Severe skin disorder means those occupationally related dermatoses, burns, and other severe skin disorders which result in death or which require hospitalization or other multiple courses of medical therapy.
A. Clinical Description
Absolute irritants include an extensive list of strong acids and bases, and reactive chemical compounds. These agents produce severe inflammation on the first exposure. The response may vary from redness to necrosis. Their potential hazard is usually recognized and skin problems arise most often as accidents or as a result of basic unfamiliarity or ignorance.
B. Sources of Exposure
Some of the more common chemical irritants are: sulfuric acid, nitric acid, hydrofluoric acid, hydrochloric acid, phosphoric acid, acetic acid, formic acid, chloroacetic acids, sodium and potassium hydroxides, calcium hydroxide, sodium and calcium hypochlorites, calcium oxides, ammonia, phosphates, silicates, sodium carbonate, and lithium hydride.
C. Population at Risk
The population at risk is people who use these chemicals at their workplace.
D. Diagnosis, Treatment, and Prognosis
Clinical signs and symptoms vary depending on the route of exposure and the particular substances involved. Due to the variety of presentations, the emergency physician must be prepared to handle all possibilities. Some exposures, such as hydrofluoric acid, may present without immediate pain and should be considered in patients with complaints of slow onset deep pain occurring after exposure to an appropriate product.
Obtain a patient history, including the concentration, physical form, and pH of the chemical agent; route, volume, and time of exposure, and the possibility of coexisting injury. Evaluate the dermal exposure by its size, depth, location, and the presence of circumferential burns.
Pre-hospital care should consist of wound irrigation immediately after exposure, preventing the contaminated irrigation solution from running onto unaffected skin, and removing contaminated clothing. Emergency-room care should consist of thoroughly removing the chemical agent. After this, the physician should assess the full extent of the injury and treat the patient as a typical burn patient. Based on the degree of injury, ensure adequate fluid resuscitation and take precautions for complications (e.g., hypothermia, infection, rhabdomyolysis).
Hydrofluoric acid burns require special consideration. They should initially be treated as any other burn, with thorough irrigation. However, due to the penetrating power of the fluoride ion, specific neutralization procedures are indicated. Fluoride can be neutralized by either calcium or magnesium. For small superficial burns, topical calcium or magnesium gels can be applied. Deeper burns usually require subcutaneous injections of calcium gluconate. Hand burns can be difficult to manage. These can be treated with subcutaneous injections of calcium, intra-arterial calcium infusions, or a Bier-type calcium infusion. There are no objective comparative studies on these different treatments. Studies on animals demonstrated that IV magnesium is as effective or more effective than subcutaneous injections of calcium for local hydrofluoric burns. In situations in which local treatment of hydrofluoric burns is not possible, this treatment is safe and should be considered. Keeping the extremity warm and treating pain maximizes blood flow and delivery of the body's intrinsic calcium and magnesium.
Other medications have a limited role in the treatment of most chemical burns. Topical antibiotic therapy is usually recommended for dermal burns. Pain medications are important for subsequent burn care. After decontamination is performed on patients with chemical burns affecting a significant portion of the body, administer standard IV fluid and narcotic therapy as used for thermal burns.
The prognosis depends entirely on the extent of tissue injury. Small dermal lesions heal well. Larger dermal burns can produce significant scarring. Hydrofluoric acid burns can cause progressive tissue injury and may result in loss of digits.
E. Prevention of Exposure
Engineering controls, personal protective measures, proper work practices, and administrative controls that minimize skin contact with potential irritants can prevent occupational dermatoses.