- Email: [email protected]
Hand burn caused by Freon gas
burns 34 (2008) 1210–1212
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Case report
Hand burn caused by Freon gas Celalettin Sever *, Ersin Ulkur, Fatih Uygur, Bahattin Celikoz Department of Plastic and Reconstructive Surgery and Burn Unit, Haydarpasha Training Hospital, Istanbul, Turkey
article info Article history: Accepted 28 September 2007
1.
Introduction
Freon is a trade name for a group of chlorofluorocarbons (CFCs) used primarily as refrigerants in industry in the form of clear, colourless, non-flammable gas or liquid [1]. Several different types of refrigeration equipment contain Freon gas, such as refrigerators, air conditioners, freezers and water coolers. CFCs are also occasionally used as dry-cleaning solvents, aerosol propellants, blowing agents, chemical excipients and topical anaesthetics [2,3]. When CFCs were first developed in the 1930s, it was thought that they were useful and non-toxic to human health. Decades later, it was discovered that CFCs harm the environment and human health. Freon gas has low toxicity, but exposure to relatively high concentrations may have adverse effects on health [1]. Despite its widespread use, few reports of injuries involving Freon gas have been published [2,4]. Freon gas produces rapid and profound cooling of the surrounding air, thus causing localised cold injury and cellular destruction in human tissue, and subsequent inactivation of sensory nerves results in numbness. Moreover, skin contact with Freon gas can lead to drying of the skin, contact dermatitis and mild skin irritation with discomfort or rash. The gas may also cause severe frostbite. Frostbite following exposure to cold gases is a recognised occupational hazard [5]. To our knowledge, only two Freon frostbite cases were reported in the English literature to date [2,6]. The aim of this paper is to record a new case in which frostbite of the left hand was caused by Freon gas.
2.
Case report
A 50-year-old man in good general health was admitted to our burn unit with frostbite involving the left hand. He told us that the injury was caused by contact with leaking Freon gas when he was repairing an air conditioner; he had used his left hand to try to prevent the gas leak. The estimated duration of exposure was seconds, not minutes. Immediately after the exposure, the skin was white and cold, followed by numbness and then increasing pain in the hand. The man arrived at our institution 1 h after injury. His hand was immediately irrigated with sterile water at 37 8C for 30 min in a cleaning tank. Initial physical examination found partial thickness injury of the palm and dorsum of the left hand (Fig. 1) with an erythematous area extending longitudinally to the wrist. The capillary circulation was clinically adequate and all the fingers were well perfused. Neurological examination showed no motor or sensory deficit. The remainder of the skin appeared normal. The man was admitted as an in-patient for close monitoring of perfusion of the damaged hand and fingers. Antioedema treatment, elevation of the hand and transfusion with high-molecular-weight dextran in saline (35 ml/h) was begun. On examination after 48 h, blisters were observed over the palm, fingers and dorsum of the damaged hand (Fig. 2) and all the fingers were severely oedematous. All haemorrhagic blisters were punctured and debrided under sedation. Burned areas were dressed every day and healed gradually over 2
* Corresponding author at: GATA Haydarpas¸a Eg˘itim Hastanesi, Plastik ve Rekonstru¨ktif Cerrahi Servisi, Selimiye Mah, Tıbbiye Cad, 34668 Kadıko¨y, I˙stanbul, Turkey. Tel.: +90 2165422656. E-mail address: [email protected] (C. Sever). 0305-4179/$34.00 # 2008 Published by Elsevier Ltd and ISBI. doi:10.1016/j.burns.2007.09.017
burns 34 (2008) 1210–1212
Fig. 1 – Frostbite on left hand, caused by Freon gas.
1211
Fig. 3 – Healing of left hand 2 weeks after frostbite caused by Freon gas.
weeks (Fig. 3). Range of motion exercises were performed to prevent contractures.
3.
Fig. 2 – Palmar and dorsal surfaces of left hand 48 h after frostbite caused by Freon gas.
Discussion
Brief exposure to Freon gas may result from inhalation, ingestion or skin contact. Inhalation results in unconsciousness, narcosis and central nervous system depression; irritation of the eyes, nose, throat and skin, and cardiac arrhythmia or arrest can also occur. Research has shown that Freon gas dissolves the natural oils of the skin, and repeated skin contact can cause dermatitis. In addition, the incidence of frostbite from skin contact with Freon gas should be emphasised in view of the increasing popularity of refrigerants in industry, although these burns are uncommon. Rapid freezing is an established treatment for viral warts and verrucas in dermatology. A cold liquid or instrument is used to freeze and destroy skin cells that require removal, and redness, swelling and blistering are expected results. There is some risk of scarring, infection and damage to underlying skin, but freezing for less than 30 s results in no or minimal scarring because the extracellular matrix and fibroblasts and collagen layer of the dermis are preserved. The extent of injury caused by Freon gas is similarly determined by the surface area of exposed tissue, the volume of Freon gas on the skin and the duration of exposure the damage occurs within seconds;
1212
burns 34 (2008) 1210–1212
there is controversy over the exposure time that leads to such severe tissue damage [7]. In Freon gas burn, the appearance of the superficial tissue is often an unreliable indicator of the viability of the underlying tissue [8], and frosted gas on the skin can hinder estimation of the extent of the injury. Damage may be more severe than in a thermal burn because the agent rapidly and deeply penetrates through the skin; Freon gas has the potential to cause irreversible damage. There is little information in the medical literature on the emergency treatment of Freon gas frostbite. The prime necessity is to remove the victim from danger and minimise the duration of exposure. The agent continues to ‘‘burn’’ until inactivated or removed. As first aid, the affected skin must be promptly washed using soap or mild detergent after removing any contaminated clothing. For frostbite, immediate rewarming in a water bath between 40 8C and 42 8C is recommended [9]. In addition, adequate prophylaxis against infection, thrombosis and compartment syndrome, burned area care and surgical debridement are all important; heparinisation for the prevention of thrombosis is still controversial [10]. In the present case, the initial appearance of frostbite was similar to that of a scald. The injury was superficial and the underlying tissues were healthy. The frostbitten areas were dressed every other day and, at the same time, the capillary circulation and range of motion of the fingers were monitored. Obviously, if exposure time had been longer, the deep tissues and muscles could have been injured. Prevention is the best strategy for reducing the morbidity and mortality of frostbite. The first step is to increase the awareness of the public and of healthcare professionals of the risks of these injuries, most of which can be prevented by education and by adequate precautions. In conclusion, even short contact with Freon gas can result in severe frostbite. Removal from exposure, followed by swift
transport of the victim to a burn centre, are the essential preliminaries to treatment. Subsequently prevention of severe oedema and compartment syndrome are of great importance, including close monitoring for deep tissue damage that can cause compartment syndrome and also for any vascular or neurological deficit.
references
[1] Salocks C, Kaley KB. Clandestine drug labs/meth hazard assessment, vol. 1. Office of Environmental Health; 2003. [2] Wegener EE, Barraza KR, Das SK. Severe frostbite caused by Freon gas. South Med J 1991;84:1143–6. [3] Hanke CW, O’Brian JJ, Solow EB. Laboratory evaluation of skin refrigerants used in dermabrasion. J Dermatol Surg Oncol 1985;11:45–9. [4] Astrom T, Jonsson A, Jarvholm B. Exposure to fluorocarbons during the filling and repair of air conditioning systems in cars: a case report. Scand J Work Environ Health 1987;13:527–8. [5] Kumar P, Chirayil PT. Helium vapour injury: a case report. Burns 1999;25:265–8. [6] Klein BR, Leape LL. Skin burn from Freon preparation. Surgery 1976;79:122. [7] Hicks LM, Hunt JL, Baxter CR. Liquid propane cold injury: clinicopathologic and experimental study. J Trauma 1979;19:701–3. [8] Aygit AC, Sarikaya A. Imaging of frostbite injury by technetium-99m-sestamibi scintigraphy: a case report. Foot Ankle Int 2002;23:56–9. [9] Heggers JP, McCauley RL, Phillips LG, Robson MC. Coldinduced injury: frostbite. In: Herndon DN, editor. Total burn care. London: WB Saunders; 1996. p. 408–14. [10] Edlich RF, Chang DE, Birk KA, Morgan RF, Tafel JA. Cold injuries. Compr Ther 1989;15:13–21.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Case report
Hand burn caused by Freon gas Celalettin Sever *, Ersin Ulkur, Fatih Uygur, Bahattin Celikoz Department of Plastic and Reconstructive Surgery and Burn Unit, Haydarpasha Training Hospital, Istanbul, Turkey
article info Article history: Accepted 28 September 2007
1.
Introduction
Freon is a trade name for a group of chlorofluorocarbons (CFCs) used primarily as refrigerants in industry in the form of clear, colourless, non-flammable gas or liquid [1]. Several different types of refrigeration equipment contain Freon gas, such as refrigerators, air conditioners, freezers and water coolers. CFCs are also occasionally used as dry-cleaning solvents, aerosol propellants, blowing agents, chemical excipients and topical anaesthetics [2,3]. When CFCs were first developed in the 1930s, it was thought that they were useful and non-toxic to human health. Decades later, it was discovered that CFCs harm the environment and human health. Freon gas has low toxicity, but exposure to relatively high concentrations may have adverse effects on health [1]. Despite its widespread use, few reports of injuries involving Freon gas have been published [2,4]. Freon gas produces rapid and profound cooling of the surrounding air, thus causing localised cold injury and cellular destruction in human tissue, and subsequent inactivation of sensory nerves results in numbness. Moreover, skin contact with Freon gas can lead to drying of the skin, contact dermatitis and mild skin irritation with discomfort or rash. The gas may also cause severe frostbite. Frostbite following exposure to cold gases is a recognised occupational hazard [5]. To our knowledge, only two Freon frostbite cases were reported in the English literature to date [2,6]. The aim of this paper is to record a new case in which frostbite of the left hand was caused by Freon gas.
2.
Case report
A 50-year-old man in good general health was admitted to our burn unit with frostbite involving the left hand. He told us that the injury was caused by contact with leaking Freon gas when he was repairing an air conditioner; he had used his left hand to try to prevent the gas leak. The estimated duration of exposure was seconds, not minutes. Immediately after the exposure, the skin was white and cold, followed by numbness and then increasing pain in the hand. The man arrived at our institution 1 h after injury. His hand was immediately irrigated with sterile water at 37 8C for 30 min in a cleaning tank. Initial physical examination found partial thickness injury of the palm and dorsum of the left hand (Fig. 1) with an erythematous area extending longitudinally to the wrist. The capillary circulation was clinically adequate and all the fingers were well perfused. Neurological examination showed no motor or sensory deficit. The remainder of the skin appeared normal. The man was admitted as an in-patient for close monitoring of perfusion of the damaged hand and fingers. Antioedema treatment, elevation of the hand and transfusion with high-molecular-weight dextran in saline (35 ml/h) was begun. On examination after 48 h, blisters were observed over the palm, fingers and dorsum of the damaged hand (Fig. 2) and all the fingers were severely oedematous. All haemorrhagic blisters were punctured and debrided under sedation. Burned areas were dressed every day and healed gradually over 2
* Corresponding author at: GATA Haydarpas¸a Eg˘itim Hastanesi, Plastik ve Rekonstru¨ktif Cerrahi Servisi, Selimiye Mah, Tıbbiye Cad, 34668 Kadıko¨y, I˙stanbul, Turkey. Tel.: +90 2165422656. E-mail address: [email protected] (C. Sever). 0305-4179/$34.00 # 2008 Published by Elsevier Ltd and ISBI. doi:10.1016/j.burns.2007.09.017
burns 34 (2008) 1210–1212
Fig. 1 – Frostbite on left hand, caused by Freon gas.
1211
Fig. 3 – Healing of left hand 2 weeks after frostbite caused by Freon gas.
weeks (Fig. 3). Range of motion exercises were performed to prevent contractures.
3.
Fig. 2 – Palmar and dorsal surfaces of left hand 48 h after frostbite caused by Freon gas.
Discussion
Brief exposure to Freon gas may result from inhalation, ingestion or skin contact. Inhalation results in unconsciousness, narcosis and central nervous system depression; irritation of the eyes, nose, throat and skin, and cardiac arrhythmia or arrest can also occur. Research has shown that Freon gas dissolves the natural oils of the skin, and repeated skin contact can cause dermatitis. In addition, the incidence of frostbite from skin contact with Freon gas should be emphasised in view of the increasing popularity of refrigerants in industry, although these burns are uncommon. Rapid freezing is an established treatment for viral warts and verrucas in dermatology. A cold liquid or instrument is used to freeze and destroy skin cells that require removal, and redness, swelling and blistering are expected results. There is some risk of scarring, infection and damage to underlying skin, but freezing for less than 30 s results in no or minimal scarring because the extracellular matrix and fibroblasts and collagen layer of the dermis are preserved. The extent of injury caused by Freon gas is similarly determined by the surface area of exposed tissue, the volume of Freon gas on the skin and the duration of exposure the damage occurs within seconds;
1212
burns 34 (2008) 1210–1212
there is controversy over the exposure time that leads to such severe tissue damage [7]. In Freon gas burn, the appearance of the superficial tissue is often an unreliable indicator of the viability of the underlying tissue [8], and frosted gas on the skin can hinder estimation of the extent of the injury. Damage may be more severe than in a thermal burn because the agent rapidly and deeply penetrates through the skin; Freon gas has the potential to cause irreversible damage. There is little information in the medical literature on the emergency treatment of Freon gas frostbite. The prime necessity is to remove the victim from danger and minimise the duration of exposure. The agent continues to ‘‘burn’’ until inactivated or removed. As first aid, the affected skin must be promptly washed using soap or mild detergent after removing any contaminated clothing. For frostbite, immediate rewarming in a water bath between 40 8C and 42 8C is recommended [9]. In addition, adequate prophylaxis against infection, thrombosis and compartment syndrome, burned area care and surgical debridement are all important; heparinisation for the prevention of thrombosis is still controversial [10]. In the present case, the initial appearance of frostbite was similar to that of a scald. The injury was superficial and the underlying tissues were healthy. The frostbitten areas were dressed every other day and, at the same time, the capillary circulation and range of motion of the fingers were monitored. Obviously, if exposure time had been longer, the deep tissues and muscles could have been injured. Prevention is the best strategy for reducing the morbidity and mortality of frostbite. The first step is to increase the awareness of the public and of healthcare professionals of the risks of these injuries, most of which can be prevented by education and by adequate precautions. In conclusion, even short contact with Freon gas can result in severe frostbite. Removal from exposure, followed by swift
transport of the victim to a burn centre, are the essential preliminaries to treatment. Subsequently prevention of severe oedema and compartment syndrome are of great importance, including close monitoring for deep tissue damage that can cause compartment syndrome and also for any vascular or neurological deficit.
references
[1] Salocks C, Kaley KB. Clandestine drug labs/meth hazard assessment, vol. 1. Office of Environmental Health; 2003. [2] Wegener EE, Barraza KR, Das SK. Severe frostbite caused by Freon gas. South Med J 1991;84:1143–6. [3] Hanke CW, O’Brian JJ, Solow EB. Laboratory evaluation of skin refrigerants used in dermabrasion. J Dermatol Surg Oncol 1985;11:45–9. [4] Astrom T, Jonsson A, Jarvholm B. Exposure to fluorocarbons during the filling and repair of air conditioning systems in cars: a case report. Scand J Work Environ Health 1987;13:527–8. [5] Kumar P, Chirayil PT. Helium vapour injury: a case report. Burns 1999;25:265–8. [6] Klein BR, Leape LL. Skin burn from Freon preparation. Surgery 1976;79:122. [7] Hicks LM, Hunt JL, Baxter CR. Liquid propane cold injury: clinicopathologic and experimental study. J Trauma 1979;19:701–3. [8] Aygit AC, Sarikaya A. Imaging of frostbite injury by technetium-99m-sestamibi scintigraphy: a case report. Foot Ankle Int 2002;23:56–9. [9] Heggers JP, McCauley RL, Phillips LG, Robson MC. Coldinduced injury: frostbite. In: Herndon DN, editor. Total burn care. London: WB Saunders; 1996. p. 408–14. [10] Edlich RF, Chang DE, Birk KA, Morgan RF, Tafel JA. Cold injuries. Compr Ther 1989;15:13–21.