- Email: [email protected]
Re-emphasizing the role of copious water irrigation in the first aid treatment of chemical burns
779
burns 40 (2014) 772–783
Burns leading to facial and body disfigurement are a known cause of profound shame, isolation and stigmatization. Deep burns can frequently cause damage to or loss of functionally and cosmetically important body parts. Hence, these patients suffer from long-term morbidity and these patients also reported low psychosocial scores in comparison to people who had no facial burns. Thanks to advancements in medical research and development of new products such as negative pressure therapy, artificial dermis, limited access dressing, silver impregnated dressings and collagen dressings, the survival rates of burn patients are expected to improve. However, in the present day world, most of the burn care community in the developing world is in the dark in relation to the need for psychological requirements of the burn victim [4]. In USA alone, the average hospital charges for a patient with extensive third-degree burns requiring skin grafting is more than $50,000. Therefore, one can imagine how difficult it must be for the low and middle class community of the developing world to cope with their burns. Burns associated with its physical pain, domestic, financial and social losses hits the patient with a lot of depression and here is when social and family support is needed. Patient goes through emotional and social harm and this is the reason why social support helps the patient recover at a faster rate. Family and its encouragement help the patient heal quicker and shorten the treatment duration [4]. Clinical observations as well as empirical studies and patient self-reports, suggest burn care of the whole person, including early and continued attention to psychosocial aspects of the patient’s life, can facilitate positive psychological adaptation to the challenges of traumatic injury, painful treatment, and permanent disfigurement. Thus the treatment goals for these people with extensive burns include recovery of optimal function for survivors to fully participate in society, physically and psychologically by social support, a treatment strategy most commonly used in the developing world where people cannot afford highly expensive treatments like the ones available in the developed world. Since the cost of rehabilitation of burn patients is high, these patients are generally neglected, especially in the developing countries. Government funding in these countries should facilitate ‘Burn support groups’, encouraging participants to share their experiences, discussing daily recovery strategies, providing encouragement and handing out support to burn survivors, the ONLY treatment left for burn patients, at least in the developing world.
Competing interest The authors declare that they have no competing interest.
references
[1] Mock C, Peck M, Peden M, Crug E. A WHO plan for burn prevention and care. World Health Organization; 2008: 1–32. [2] Khan N, Malik MA. Presentation of burn injuries and their management outcome. J Pak Med Assoc 2006; 56(September (9)):394–7.
[3] Peck M. Commentary on socio-economic burden of burns: how do families of patients cope? Indian J Burns 2012;20(1):55–6. [4] Misra A, Thussu DM, Agrawal K. Assessment of psychological status and quality of life in patients with facial burn scars. Indian J Burns 2012;20(1):57–61.
Areeba Altaf Natasha Maqsood Syed Raza Shah* Dow University of Health Sciences (DUHS), Karachi, Pakistan *Corresponding author. Tel.: +92 3452454610; fax: +92 3344228777 E-mail addresses: [email protected] (A. Altaf) [email protected] (N. Maqsood) [email protected] [email protected] (S.R. Shah) 0305-4179/$36.00. # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.11.016
Letter to the Editor Re-emphasizing the role of copious water irrigation in the first aid treatment of chemical burns To the Editor, It was with great interest that we read the recent article published by Li and colleagues [1]. In the article, the authors survey the 10-year epidemiology of chemical burn in the Jinshan district of Shanghai in China, and discuss their experience in treating various chemical injuries. A few notable exceptions of chemical burns unsuitable for treatment by water irrigation are mentioned [1]. We respectfully disagree with these exceptions, and would like to re-emphasize the importance of copious water irrigation in the first aid treatment of chemical burns. First, the authors stated that ‘‘The result of irrigation by water alone is unsatisfactory to some water-insoluble chemicals. For example, phenol is insoluble in water and should be first wiped off the skin with sponges soaked in its solubilizing agents such as 50% polyethylene glycol or 70% ethanol until the smell of phenol has disappeared; then water lavage is performed.’’ Phenol, also known as carbolic acid, is an aromatic organic compound. Burns from phenol exposure are not a common chemical injury. Knowledge of the mechanism of injury in phenol burns and of proper emergency management of the affected area will facilitate treatment and improve outcomes [2]. Phenol is appreciably water-soluble, with about 8.42 g of phenol dissolving in 100 mL of water. Due to the accessibility of water in the workplace, copious water irrigation is generally the first choice of treatment for phenol skin burns. If readily
780
burns 40 (2014) 772–783
available prior to water irrigation, solvent cleaners with both hydrophilic and hydrophobic portions, such as polyethylene glycol 300 or 400 [3], or isopropyl alcohol [4], can also be used to remove phenol from the skin. To date, animal studies have shown no evidence to suggest that polyethylene glycol is more effective than copious water irrigation in these cases [5]. Ethanol has sometimes been used as a decontaminant for the removal of phenol, because it can enhance the absorption of phenol from burn wounds [6]. Second, Li et al. indicated that ‘‘Dry lime or contains calcium oxide, which can react with water to form calcium hydroxide, an injurious strong alkali, and generate extreme heat at the same time. Therefore, dry lime or cement should be dusted off the skin before water irrigation.’’ While we agree with the recommendation to dust dry lime or cement from the skin, this should not delay the application of copious water irrigation. In most situations, with or without thick clothes, secretions and sweat on the surface of the skin cause chemical reactions and injury to occur immediately, especially for heavy manual laborers. In these cases, thorough and copious water lavage can provide better protection for victims by quickly removing both the chemicals and the generated heat from the affected area. Lavage with large quantities of water or even high-pressure water flow can be very beneficial. In the case of wet cement, it has been reported that 1 h of exposure is required to produce third-degree burns [7]. For patients with obvious burns, the wounds should be cleaned with sterile water and dressed with topical antibacterial cream and non-adherent dressings in a hospital [8]. Third, the authors’ further opinion showed that ‘‘Concentrated sulphuric acid and muriatic acid create significant exothermy when combined with water; hence these agents should be neutralized with soap or lime water prior to water lavage.’’ In the case of sulfuric acid exposure, irrigation with lime water offers the theoretical benefit of neutralizing the acid while minimizing exothermic reactions. However, no recent experimental data suggest that neutralizing agents are more effective or safer than water [9]. Immediate copious irrigation with tap water seems essential to early treatment [10]. For first aid of acid burns, we have to reemphasize the priority and importance of copious water irrigation. In our opinion, prehospital treatment of chemical burns deserves focus. Water, as a cheap, accessible and safe substance, can be used preferentially to treat acute chemical injuries in the workplace prior to hospital care. For on-site first-aid education of workers, the simplest treatment method is often the most practical. After all, in emergency situations, physicians or clinicians are not immediately available. Although the proper usage of neutralizing agents is very important, it is a treatment measure best used under the care of a trained physician.
Conflict of interest None of the authors has any financial interest with the information presented.
references
[1] Li W, Wu X, Gao C. Ten-year epidemiological study of chemical burns in Jinshan, Shanghai, PR China. Burns: Journal of the International Society for Burn Injuries 2013;39:1468–73. [2] Lin TM, Lee SS, Lai CS, Lin SD. Phenol burn. Burns: Journal of the International Society for Burn Injuries 2006;32:517– 21. [3] Brown VK, Box VL, Simpson BJ. Decontamination procedures for skin exposed to phenolic substances. Archives of Environmental Health 1975;30:1–6. [4] Hunter DM, Timerding BL, Leonard RB, McCalmont TH, Schwartz E. Effects of isopropyl alcohol, ethanol, and polyethylene glycol/industrial methylated spirits in the treatment of acute phenol burns. Annals of Emergency Medicine 1992;21:1303–7. [5] Pullin TG, Pinkerton MN, Johnston RV, Kilian DJ. Decontamination of the skin of swine following phenol exposure: a comparison of the relative efficacy of water versus polyethylene glycol/industrial methylated spirits. Toxicology and Applied Pharmacology 1978; 43:199–206. [6] Zhang JC, Ye SJ, Zhang WZ. Management of severe phenol burn combined with poisoning: report of one case. Di 1 jun yi da xue xue bao Academic Journal of the First Medical College of PLA2005;25:14. [7] Greening NR, Tonry JR. Burn hazard with cement. British Medical Journal 1978;2:1370. [8] Sherman SC, Larkin K. Cement burns. Journal of Emergency Medicine 2005;29:97–9. [9] Davidson EC. The treatment of acid and alkali burns: an experimental study. Annals of Surgery 1927;85:481–9. [10] Roock SD, Deleuze JP, Rose T, Jennes S, Hantson P. Severe metabolic acidosis following assault chemical burn. Journal of Emergencies Trauma and Shock 2012;5:178–80.
Xingang Wang* Chunmao Han Department of Burns & Wound Care Center, 2nd Affiliated hospital of Zhejiang University, College of Medicine, Hangzhou, China *Corresponding author. Tel.: +86 15858264885 E-mail address: [email protected] (X. Wang) http://dx.doi.org/10.1016/j.burns.2013.12.029 0305-4179/ # 2014 Elsevier Ltd and ISBI. All rights reserved.
Letter to the Editor Cost savings in plastic surgery: Boardless skin meshers?
Dear Sir Skin graft meshers are essential tools in the surgical management of burn injuries. At our hospital we have used the nonboard (Brennen, Minnesota, US) skin meshers since 2002.
burns 40 (2014) 772–783
Burns leading to facial and body disfigurement are a known cause of profound shame, isolation and stigmatization. Deep burns can frequently cause damage to or loss of functionally and cosmetically important body parts. Hence, these patients suffer from long-term morbidity and these patients also reported low psychosocial scores in comparison to people who had no facial burns. Thanks to advancements in medical research and development of new products such as negative pressure therapy, artificial dermis, limited access dressing, silver impregnated dressings and collagen dressings, the survival rates of burn patients are expected to improve. However, in the present day world, most of the burn care community in the developing world is in the dark in relation to the need for psychological requirements of the burn victim [4]. In USA alone, the average hospital charges for a patient with extensive third-degree burns requiring skin grafting is more than $50,000. Therefore, one can imagine how difficult it must be for the low and middle class community of the developing world to cope with their burns. Burns associated with its physical pain, domestic, financial and social losses hits the patient with a lot of depression and here is when social and family support is needed. Patient goes through emotional and social harm and this is the reason why social support helps the patient recover at a faster rate. Family and its encouragement help the patient heal quicker and shorten the treatment duration [4]. Clinical observations as well as empirical studies and patient self-reports, suggest burn care of the whole person, including early and continued attention to psychosocial aspects of the patient’s life, can facilitate positive psychological adaptation to the challenges of traumatic injury, painful treatment, and permanent disfigurement. Thus the treatment goals for these people with extensive burns include recovery of optimal function for survivors to fully participate in society, physically and psychologically by social support, a treatment strategy most commonly used in the developing world where people cannot afford highly expensive treatments like the ones available in the developed world. Since the cost of rehabilitation of burn patients is high, these patients are generally neglected, especially in the developing countries. Government funding in these countries should facilitate ‘Burn support groups’, encouraging participants to share their experiences, discussing daily recovery strategies, providing encouragement and handing out support to burn survivors, the ONLY treatment left for burn patients, at least in the developing world.
Competing interest The authors declare that they have no competing interest.
references
[1] Mock C, Peck M, Peden M, Crug E. A WHO plan for burn prevention and care. World Health Organization; 2008: 1–32. [2] Khan N, Malik MA. Presentation of burn injuries and their management outcome. J Pak Med Assoc 2006; 56(September (9)):394–7.
[3] Peck M. Commentary on socio-economic burden of burns: how do families of patients cope? Indian J Burns 2012;20(1):55–6. [4] Misra A, Thussu DM, Agrawal K. Assessment of psychological status and quality of life in patients with facial burn scars. Indian J Burns 2012;20(1):57–61.
Areeba Altaf Natasha Maqsood Syed Raza Shah* Dow University of Health Sciences (DUHS), Karachi, Pakistan *Corresponding author. Tel.: +92 3452454610; fax: +92 3344228777 E-mail addresses: [email protected] (A. Altaf) [email protected] (N. Maqsood) [email protected] [email protected] (S.R. Shah) 0305-4179/$36.00. # 2013 Elsevier Ltd and ISBI. All rights reserved. http://dx.doi.org/10.1016/j.burns.2013.11.016
Letter to the Editor Re-emphasizing the role of copious water irrigation in the first aid treatment of chemical burns To the Editor, It was with great interest that we read the recent article published by Li and colleagues [1]. In the article, the authors survey the 10-year epidemiology of chemical burn in the Jinshan district of Shanghai in China, and discuss their experience in treating various chemical injuries. A few notable exceptions of chemical burns unsuitable for treatment by water irrigation are mentioned [1]. We respectfully disagree with these exceptions, and would like to re-emphasize the importance of copious water irrigation in the first aid treatment of chemical burns. First, the authors stated that ‘‘The result of irrigation by water alone is unsatisfactory to some water-insoluble chemicals. For example, phenol is insoluble in water and should be first wiped off the skin with sponges soaked in its solubilizing agents such as 50% polyethylene glycol or 70% ethanol until the smell of phenol has disappeared; then water lavage is performed.’’ Phenol, also known as carbolic acid, is an aromatic organic compound. Burns from phenol exposure are not a common chemical injury. Knowledge of the mechanism of injury in phenol burns and of proper emergency management of the affected area will facilitate treatment and improve outcomes [2]. Phenol is appreciably water-soluble, with about 8.42 g of phenol dissolving in 100 mL of water. Due to the accessibility of water in the workplace, copious water irrigation is generally the first choice of treatment for phenol skin burns. If readily
780
burns 40 (2014) 772–783
available prior to water irrigation, solvent cleaners with both hydrophilic and hydrophobic portions, such as polyethylene glycol 300 or 400 [3], or isopropyl alcohol [4], can also be used to remove phenol from the skin. To date, animal studies have shown no evidence to suggest that polyethylene glycol is more effective than copious water irrigation in these cases [5]. Ethanol has sometimes been used as a decontaminant for the removal of phenol, because it can enhance the absorption of phenol from burn wounds [6]. Second, Li et al. indicated that ‘‘Dry lime or contains calcium oxide, which can react with water to form calcium hydroxide, an injurious strong alkali, and generate extreme heat at the same time. Therefore, dry lime or cement should be dusted off the skin before water irrigation.’’ While we agree with the recommendation to dust dry lime or cement from the skin, this should not delay the application of copious water irrigation. In most situations, with or without thick clothes, secretions and sweat on the surface of the skin cause chemical reactions and injury to occur immediately, especially for heavy manual laborers. In these cases, thorough and copious water lavage can provide better protection for victims by quickly removing both the chemicals and the generated heat from the affected area. Lavage with large quantities of water or even high-pressure water flow can be very beneficial. In the case of wet cement, it has been reported that 1 h of exposure is required to produce third-degree burns [7]. For patients with obvious burns, the wounds should be cleaned with sterile water and dressed with topical antibacterial cream and non-adherent dressings in a hospital [8]. Third, the authors’ further opinion showed that ‘‘Concentrated sulphuric acid and muriatic acid create significant exothermy when combined with water; hence these agents should be neutralized with soap or lime water prior to water lavage.’’ In the case of sulfuric acid exposure, irrigation with lime water offers the theoretical benefit of neutralizing the acid while minimizing exothermic reactions. However, no recent experimental data suggest that neutralizing agents are more effective or safer than water [9]. Immediate copious irrigation with tap water seems essential to early treatment [10]. For first aid of acid burns, we have to reemphasize the priority and importance of copious water irrigation. In our opinion, prehospital treatment of chemical burns deserves focus. Water, as a cheap, accessible and safe substance, can be used preferentially to treat acute chemical injuries in the workplace prior to hospital care. For on-site first-aid education of workers, the simplest treatment method is often the most practical. After all, in emergency situations, physicians or clinicians are not immediately available. Although the proper usage of neutralizing agents is very important, it is a treatment measure best used under the care of a trained physician.
Conflict of interest None of the authors has any financial interest with the information presented.
references
[1] Li W, Wu X, Gao C. Ten-year epidemiological study of chemical burns in Jinshan, Shanghai, PR China. Burns: Journal of the International Society for Burn Injuries 2013;39:1468–73. [2] Lin TM, Lee SS, Lai CS, Lin SD. Phenol burn. Burns: Journal of the International Society for Burn Injuries 2006;32:517– 21. [3] Brown VK, Box VL, Simpson BJ. Decontamination procedures for skin exposed to phenolic substances. Archives of Environmental Health 1975;30:1–6. [4] Hunter DM, Timerding BL, Leonard RB, McCalmont TH, Schwartz E. Effects of isopropyl alcohol, ethanol, and polyethylene glycol/industrial methylated spirits in the treatment of acute phenol burns. Annals of Emergency Medicine 1992;21:1303–7. [5] Pullin TG, Pinkerton MN, Johnston RV, Kilian DJ. Decontamination of the skin of swine following phenol exposure: a comparison of the relative efficacy of water versus polyethylene glycol/industrial methylated spirits. Toxicology and Applied Pharmacology 1978; 43:199–206. [6] Zhang JC, Ye SJ, Zhang WZ. Management of severe phenol burn combined with poisoning: report of one case. Di 1 jun yi da xue xue bao Academic Journal of the First Medical College of PLA2005;25:14. [7] Greening NR, Tonry JR. Burn hazard with cement. British Medical Journal 1978;2:1370. [8] Sherman SC, Larkin K. Cement burns. Journal of Emergency Medicine 2005;29:97–9. [9] Davidson EC. The treatment of acid and alkali burns: an experimental study. Annals of Surgery 1927;85:481–9. [10] Roock SD, Deleuze JP, Rose T, Jennes S, Hantson P. Severe metabolic acidosis following assault chemical burn. Journal of Emergencies Trauma and Shock 2012;5:178–80.
Xingang Wang* Chunmao Han Department of Burns & Wound Care Center, 2nd Affiliated hospital of Zhejiang University, College of Medicine, Hangzhou, China *Corresponding author. Tel.: +86 15858264885 E-mail address: [email protected] (X. Wang) http://dx.doi.org/10.1016/j.burns.2013.12.029 0305-4179/ # 2014 Elsevier Ltd and ISBI. All rights reserved.
Letter to the Editor Cost savings in plastic surgery: Boardless skin meshers?
Dear Sir Skin graft meshers are essential tools in the surgical management of burn injuries. At our hospital we have used the nonboard (Brennen, Minnesota, US) skin meshers since 2002.