Hydrofluoric Acid Burns of the Hand by vwm20081

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Hydrofluoric Acid Burns of the Hand
DAVID G. DIBBELL, RONALD E. IVERSON, WALLACE JONES, DONALD H. LAUB and MITCHELL S.
MADISON
J Bone Joint Surg Am. 1970;52:931-936.



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                                     Hydrofluoric                                                                  Acid                         Burns                             of the                             Hand*
       BY          DAVID                  G.          I)IBBELL,                          M.D.t,                  RONALD                        E.                M.D.t,
                                                                                                                                                          IVER5ON,                        WALLACE                          JONES,                      M.D.t,

DONALD                         H.         LAUB,                      M.D.t,                AND                MITCHELL S.                   MADISON,                           M.D.t,      PALO               ALTO,                   CALIFORNIA


                           From               1/ic        Department                           of    Surgery,                   Stanfor(l                   University                   Medical               Center,                Palo            Alto


                H’vdrofluoric                                    acid                produces                             burtsswhich                        may                 be        disablinsg                         if         nsot           properly
treated.                      Prompt                        recogtiitiots                              of a buns                       due             to        hydrofluoric                           acid           atsd              specific                treatmetst
by          the            first          phmysicinuti to                       see             time          patienst           are         extremely                          irnportnstst.                        Hydrofluoric                                   acid
burnss                  occur                  mainly                    ins workers                               its a            few             specialized                         itsdustries,                       and                they              differ            fn-om
other                 acid           burnis                 ins several ways.                             Little                has          beets               published                     ins the           widely                       read            medical
journals                       concerning                                their                  care
                                                                                                   tJO,


                                                                                                                   Classification
                The            National                              Itistitutes                       of          Health has               classified                       human                 isydnofluoric                    acid          burnss
into             three               categories                               ons the                     basis                of       the            concetstratiots                                 of       acid
                                                                                                                                                                                                               (Table                I).             These
categories                           are             very              broad                   and            take              into            considerations                                 olsly         thse          conscetstnatiots                                of the
acid.                 We            hsave                 seens              mansy                  exceptiotms                           to          these              categories.                           Factors                        other               timats          cots-
centrations                              of         thme         acid,               such              as           duration                         of          exposure,                      must             be           coissidered                           wisets             at-
tempting                            to         categorize                            burnss                   of        this          type.

                                                                                                            Pathophysiology
                Hydrofluoric                                     acid               is      onse            of          the           stronigest                        of       insorgansic                    acids.                   It       is      used              its      the
productions                           of plastics,       germicides,                                                          dyes,            tatsning                    agetsts,                stable        solvetsts,                               fireproofitsg
materials,                           ansd  semiconiductors,          as                                            w-ell         as          for     the                etching                  ansd     frostitsg         of                          glass,        the
removal                        of         defects               in       the             glazing                    of         pottery,                      the             removal                   of       sansd               from               castings                   in
foundries,                           ansd             thse            removal                        of        rust.
                Of         tise          mansy                   salts              formed                         by          hydrofluoric                              acid            ins the               tissues,                       calcium                    fluoride
and              magnsesium                               fluoride                       are        the            only
                                                                                                                     insoluble                         onses.            The             others                are         soluble                     atsd         fully
dissociable,                              releasinsg                          the           fluoride                      ions         to           continue                     tissue               destruction
                                                                                                                                                                                                                .


                The            fluoride                         ions          readily                  pensetrates                              skin              and           goes’           quickly                  to          deep               tissue              layers
causinig                     liquefaction                                nsecrosis                     of the                   soft            tissues                 and             decalcifications                            ansd corrosioni                                  of
bonse             as       is-eli             as          the           type                of         dehydrationi                                   and            corrosion                        of       the            which
                                                                                                                                                                                                                              tissues    other
mineral                       acids                  produce.                        The               destruction                                  produced                       is      excruciatingly painsful                             perhaps
because                       tim             ionized                    calcium                       ansd             magnesium                                 is trapped                       forming                         relatively                       insoluble
calcium                      and               magnesium                                  fluoride        6        The          process                     of      tissue              destructions                            and             tseutrahiza-
tioni            of      the             hydrofluoric                                       is
                                                                                         acid proloniged                                  for         days,              unlike                 the          other                 acids               w-hich              are
rapidly                      neutralized.
                Flauder,                           Shselansski,                          atid          Gabriel,                        using                rabbits,                    demonstrated tisat                         the          amount
of      tissue                     damage                            increased              with              inscreased                            cotscetstrations                       of          the           acid.                Paley                  and
Seifter                    showed                         that                calcium                         glucotsate                            itsjection                    shortens                      the             healitsg                     time            of        the
burn                 ulcer               ins rats.

                                                                                                     Clinical                       Appearance

                Jones                provided                             one              of          the               earliest                     clinical                  descriptionss                              of         Isydrofluoric                               acid
burns                  ins which                      lie        remarked                            ons the                    intense                   pain            at       the          insjury               site,           the            w’hite              areas             of
          Read
            *      at                         the       Annual                   Meeting                       of the               Americans                      Society               for      Surgery                  of       the         Hand,               Chicago,
Illinois,    January                                 16, 1970.
            t    Department                          of     Surgery                      11212,           Stanford                    University                        Medical                Center,               300           Pasteur                Drive,             Palo
Alto,            Calnfornia                     94304.
VOL.            52-A,         NO.         5,        JULY              1970                                                                                                                                                                                931
932                                                                          D.     G.          DIBBELL                 AND           ASSOCIATES


                                                                                                          TABLE                  I
                            CmtsSmFICATIoN                             OF         IIYDROFLUORIC                      ACID            BURNS            PRoPosED                  BY       DIvtSI0N
                                           OF      INDUSTRIAL                         HYGIENE,                      NATIONAL                   INSTITUTES                 OF          HEALTH


                                           Hydrofluoric                           Acid                                                         Human             Burn
                                             Concentration

                                                                 0-20                    HF                         This           manifests
                                                                                                                                burn             itself
                                                                                                                        by pain   amsd erythema         as late
                                                                                                                        as 24 hours     after  burn.
                                                                20-50                    hF                         This    burn  becomes       apparent
                                                                                                                        1 to 8 hours    following        exposure
                                                                                                                       to the acid.
                                     Greater                   than          50            HF                       This     burns is felt immediately
                                                                                                                       and tissue       destruction    is
                                                                                                                       rapidly     apparent.




                                                                                                         TABLE                  II
                                                                RESULTS                  OF       TREATMENT                          OF        HYDROFLUORIC
                                                                                                        ACID           BURNS


                                                                                                                                                                                                       Per cent
                                                                                                                                Number                 of                 Tissue                          with
                            Method                  of         Treatment                                                                  Ca.ses                              Loss                   Tissue             Loss

1.      10         calcium      glucotiate   imijections                                           locally
             through       a 27 or 30-gauge         iseedle                                          after
             washing       with     water; the amoutit                                                of cal-
             cium         gluconate                      was       minsimum                      ansd       did        tiot
             distend           the          tissues;               no anesthetic                           was         used
             prior        to       the      injections
             Immediately                         after          exposure                                                                    13                                  0                                  0
             24 hours               after          exposure                                                                                    3                        3-prior          to                      100
                                                                                                                                                                        injection

2.      Iced         zephirari           soaks            for         over          1 hour               followed                              S                                4                                 50
           by        Kenalog                cream               or Neodecadrots                                cream
3.      Iced         zephirami              soaks     for over hour
                                                               1                                   followed                                     4                                 2                               50
           by        magnsesium                 oxide    oitstment.
4.      Iced           zephiran              soaks              for      over             1 hour                                               3                                  1                               33
5.      Magnesium                        oxide            ointment                   after          washing                                    4                                  2                               50
          with    water

6.      Neodecadron                         cream               after         wa.shing                  with        water                      6                                  3                               50
7.      Washing                   with          water            only                                                                          3                                3                                100

8.      Ammonia                    soaks            followed                  by         magnesium                                              1                                 1                              100
             oxide         ointmetit
                                                                                                                                            45




coagulation                          and          blistering,                        and           the          surrounding                          area         of     erythema.                     He        also          noted     that
there             seems              to       be          a predilection                                  for        subungual                        tissues,             a clinically                      important                 point
because                  of the              inaccessibility                                    of this             site        to local                   applicationis.
             In        our series                   ss’e         found                   that            Jones’s                description                        applied                    best          to    patients              who
are          first         seen             many                  hours                  after             the          burn              or        svho         have             received                  inadequate                  initial
treatment.                         The           patients                     seen              early           have           swollen,                erythematous, hot,                 and         tender              burn
sites           which               do       not           progress                       to       the          appearance                          described                  by        Jones              if adequate                treat-
ment            is      given.
             The         intensity                       and            rapidity                    of         onset           of         symptoms                      and           signs          vary          with          the    con-

                                                                                                                               THE          JOURNAL               OF       BONE           AND         JOINT            SURGERY
                                                                     HYDROFLUORIC                                        ACiD                BURNS                      OF         THE               HAND                                                                 933

centration                            of          acid,                    the            duration                                  of            contact,                         the               total                amoutst                            of       acid,                  and            the
penetrability                                 or          resistance                             of          the            tissue                      exposed                         to        the             acid.                It         is common                                  for          the
symptoms                             not           to          appear                      for           more                   than                   an          hour                 after              injury.

                                                                                                                          Materials

            Forty-five                             hydrofluoric                                    acid                  burns                    of         the            hand,                 personally                                 seen             ansd          treated                        by
the         authors                    durinsg                        the             period                      1960               to           1969,                 ivere                    Many
                                                                                                                                                                                           reviewed.                           of      these                  patients
were         employed                              in      the              semiconductor                                industry                            where                  hydrofluoric                                    acid               is used              to          etch
the        silica               semiconductor.                                   Some                   of         the           patients                          were                  employed                              ins insdustries                              ins w-hichs
hydrofluoric                               acid                is used                    to        clean                   glass                  ansd            to         remove                           rust            frons               metal                  parts.                These
patieists                  received                            care              by        the               insdustrial                               physician.                            Some                 patients                         w’ere             burned                        when
they             used            household                                  rust            removers.

                                                                                                   Results                           of         Treatment

            Thie           forty-five                            burns                    were                    treated                       as           shown                   ons         Table                   II.          Sixteens                      patiensts                       were
treated                 by           injections                         of        10        per              censt             calcium                          gluconate                            into              the           burns               area.              Thirteeti                        of
these             sixteen                        patients                        who               were                  sects                  immediately                                      after                exposure                          and               received                        cal-
cium             itsjectionss                        immediately,                                         all            had              immediate                                 relief                of      pains,               iso         tissue                 loss,              atsd          no
complications.                                The               other                    three                    patients                             is-ho            received                          calcium                          injectionss                          were                not
seen         by           us         initially                        and               received                         their                  injections                           late             (more                    thans               twenty-four                                 hours
after            the           burns).                  These                    patients                          all         had              relief                of       pain               from                 the          calcium                       injections,                             but
all       three                 required                         prompt                            d#{233}bridement                                     of       the               burned                       tissue                 under                      regional                      block
anesthesia.
            Thse           remainsinsg                               tw-ensty-nsinse                               patients                            were                 treated                       by          other                 methods.                        When                     the
fifteen                burns                     treated                        is-iths          zephirats                               (Table                       II,            \Iethods                           2 to               4)          are          conssidered                            to-
gether,                 tissue                    loss           occurred                               ins seven                           of          the             fifteen                   (44             per           cent).                   The               spectrum                              of
tissue              loss             ranged                      from                   skin                 vesicles                       to           partial                     loss             of         a digit.                         All          of         the           patiensts
treated                   with                   zephiran                             required                           ansalgesics                               during                        and              after                the               soaks.                   The               other
methods                     of        treatmenst                                 (Table                      II,           Methods                              5 to               5)           w’ere            also               associated                            withs              a higis
incidence                       of         tissue                loss.

                                                                                                                   Case                   Reports
            Three                    represenstative                                  cases                  are           presented                               ; two                   to         substantiate                   the               dangers                     of
inadequate                            treatmenst                                 ansd            orse              to        demonstrate                                        the              effectiveness                                    of          adequate                         itsitial
treatment.

          CASE            1. T.            0.,          a male                  gla.ssblower,                            twenty-eight-years-old,                                    sustaitsed                        a hydrofluoric                              acid          burn
of the           index           and             long          fingers of his                   right              hand               approximately                          thirty-six                    hours               prior              to     consultatiomm.
Imniediately                          after              his         exposure                      he         was
                                                                                                              seen          by            his          local           physiciatm                     who              wa.s          hot   familiar   the
                                                                                                                                                                                                                                                      with
effects          of hydrofluoric                                 acid.             The           physicians                         carefully                      cleaned                 the         patient’s                     fimmgers amid dressed                                    them
with        a bland                   ointnuent.                        The             patient,                    experiemiced                               with           hydrofluoric                             acid,           suggested                      that              he     should
be given                 a calcium                     gluconate                           injectiotm.                          The             physiciati                      admitiistered                           an
                                                                                                                                                                                                                 imitravemious                          imijectiomi                of
calciuns               gluconate                    and asked                           the patietitto                    returls                 in      a few              days.              Approximately                       twelve               hours             after
exposure                  the        patient                    noticed                   the           onset              of        fairly              deep               anid         severe
                                                                                                                                                                                        burning                   in   the tip               and             subumigual
area        of      the          index              and              bug              fingers                of      his            right              hand.
          Thirty-six                       hours                after             his        exposure                          to        hydrofluoric                              acid,             he         came            to          the         Stamiford                  University
hospital             emergency                              room.                  Examination                                  then              showed                     the         skimi around                         the
                                                                                                                                                                                                                       subutigual                      area          of      time
index            amid long fimmgers                             to         be         blistered,                     pasty                  white,                 hot,            and           firmly                edematous.                             The          pasty               white
areas        were               surrounded                            with              atm erythensatous                        flair.              The           bummed                    areas              were           excruciatimigly                              painful.
Before              anesthetizing                        the      digit,                  minute quamitities          of 10 per       edit       calcium      gluconate          were     itijected
carefully              inito         the          most.         paimmful                  area using       a 30-gauge        needle      atmd tuberculin syringe.           Themm after
blocking               the digital    nerves     with                                      per celst
                                                                                            1           xylocainse,     the blistered       skin was removed            and     the   cheesy
necrotic               material    ins the   bases                                        of the     blisters       was    debrided,         and       the  the index
                                                                                                                                                           nail     of        finger     was
removed.
          The          hand was                    dressed                      and        elevated,                       arid             the          patient                   was          hospitalized                           overnight.                         Immediately
following                 the         injections                      of        the       involved                        area              with             calcium                  gluconate                         the         patietst’s disappeared
                                                                                                                                                                                                                                                      pain

VOL.        52-A,          NO.         5.        JULY                1970
934                                                                                        D.      G.       DIBBELL                                AND             ASSOCIATES


permamsently.                                The           edema                amid             erythema                         subsided                        rapidly.                  The              burned                  area           healed                 satisfactorily                        in
the        course                of         the          next           fourteen                    days.

            C.&SE             2. V.               G.,      a wonsan,                        twenty-five                               years               old,         worked                  in a chemical                               factory.                  Through                   a hole
its      the          thumb                       of      her       protective                            glove                  hydrofluoric                               acid            gained                   access                to       the         skits          of      her          thumb.
Gr&lually       increasing         pain                                          caused            her          to         see             the         plant              physician.                           lie           washed                 the         hand                amsd         pre-
scribed    Percodan.           Three                                            hours                   later              she             saw             her           local             doctor                    who          administered
                                                                                                                                                                                                                                           Detnerol,                   100
milligrams         intramuscularly                                                     but              gave               her         no          other               treatmetst.                          The              severe             pain          continued                      atid         she
consulted                       a third                   physiciats                       an       hour              or         so         later.           He           admitted                          her         to      a hospital.                      On           adnsissiots                  (five
hours             after               she          sustained                    the             burts)               the         distal                segment                      of      her          right               thumb                was         tender,                 white,             hard,
and swollen.          She was given    pain      medication          and      was    discharged          forty-eight            hours       later.      Sixteen        days
later      she was readmitted         with a painful            gangrenous           palmar        surface        of the distal          segment right
                                                                                                                                          of the
thumb.          This     was debrided       utider      general       anesthesia.           Healimig      by secotid
                                                                                                                  intentioms         occurred            in six
weeks.       She did not complaiti          of painat follow-up           examinatiots            two    years        later,     at which          time       it could
be seen that           there  was complete          healing but   with      loss   of about         20 per        cent       of the distal           thumb        pulp
substance.         It was temmder.

      CASE  3. L. S., ahousewife,        twenty-seven      years      old, while         workitig     in a pottery                                                                                                                                                          class, used
Whimmk (a rust      remover,    approximately         20 per     edit     hydrofluoric          acid)    to improve                                                                                                                                                        the glaze    on                       a
vase.   She failed to read   the warnimig on the bottle      and did not     wear      gloves     to protect     Iser                                                                                                                                                hands             from
the        hydrofluoric                                 acid.           After                   using            the             solution                        for        approximately otse                       hour            and           fifteets                minutes,
she        noted                burning                pain        its    the         fitigers                  of her                right               hand.       with soap
                                                                                                                                                                          She             washed                   the         hand              vigorously
and water                       but        the pails     persisted.       Approximately          onse hour      after     exposure       to the      acid,     she    came      to
the         Stanford                      University             Hospital      emergency room.        All digits on the            right     hand         were     swollen,
erythematous,                           temider      and hot, particularly               on the palmar           surface      of the distal       arid middle          segments
(Fig. 1 ). The                         dorsal        aspect       of the distal       segments        including         the subungual           areas showed
                                                                                                                                             also                   signs
of inflammation.                               The patient            was given        injections      of 10 per cent calcium               gluconate          with     a 30-gauge
needle                its all        paiisful                 erythematous                         areas.              This                was            done           without                       ansesthesia.                    She              obtained                  complete
relief of all pairs     within                                          tens     mintntes.                       No          skims               vesicles                developed                          and          no      d#{233}bridemetit                      was         tiecessary.
Sixteets  hours     later pails                                    recurred                       in      the         distal                  palmar                   segment                    of        the         index              finger             and             was area
                                                                                                                                                                                                                                                                            this
injected               with                0.8          cubic           censtimeter                         of        10         per              cetst          calcium                    gluconate.                          Paims             was          relieved                 ims twenty
minutes.                   At follow                          tip visit.s              forty-eight                           and                 sevetity-two                            hours              laterwas she
                                                                                                                                                                                                                       free                 of      pairs            and          there
was         no         loss           of      tissue              (Fig.              2).


                                                                                                                           Discussion
               Proper                         therapy                           of              hydrofluoric                      acid                     burns                    should                        accomplish                                  dilutioti                      atsd
neutralizations                                   of       the           acid               and             then                  precipitation                                      and                elimination                                of       thie           free           fluoride
ions.             There                          is      general                      agreement                                    on             the             iseed               for           dilutions                        and                           One
                                                                                                                                                                                                                                                     iseutralizations.
should                     immediately                                  and                copiously                                  wash                   the              area                 with                  water                     and               (if        available)
sodium                        bicarbonate.
               Authorities                                    differ,            how-ever,                             as             to         the         best              way                to        prevenst                    the              destructive                             effects
of       the            fluoride                         ion        in          the              tissues.                        Some                     coat              the           injured                        area              w’ith              magnsesiuns                               oxide
paste                  (hydrofluoric                                      acid                  burns                ointment)                                   hoping                     to           precipitate                                the          fluoride
                                                                                                                                                                                                                                                                ‘.  Since
magnesium                                    oxide                is quite                       insoluble,                            the             ointment                            may                supply                   insufficienst                              magnesium
ions             to        precipitate                                  all          the            fluoride                           active                    on           the           burn                  surface.
               Others                       believe                     that                calcium                          ghuconate                                 injections                             into              the             area            of          the           burn             are
more              effective                       2.56          since            injections                                 place                    the          therapeutic                                     agent               in          the         deep                tissues                 at
the            site             of         continuing                            injury.                         In          practice,                             these                  injections                          in result
                                                                                                                                                                                                                                    prompt                           relief            of
local             pain,                    ansd          the            elimination                                  of       pain                   may               be          used                as         a guide                   to          dosage.                   Recurrence
of       pails             insdicates                            cotstinued                              activity                           of         the             acid              and             the             need               for          additional                            calcium
gluconate                              injections.
               When                        calcium                       gluconate                               injections                                        are             used                 one             should                     remember                               that             the
injections                             themselves                                are              painful,                            the            injured                        tissues                    are            prone                 to         infection,                         and,                if
too              much                      solutions                      is          injected,                              especially                                 into                the               fingers,                      pressure                          necrosis                     and
sloughing                              may                    result.                  Regional                                  block                     anesthesia                               (digital                      or            metacarpal                                block)                      is
getierally                            employed                            prior                   to        the             local                    calcium                        gluconate                                injection.
               Recently                                soaking                   the               burned                           with
                                                                                                                                  area                    cold            Hyamine                                 No.           1622                (a        highs               molec-
ular             weight                       quaternary                                    ammonium                                         compound)                                      has              been                recommended,12#{149}
                                                                                                                                                                                                                                           9                                  has

                                                                                                                                                           THE            JOURNAL                        OF          BONE             AND               JOINT               SURGERY
                                                                    HYDROFLUORIC                                     ACID           BURNS                   OF       THE               HAND                                                          935

beets            J)0stttltLted                         thiat               thse        quatertsarv                anirnonium                       nitrogen                        exchmatsges                           iotiized                chloride
for       fluoride                      ion           to        l)rodnnce                      a tsoti-iotsized                             fluoride                       consplex.                         Its        additiots
                                                                                                                                                                                                                          it is              j)Ossible
that             the           consi)ound                       nsay              dinectly                      alter            the         permeability                         of        tissue                  cell          membranses.
Iced             aqueous                  tit        alcolsolic                        hsyansitie                     solutioni               used
                                                                                                                                               is                  as a soak     for                                omie to four    hours
combitmed                        with                ansalgesics                            for         the          relief            of     paits.                Cold  is thought                                    to be betseficial                                        be-
cntuse            it        restricts                the        flow-             of        lymph                anmd blood                       atid                     t
                                                                                                                                                                   hsinsdershe                  developtisetit                               of edema
nitid the progression             of the fluoride       ion thronngls                                                                                            the tissues.         \Vetimet’lmold      nuid Shepard
have     poilsted      out that      Zephin-ans    (benzalikoniium                                                                                                 chloride)        cats be used        equally      well                                                             if
lmyamiise      is isot available.        Its their    series         200
                                                                 of over                                                                                          cases      of this    type     of itsjury     they
foutsd                 that              hivansinse                         soaks                  were               as
                                                                                                                     effective               as             calcium                     glucotsate                           itsjectiotss                      atmcl
nsagtsesium                        oxide                   topical                     burts             oi tstmetst.




                                              FIG.         1                                                                                                                FIG.            2
        Fig.     1: Right                        hand     of L. S. (Case               3) demonstrating the                                                      swollems         amid         erythensatous                           distal     arid
nsiddle           palmar                       segmnemsts        of the     fllsgers.        This   )hotograph                                                              was             takels        prior                  to       calcium                  glrrcolsate
irsjectiolis         115    the                l)atiemmt    arrived   at the ensergerscy            room.
       Fig.    2: flight                      isatmd of L. S. (Case             3) sevemsty-two            hours                                                   after          her         hydrofluoric                        acid    burms amid                     treat-
flielit      with        local                  10 per     cent     calcium         glucolsate       itsjections.                                                          Note             that      there                 is    rso tissue    loss.


            Of          the             three                   nsethod                           of      treatnsenst,                          calcium                       gluconate                                 itsjections                       seem             most
appropriate.                            Ins           our             series                 calcium                        gluconate                            injectionss                           were                most               successful                         in
prevetstitig                            tissue                  loss           ansd               eliminatinsg                          pain.                Reinisardt                               ansd          associates                            stated             that
iivaniitse                      baths                for            onse               to          four               hsours                are              easier                    to             adniitsister                            than                 calcium
glucotsate                         insjectiotss;                             but             ins a            busy               emergency                                 room                  or        office,                calcium                     gluconsate
insjectiotss                    which                   require    five                                 to    tens minsutes      would      seem    more    efficienst. It is also
nsoted       that                some                  of the authors                                      who recommensd           hyamine      soaks   recommetsd       calcium
insjectiotss                    whets                 the isails   are                                 insvolved.     Therefore,       w’e urge    the use of calcium          itsjec-
tiOIss       itsto            the             affected                       tissue,                   insciuding                   utsgual                  areas,               as            a standard                            part           of      thse       treat-
rnenst            of        hydrofluoric                                    acid            burnss.

                                                                                                   Proposed                         Treatment
            Ots         time basis-                        of        our            results,                  the             following                      outline                   of therapy                                is proPosed:
            1.         Copious                        washuinsg                        withs             large               volumes                        of      ice           cold water
                                                                                                                                                                                          tap                  susd              au          alkalinse
soap             is given                 as          first            aid             at      the            time             of      insjury.
            2.         The               hansd                 is      immediately                                      dressed                   at         the            time                 of       insjury                 with               a      soft          bulky
dressitig                   liberally                       soaked                      w-ithi           iced           zephsiran                      or        hyaminse                       chloride.
            3.         The               patienit                      is         referred                      to       a       physicians                         who                sisould                     be        made                 aw-are                of        tise
concenstrations                                 of         thse         hsydrofluoric                                 acid.
            4.         If       the              offending                             agent                  contained                         less              than                 20         per              censt              hydrofluoric                           acid,
treatmenst                         need                not             go          beyond                     iced             zephiran                      or         hyamine                          chloride                       soaks               for        one            to
four             hours                   with                  certain                      exceptions.                             Meticulous                               follow-up                             is       recommensded.
            If      the          concenstrations                                       of the             acid           was           greater                   than             20         per          cent,             or         the       burns                appear

VOL.        52-A,            NO.         5.     JULY                1970
936                                                                               D.       G.        DIBBELL                    AND                ASSOCIATES


to        be          deep,                  on- if          tisere              is        exquisite                     pain,                the          paitsful                 areas             should                 be       cautiously                           in-
jected                  with                 10       per           censt          calcium                     gluconsate.                          The            calcium                  gluconsate                      injectionss                     should
be         ins         milliliter                         ciuantities                        ins       order              not            to          distensd                 the           tissues                and             they             should                  be
injected                       through                       a       30-gauge                        needle.                   Block                anesthesia                        is genserally                         used             if     nsecessary
but            if tsot,                 by        utilizing                    the          patient’s                     pain           as          a monitor,                       the          smallest                   effective                    amount
of        calcium                       gluconsate                          may              be        determined.                                 Furthermore,          the          patienst                   cans       accurately
localize                  the areas                         requiring                      treatment.                            The               calcium                gluconsate                        is     infiltrated                       directly
itito            the           affected                       dermis                    and               subcutaneous              tissue                 using               a     tecisnsique                        similar               to       the
insfiltratiots                           of          a        local              anesthetic                            agent.                  Approximately                                     0.5             milliliter                   of       calcium
glucotsate                          per           s(luare                 ceistimeter                          of      burnsed                     surface               area          is a rough                        guide              to       the        usual
effective                      dose.                 The            insfiltration                         is carried                   0.5           censtimeter                      aw-ay             from              the         margins                of      the
obviously       insjured                                      tissue                 insto           the        surrounding                               apparently                          uninjured                         areas.
       5. After      the                                    calcium                    gluconate                       injections,                     the          burnt              area            of        patients                  with             severe
burtis                 nitty             be          carefully                       debrided.                      The             physician                          should                nsot        hesitate                    to       remove                  the
finigertmnil                       if        there               is aisy               question                     of         serious                 subungual                        exposure.
            6.          If the                 d#{233}bridement                         is performed,                              probably                        the          patient                should                be       hospitalized.
The              hansd              should                    be         dressed                     in      a soft               bulky                dressinsg,                    elevated,                     and             observed                   care-
fuhl’            for         the             next            forty-eight                             hours.              If      the           paits          recurs,                 additional                         calcium                   gluconate
insjections                        should                    be         givens.
            7.          The             patient                        should                   be          carefully                       follow-ed                     and             reconsstructive procedures
should                  be         instituted                          whsen            appropriate.

                                                                                                               Summary

            Hydrofluoric                                     acid           burns,                   if not              promptly                         recognized                        anid         properly                     treated,                    may
produce                      serious                   itijury              arid           prolonged                          disability.                     Chinsically,                      characteristicand                 specific
treatmetst,                             given               early,               is very                  effective.                   A series                   of     forty-five                    burns                is review-ed                      ansd          a
plan             of       treatment                               is      proposed                          which                depends                      in       part            on        the             severity                  of       the           tissue
itijury                and              includes                       local            injections                        of      10          per          ceist          calcium                   gluconate.

                                                                                                              References
     1.   BLUNT,                C. P.: Treatnierit       of Hydrofluoric                                                           Acid Skins Burtis Inmjectioms with
                                                                                                                                                by                                                                   Calciuns                Glu-
          cotsate.              hid. Med.    atid Surg.,    33 : 869-871,                                                         1964.
  2.      CRA1G,               11. D. P.: Hydrofittoric      Acid     Burns                                                       of the Hands.     British     J. Plast.                                                 Surg., 53-59,
                                                                                                                                                                                                                          17 :
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  3.       DIvIsIoN    OF INDUSTRIAL                                                   hYGIENE-NATIONAL                                INSTITUTES                        OF         IIE,SLTH:          Hydrofittoric                        Acid
          Burns.    mmd. Med., 12 : 634,                                             1943.
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          130-133.                 Philadelphia,        W. B. Saunders        Co.,  1960.
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                                                                                                                                                                                                                                          Toxicol.,
          205-212,                  1939.
  6.      hLAUDER,                   J. V. ; SHELANSKI,    L. ; and GABRIEL,       K.: Itidirstrial      Uses      of Compoutsds                                                                                              of     Fluorine
          atid          Oxalic             Acids.                 Arch.              md.           Health,            12 : 412-419,                            1955.
  7.      MAYER,                    Louts,     and               GUELICH,                    JOSEPH:                Hydrogen   Fluoride                           (hF)              Imihalation                   and        Burns.                Arch.
          Elsvirolm.               Health,                  7 : 445-447,                        1963.
 8.       PALEY,                AARON,               arid        SEIrrER,              JOSEPH:                Treatment                       of     Experimental               Ilydrofluoric                    Acid       Corrosion.
          Proc.           Soc.               Exp.           Biol.         arid         Med.,46:             190-192,                   1941.
  9.      REINHARDT,                          (2. F. ; HUME,                     W. U.;               LrNcH,      arid A. L.;                       WETHERHOLD,                        J. M.:            Hydrofluoric                        Acid
          Burn               Treatment.                     J. Am.             md.           Hygiene, 27 : 166-171,                                       1966.
10.       SIEDLECKI,                     J. T.: Hydrofluoric                                 Acid Burns. In Questiotss                                       and       Answers.                 J. Am.             Med.            Assns.,
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11.       SIMONS,   J.:                      Fluorine                Chemistry.                       Vol. I, p. 251.                          New   York,      Academic                                 Press,     1950.
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