Intra-Arterial Calcium Gluconate Treatment After Hydrofluoric Acid Burn of the Hand

Analysis of Factors Contributing to the Occurrence of Systemic Toxicity in Patients with Hydrofluoric Acid Skin Exposure Injury: An Individual Participant Data Meta-Analysis of 125 Clinical Cases from 1979 to 2020

The purpose of this study is to analyze the factors contributing to the occurrence of systemic toxicity in patients injured after skin exposure to hydrofluoric acid (HFA) and to present guidelines for active treatment intervention based on this analysis. Data were acquired from EMBASE, PubMed, and Cochrane library for individual participant data (IPD) meta-analysis. Key searching terms included calcium gluconate (CAG), hydrofluoric acid, and case. This research consisted of case studies published between 1979 and 2020. Systemic toxicity was set as the main outcome. Data sets from 50 case studies (N = 125 participants) were analyzed. Multivariate binary logistic regression analyses of IPD found significant association effect of the total body surface area (TBSA) burned, indicating systemic toxicity [Regression coefficient estimate, 0.82; SE, 0.41; Odds ratio, 2.28; [95% confidence interval, 1.03-5.06], and p = 0.0424]. The optimal cutoff point (sensitivity; specificity) of the receiver operating characteristic curve of the total body surface area (TBSA) burned for contributing occurrence of systemic toxicity was 2.38(0.875; 0.959). IPD meta-analysis indicates that existing evidence supports the positive proportional association of the TBSA burned for systemic toxicity. If the TBSA burned (%) in patients exposed to hydrofluoric acid is greater than 2.38, early aggressive treatment intervention, including decontamination and various CAG application, should be recommended as the guideline.

Dermal Hydrofluoric Acid Toxicity Case Review: Looks Can Be Deceiving

Hydrofluoric acid is a caustic compound found in a wide variety of items for household and industrial uses. Dermal exposures can be visually unimpressive on presentation but still have fatal complications. This case review includes a description of a patient presenting with a dermal hydrofluoric acid burn that was effectively treated with topical calcium gluconate gel. Also highlighted are the challenges faced with recognizing the severity and appropriately treating dermal hydrofluoric acid burns in the emergency department.

Hydrofluoric Acid: Burns and Systemic Toxicity, Protective Measures, Immediate and Hospital Medical Treatment

BACKGROUND

Hydrofluoric acid is a commonly used chemical in many industrial branches, but it can also be found as an ingredient in household products such as cleaning agents. Possessing high corrosive potential, HF acid causes burns and tissue necrosis, while when absorbed and distributed through the bloodstream, its extremely high toxic potential is expressed. Acute symptoms are often followed by pain, particularly in the case of skin burns, which intensiveness does not often correlate with the expressiveness of the clinical findings. Even exposure to low-concentrated solutions or gasses, or low-doses of high-concentrated acid, may provoke delayed systemic disorder which may eventually have a lethal outcome.

AIM

Therefore, having information regarding the possible hazardous effects of hydrofluoric acid usage, a variety of symptoms, as well as a treatment approach, is of great importance in the case of HF exposure.

METHODS

Available scientific articles published in literature databases, scientific reports and governmental recommendations from the internet websites, written in English, using the following search terms "Hydrofluoric acid, skin burns, eye injury, ingestion, inhalation, systemic toxicity, decontamination, antidote, medical treatment" have been reviewed.

RESULTS

This review is useful not only for physicians but for everyone who may come in contact with a person exposed to HF acid.

CONCLUSION

It highlights the mechanism of action, presents the acute and chronic symptoms, personal and general protective measures and devices that should be used, as well as decontamination procedures, immediate, antidote and hospital medical treatment.

[Physical and chemical emergencies in dermatology]

Physical and chemical emergencies are often caused by household or work accidents. Regardless of the medical field and outside specialized clinics, the physician may be confronted with the situation for first or secondary care. The identification of the causing agent and a rapid assessment of the extent and severity of the tissue damage are essential to initiate early transfer to a specialized burn clinic. Grade 2b tissue damage is usually surgically treated. Smaller and superficial injuries can often be conservatively treated. Even supposedly safe and over-the-counter medicines can also lead to serious tissue damage.

Clinical arterial infusion of calcium gluconate: the preferred method for treating hydrofluoric acid burns of distal human limbs

OBJECTIVE

This study was designed to evaluate the efficiency and safety of arterial infusions of calcium gluconate to treat hydrofluoric (HF) acid burns of the distal human limbs.

MATERIALS AND METHODS

Eligible patients with HF burn limbs, collected from January 2008 to October 2011, were given the arterial infusion of calcium gluconate into the injured limbs. The measures of pain were conducted before the infusion, immediately after the infusion, 4 h after the infusion, and 2 days after the infusion by the visual analogy score (VAS). If the VAS score was higher than 4.0 at the time point 4 h after the first infusion, the infusion was repeated. The time of wound healing, and the number and ratio of the cases receiving the surgical operation were also evaluated.

RESULTS

A total of 118 patients, male (107 cases) and female (11 cases), were collected, including 64 cases of outpatients and 54 cases of inpatients. The age of the subjects ranged from 16 to 60 years, with the mean age of 37.6. The burn sites were located in the lateral limbs (28 cases) and in the unilateral limbs (90 cases). For 107 cases, the pain scores decreased quickly after the first infusion. The other 11 cases, with the VAS score higher than 4.0 at the time point 4 h after the first infusion, received the second infusion. The average time of wound healing and the ratio of the cases receiving the surgical operation were closely related to the interval from the injury to the reception of infusion.

CONCLUSIONS

Arterial infusion of calcium gluconate, effectively relieving the pain, blocking wound progressive deepening, and causing no adverse effects, could be the preferential method to treat hydrofluoric acid burns of the distal human limbs.

[Dermal and inhalation poisoning. Rare guests in our intensive care units?]

Patients with dermal and inhalation poisoning are uncommon in intensive care treatment. We describe the diagnostics and specific toxicological treatment of patients with hydrofluoric acid burns. For inhalation poisoning, we focus on smoke inhalation, especially the management of cyanide and carbon monoxide poisoning. Special attention is given to the use of hyperbaric oxygenation for the treatment of carbon monoxide poisoning.

Part 2. Comparison of emergency washing solutions in 70% hydrofluoric acid-burned human skin in an established ex vivo explants model

BACKGROUND

Hydrofluoric acid (HF) is a small and partially dissociated acid (pK(a) 3.2), able to deeply penetrate into human skin in addition to the corrosiveness of the hydrogen ion (H(+)) and the toxicity of the fluoride ion (F(-)). However, there has been a lack of experimental studies to objectively characterize the results of human HF skin exposure decontamination.

METHODOLOGY/PRINCIPAL FINDINGS

A previously established experimental method using a human skin explants ex vivo model (Part 1. Experimental 70% hydrofluoric acid (HF) burns: Histological observations in an established human skin explants ex vivo model) described the lesions that appeared following 70% HF penetration. Within 5 min, 70% HF penetrates to the dermis. Using the same experimental conditions, a comparison study of two different washing protocols was performed: water + topical calcium gluconate (CaG) versus Hexafluorine(®). In these conditions, washing for 15 min with running tap water followed by topical CaG ointment only delayed burn onset, while severe tissue damage appeared later. In contrast, after washing with Hexafluorine(®) over 10 min, no histological lesions developed. These results are in accordance with the results of accidental human industrial case reports.

CONCLUSION/SIGNIFICANCE

Amphoteric and hypertonic Hexafluorine(®) can deactivate H(+) and chelate F(-) ions. Based on these results, it should be considered as a promising first-aid decontamination solution to prevent or minimize significant local and systemic consequences of concentrated HF skin exposures.