Intravenous regional calcium gluconate for hydrofluoric acid burns of the digits

Objective: To describe an alternative, simple and effective treatment of digital burns from hydrofluoric acid. Clinical features: Two patients are described with typical presentations from digital exposure to hydrofluoric acid. In both cases topical treatment with calcium gluconate gel was unsuccessful in relieving symptoms. Intervention and outcome: Both patients were successfully treated with intravenous regional calcium gluconate based on a Bier's block technique. Conclusion: Digital burns from hydrofluoric acid resistant to treatment with calcium gluconate gel may be successfully treated with this technique, without the need for removal of finger nails or the complicated, protracted technique of intra-arterial calcium infusions.     

Treatment of hydrofluoric acid burn to the face by carotid artery infusion of calcium gluconate

Hydrofluoric acid (HF) is highly corrosive substance often used in industrial processes. HF burns to the skin cause local tissue injury. Systemic hypocalcemia may ensue, with the potential to produce life-threatening arrhythmias. Medical treatment consists of local application of topical calcium gels, subcutaneous injection of calcium gluconate, and intravenous or intra-arterial infusion of calcium gluconate. Calcium gluconate infusions have been used for HF burns on distal extremities and digits. We report a case of HF burn to the face that was treated by the use of calcium gluconate infusion via the external carotid artery.     

Fatal hydrofluoric acid cutaneous exposure with refractory ventricular fibrillation

A patient with hydrofluoric acid burns involving only 8% of his body surface area died from intractable cardiac arrhythmia secondary to the depletion of ionized calcium by fluoride ion. For burns of this type, immediate subcutaneous injection of 10% calcium gluconate into the burn wound is recommended and the dose given should be titrated to the relief of local pain. Immediate debridgement of the burn wound also can decrease the treacherous aspect of the circulating fluoride ion, which binds to calcium to form an insoluble salt, effectively removing the calcium ion from any physiologic interaction.     

Hydrofluoric acid burns

Hydrofluoric acid is used in a variety of industries and poses a considerable medical hazard. The dual mechanism of injury makes hydrofluoric acid burns among the most severe and lethal seen. Prompt treatment with copious irrigation, iced benzethonium or benzalkonium soaks, calcium gluconate gel application and calcium gluconate injections may well prove to be lifesaving.     

Survival after hypocalcemia,hypomagnesemia, hypokalemia and cardiac arrest following mild hydrofluoric acid burn

Background.?Although hydrofluoric (HF) acid burns may cause extensive tissue damage, severe systemic toxicity is not common after mild dermal exposure. Case.?A 36-year-old worker suffered a first-degree burn of 3% of his total body surface area as a result of being splashed on the right thigh with 20% HF acid. Immediate irrigation and topical use of calcium gluconate gel prevented local injury. However, the patient developed hypocalcemia and hypomagnesemia, hypokalemia, bradycardia, and eventually had asystole at 16?h post-exposure, which were unusual findings. He was successfully resuscitated by administration of calcium, magnesium, and potassium. Conclusion.?This report highlights a late risk of HF acid dermal exposure.     

Hydrofluoric acid burns: a 15-year experience

Hydrofluoric acid (HF) is a strong inorganic acid commonly used in many domestic and industrial settings. It is one of the most common chemical burns encountered in a burn center and frequently engenders controversy in its management. We report our 15 year experience with management of HF burns. We reviewed our experience from 1990 to 2005 for patients admitted with HF burns. Primary treatment was with calcium gluconate gel. Arterial infusion of calcium and fingernail removal were reserved for unrelenting symptoms. There were 7944 acute burn admissions to our center during this study period, 204 of which were chemical burns. HF burns comprised 17% of these chemical burn admissions (35 patients). All were men, with a mean burn size of 2.1 +/- 1.5% (range, 1-6%) and hospital stay of 1.6 +/- 0.7 days (range, 0-3 days). The most common seasonal time of injury was in the summer. Twelve patients (34%) were admitted to the intensive care unit for a total of 14 intensive care unit days, primarily for arterial infusions. Ventilator support was not required in any patient. No electrolyte abnormalities occurred. All burns were either partial thickness or small full thickness with no operative intervention required and no deaths. The upper extremity was most commonly involved (29 patients, 83%). The most common cause was air conditioner cleaner (8 patients, 23%). HF is a common cause of chemical burns. Although hospital admission is usually required for vigorous treatment and pain control, burn size is usually small and does not cause electrolyte abnormalities, significant morbidity, or death.     

Systemic and topical effects of intradermal hydrofluoric acid

A 35-year-old man attempted suicide by subcutaneous self-administration of hydrofluoric acid (5 cc of a domestic rust removal solution containing 7% hydrofluoric acid). A burn 9 × 7 cm in diameter immediately appeared at the injection site (left forearm and fold of the elbow). In the emergency department, the burn was copiously washed with isotonic solution and treated with cutaneous and subcutaneous injections of magnesium chloride, 10% solution of calcium gluconate, and 2% xilocain, then continuously maintained under topical treatment with calcium gluconate. Seven hours after injection, the patient was severely hypocalcemic (Ca⁺⁺ 0.64 mmol/L). Ten hours after injection, in addition to the persistent hypocalcemia (Ca⁺⁺ 0.81 mmol/L), hyponatremia (123 mmol/d), hypokalemia (3.4 mmol/L), and hypochloremia (95.6 mmol/L) had developed. The hypocalcemia was corrected with infusion of calcium gluconate (8.92 mEq of Ca⁺⁺ as total amount). The patient underwent surgical intervention 7 days after admission, followed by several interventions of plastic surgery.     

Regional intravenous calcium--an effective method of treating hydrofluoric acid burns to limb peripheries.

An effective method of providing pain relief in hydrofluoric acid burns is reported, using a Bier's block type technique and regional intravenous calcium gluconate. This method allows satisfactory analgesia and prevents further tissue destruction, without the risk and added discomfort of increased tissue tensions associated with local infiltration of calcium.     

Chemical burns: retrospective review

The records of 51 patients with chemical burns were reviewed to identify demographics, mechanism and place of injury, cause, distribution, initial management, and outcome of treatment. Patients were classified as having received adequate (immediate dilution or neutralization of the chemical treatment--group A, or inadequate (delayed or inappropriate) treatment--group B. Inpatient mortality for chemical burns was 13% compared to 15% overall burn center mortality. Of the burns, 79% occurred in the 21-50 age group; 69% of burns were work-related in men and 17% in women. In group A, 19% required skin grafting (mortality 9.5%); in group B, 36% required grafting (mortality 21%). Alkali were the most frequent cause of burns, followed by sulfuric acid and, less often, gasoline, anhydrous ammonia, white phosphorus, and hydrofluoric acid.     

In vitro transdermal iontophoretic transport of timolol maleate: effect of age and species.

Transdermal iontophoresis would be a promising method for the systemic delivery of water soluble and ionic drugs of relatively high molecular size, including peptides. In the present study, the effect of biological parameters such as age of the animal and species variation (rat, rabbit, mouse, guinea pig and human) on the transdermal iontophoretic transport was studied using timolol maleate (TM) as a model drug. The iontophoretic transport of TM across the skins obtained from the rats of different age groups was found to be similar. The results of the present study suggest that the age of the animal (Wistar rats: 1-8 months) did not appear to influence the transdermal iontophoretic transport of TM significantly. The amount of TM transported during iontophoresis (2 h) was significantly different among the different skin species. But the total amount of TM transported up to 24 h (2 h iontophoresis+22 h post-iontophoretic passive diffusion) was not significantly different among the different species studied. The present study provides further evidence that iontophoresis technique reduces the interspecies differences in the transdermal permeation of drugs, which is normally observed in passive diffusion of drugs. However, it must be noted that excised skins have been used in the present study to investigate the role of age and species variation on the iontophoretic transport of TM. The influence of these parameters under in vivo conditions might be different considering the physiological differences in different species and in the animals of different age groups.     

Hydrofluoric acid burns.

Hydrofluoric acid is widely used in both industrial and household settings. The acid may cause insidious burns that can be very destructive. If the burns are not treated appropriately, the continued action of the free fluoride ion leads to liquefaction necrosis of the affected soft tissues, bony erosion and, ultimately, potentially lethal hypocalcemia. Immediate and copious irrigation, followed by topical, subcutaneous or intra-arterial administration of calcium carbonate, minimizes the extent of injury. In major exposure to hydrofluoric acid, management includes serum electrolyte and electrocardiographic monitoring, as well as aggressive repletion of calcium deficiency.     

Application of split-thickness dermal grafts in deep partial- and full-thickness burns: a new source of auto-skin grafting

Early tangential excision of nonviable burn tissue, followed by immediate skin grafting with autograft or allograft, has resulted in the improvement of burn patient survival. The aim of this study was to add split-thickness dermal grafts (STDGs) as a new source of auto-skin grafting tool to our reconstructive armamentarium in deep partial- and full-thickness burns and soft tissue defects. The authors successfully applied STDGs along with split-thickness skin grafts as a new source of auto-skin grafting in 11 deep partial- and full-thickness burns over a period of 1 year without any significant donor site morbidity. Dermal graft take was complete in all but one patient. There was no donor site healing problem, and donor site epithelization was completed generally 1 week later than split-thickness skin graft by semi-open technique. Autologous split-thickness skin grafting still remains the standard therapy for burn wound closure but may be in limited availability in severe burns. The authors conclude that STDGs may be a new source of auto-skin grafting tool in extensive deep partial- and full-thickness burns.     

高密度脂蛋白对严重烧伤大鼠肝组织保护的组织学观察

目的：探讨高密度脂蛋白（HDL）对严重烧伤大鼠肝脏的保护作用。方法：制作大鼠30％体表Ⅲ度烫伤模型，观察正常对照组（不作任何处理），烧伤组（烫伤后30min补充平衡溶液）及实验组（烫伤后立即静脉注入HDL）。伤后12、24、48、72h4个时间点的肝组织学变化和细胞间粘附分子1（ICAml）的表达。结果：（1）组织学观察：烫伤后各组大鼠肝细胞均有不同程度损伤，其中以烧伤组伤后24h最重，肝窦扩张充血，窦内炎细胞浸润，肝细胞变性，点灶性坏死，实验组24h肝组织学改变与烧伤组比较上述损伤明显改善。正常对照组肝组织结构基本正常。（2）ICAm-1免疫组化检测：正常对照组无表达，烧伤组与实验组ICAm-1平均表达率分别为81．6％（49／60）及36．6％（22／60），两组24h时段的表达率分别为86．6％（13／15）及20％（3／15），烧伤组表达强度明显高于实验组（P〈O．01），而两组各其他时段表达强度差异无显著性（P〉0．05）。结论：严重烧伤大鼠早期应用HDL对抑制肝细胞中ICAm-1的表达，减少肝细胞免疫损伤有良好的效果。     

Burn depth evaluation with fluorometry: is it really definitive?

Clinical evaluation of burn depth soon after injury is subjective, based on gross visual assessment. Previous investigators have quantified this process using fluorometry. Their studies show fluorescein levels in full-thickness burns to be far below control levels and partial-thickness burns to be about 60% of nonburned skin. In both rat and human models, 59 burn sites (eight rats) and 37 burn sites (seven patients) were assessed. Readings were taken for three hours on the rats and one hour on the patients during the first 48 hours, and the procedure was repeated for five days postburn. Maximum values during these periods were determined for burn and nonburn sites, and background levels were subtracted from these values. The rate of fluorescein uptake and the peak times for burn and nonburn sites were then compared. Actual depth of burn was determined by whether or not healing had occurred. The results showed no significant difference between partial-thickness and full-thickness burns using fluorometry, as standard deviations in both models for both depths of burn were large. Therefore, fluorometry did not provide a definitive evaluation of burn depth. These results differ from those reported by previous investigators.     

Reduced wound contraction after grafting of full-thickness burns with a collagen and chondroitin-6-sulfate (GAG) dermal skin substitute and coverage with biobrane

Full-thickness burns destroy both the epidermal and dermal tissues of the skin. This study evaluates a collagen and chondroitin-6-sulfate dermal skin substitute (graft) that was applied to excised full-thickness burns and covered with Biobrane. Experimental conditions included: (a) no burn, subcutaneous implantation of the graft; (b) burn, excision, graft, coverage with Biobrane and bandages; (c) burn, excision, no graft, coverage with Biobrane and bandages; (d) burn only. forty-one days post-surgery, subcutaneous implantation (N = 3) of the graft caused no detectable contraction or necrosis of the overlying skin, whereas all burn wounds contracted. Measurements of wounds (percentage of original wound size) showed statistically significant differences between the following treatments; (a) graft plus Biobrane (N = 10), 34%; (b) no graft plus Biobrane (N = 9), 25%; (c) untreated burns (N = 6), 16%. Semi-quantitative evaluation of time to healing indicated by spontaneous detachment of Biobrane from wounds showed that grafted, excised wounds healed in an average of 2.7 weeks, while ungrafted, excised wounds required an average of 4.3 weeks to heal. Histological appearance of healed wounds after grafting and coverage with Biobrane resembles undamaged skin without epidermal adnexal structures. Excision of full-thickness burn eschar, followed by grafting with a collagen and chondroitin-6-sulfate dermal skin substitute and coverage with Biobrane provides reduced wound contraction within a six-week period of observation compared to non-excised wounds. Both more rapid and more complete wound healing took place compared to excised wounds that were not grafted.     

Iontophoresis of vincristine versus saline in post-herpetic neuralgia. A controlled trial

Twenty patients with post-herpetic neuralgia (median duration 28.5 months) were randomly allocated to receive transdermal iontophoresis of either vincristine or saline. Although significant improvement in pain by word score and visual analogue scale (P = 0.05) was reported by 6 out of 10 of the vincristine group, none of the patients considered themselves 'cured.' There was no significant change in the saline group. No adverse haematological or neurological side effects were seen, but skin irritation and painless electrical burns were common in both groups. The dramatic relief of pain in patients with post-herpetic neuralgia of 3 months or less reported elsewhere was not seen in our group who had pain of a longer duration. This present trial does not confirm the value of vincristine iontophoresis in the treatment of post-herpetic neuralgia of over 6 months duration.     

Burns caused by automobile radiators: a continuing problem.

In spite of the fact that injury warning labels have been placed on radiator caps for the last 15 years, automobile radiator scald burns continue to be a burn prevention problem. The temperature of radiator fluid may be as high as 100 degrees F to 250 degrees F in a properly functioning car and higher in an overheated vehicle. From 1974 to 1990, 100 patients with burns that were caused by automobile radiators have been admitted to the Parkland Memorial Hospital Burn Unit (1.5% of acute admissions). Eighty-two percent of the injuries occurred in the summer months, and 93% of the patients were male. Mean age was 31 +/- 17 years (range, 8 months to 79 years), and mean burn size was 11.3% total body surface area (TBSA) (range, 1% to 32%) with a mean full-thickness burn size of 0.6% TBSA. Length of stay was 7 +/- 7.4 days (range, 1 to 38 days). Burns to the face, neck, and trunk necessitated most admissions. Although there were no deaths, five patients required intensive care for airway monitoring; mean length of stay was 6 days. One patient required endotracheal intubation for a total of 11 days. Ten patients required one or more skin grafting procedures, and three patients required burn resuscitation. Four patients sustained minor ocular injuries. A subgroup of patients demands special review: 10 children younger than 10 years of age (mean age, 4.1 years) of which 70% were boys. Mean burn size was 15.5% TBSA; mean full-thickness burn size was 2.4% (four times larger than the mean burn size for the adult population).(ABSTRACT TRUNCATED AT 250 WORDS)     

The 1999 clinical research award. Cultured skin substitutes combined with Integra Artificial Skin to replace native skin autograft and allograft for the closure of excised full-thickness burns

Prompt and permanent closure of excised full-thickness burns remains a critical factor in a patient's recovery from massive burn injuries. Hypothetically, Integra Artificial Skin (Integra) may replace the need for allografts for immediate wound coverage, and cultured skin substitutes (CSS) that contain stratified epithelium may replace the need for autografts for definitive wound closure. To test this hypothesis, 3 patients with full-thickness burns of greater than 60% of their total body surface areas had their eschar excised within 14 days of admission. Integra was applied, and a skin biopsy was collected from each patient for the preparation of CSS. At 3 weeks or more after the application of the Integra and the collection of skin biopsies, the outer silastic cover of the Integra was removed and CSS were grafted. The CSS were irrigated with nutrients and antimicrobials for 6 days and then dressed with antimicrobial ointment and cotton gauze. Treated wounds were traced on days 14 and 28 after the grafting of CSS for determination of engraftment and wound closure, respectively. Cost analysis was not performed. Engraftment on postoperative day (POD) 14 was 98%+/-1% (mean +/- standard error of the mean), the ratio of closed:donor areas on POD 28 was 52.3+/-5.2, and no treated sites required regrafting. The histology of the closed wounds showed stable epithelium that covered a layer of newly formed fibrovascular tissue above the reticulated structure of the degrading Integra. The clinical outcomes of the closed wounds after POD 28 demonstrated smooth, pliable, and hypopigmented skin. Two patients who had received CSS grafts over Integra on their backs were positioned supine on air beds from POD 8 or POD 9 with minimal graft loss because of mechanical loading. One patient with a full-thickness burn of 88% of the total body surface area was covered definitively at 55 days postburn. These results demonstrate that the combination of CSS and Integra can accomplish functionally stable and cosmetically acceptable wound closure in patients with extensive full-thickness burns. This combination of alternatives to the conventional grafting of split-thickness skin permits the substitution of cadaveric allograft with Integra and the substitution of donor autograft with CSS. This approach to the closure of excised full-thickness burns is expected to reduce greatly the time to definitive closure of burn wounds and to reduce the morbidity associated with the harvesting of donor sites for split-thickness skin autografts.