Na+/K+ pump
- Expect hypocalcemia and hyperkalemia
- Monitor EKG for signs of electrolyte abnormality
Management
- Decontamination: remove soiled clothing and irrigate thoroughly.
- Mainstay of treatment is application of calcium to affected area.
Cutaneous Burns
Minor injuries (<50 cm2 from dilute solutions <20%)
- Application of gel paste of Ca gluconate or benzalkonium Cl
- Rub into affected area for 10-15min with pain relief being used as end-point of treatment
- Calcium gel is commercially available (found in industrial first-aid kits)
- Calcium gel can be made:
- Mix calcium gluconate powder 3.5gm with 150mL water-soluble lubricant OR
- Mix 25mL 10% calcium gluconate solution with 75mL water-soluble lubricant
- Benzalkonium Cl is commercially available
- If calcium gluconate is not available calcium chloride can be used
Severe injuries
- Treat with intradermal injections of 5% calcium gluconate
- Prepare by diluting conventional 10% Ca gluconate with sterile NS in 1:1 ratio
- Inject in and around the burned area in amount not to exceed 0.5mL per cm2
Refractory injuries
- Treat with intra-arterial infusion of calcium gluconate
- Deliver via arterial line placed proximal to injury in the same limb
- Infuse 10mL of 10% Ca gluconate dilued in 40mL of NS or D5water over 4 hr
Ocular burns
- Irrigate with saline for at least 5 min
- If persistent pain administer 1% calcium gluconate to eye (dilute 10% calcium gluconate with normal saline)
- Consult ophthalmology due to irritation effect of calcium salts to eye
Ingestion
- If <1hr of ingestion, may consider NG tube for suction and gastric lavage
- Follow lavage by 300mL 10% Ca gluconate down NGT
- Consider intubation for airway protection
Inhalation
- Oxygen via NRB
- Nebulized 2.5% calcium gluconate
Systemic toxicity
- Administer calcium gluconate 100mg IV (10 mL of a 10 percent solution) over 2-3 minutes
- May also need to replete magnesium (4g IV over 20 minutes)
- May see QTc prolongation, cardiac arrhythmia, or obvious systemic illness
- Treat hyperkalemia as needed
Disposition
- Consultation with poison center and burn center transfer per Burn center criteria
- Admission for all patients with arrhythmia on ECG or severe electrolyte disturbance
