Hydrofluoric acid: Difference between revisions
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==Background== | ==Background== | ||
*Used in both commercial and home setting | *Used in both commercial and home setting<ref>Cheong H, Kim J. Fatal hydrofluoric acid poisoning: histologic findings and review of the literature. Forensic Sci Med Pathol. 2023 Mar;19(1):67-71. PMID 36334175</ref> | ||
**Rust remover (most common home use) | **Rust remover (most common home use) | ||
**Glass etching, chrome and other metal cleaning, petroleum processing | **Glass etching, chrome and other metal cleaning, petroleum processing | ||
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***Pain immediately (even if wound appears minor) implies severe injury | ***Pain immediately (even if wound appears minor) implies severe injury | ||
*Burn itself may appear relatively minor | *Burn itself may appear relatively minor | ||
*Toxicity caused by binding of calcium | *Toxicity caused by binding of calcium and magnesium leading to electrolyte derangement and myocardial dysfunction<ref>McKee D, et al. A review of hydrofluoric acid burn management. Plast Surg (Oakv). 2014 Summer;22(2):95-8. PMID 25114621</ref> | ||
==Clinical Features== | ==Clinical Features== | ||
[[File:HF burned hands.jpg|thumb|Hydrofluoric acid (HF) burns, which were not evident until a day after exposure.]] | |||
[[File:Hydrofluoric_acid_burn.png|thumb|Hydrofluoric acid burn]] | [[File:Hydrofluoric_acid_burn.png|thumb|Hydrofluoric acid burn]] | ||
*Skin exposure | *Skin exposure | ||
**[[Burns]] | **[[Burns]] | ||
**Pain out of proportion to extent of burn | |||
*Ophthalmic exposure | *Ophthalmic exposure | ||
**[[Eye pain]] | **[[Eye pain]] | ||
**Erythema | **Erythema | ||
*Ingestion | *Ingestion | ||
**[[ | **[[Nausea and vomiting]] | ||
**[[Abdominal pain]] | **[[Abdominal pain]] | ||
*Inhalation | *Inhalation | ||
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*Trend calcium, magnesium, and potassium levels | *Trend calcium, magnesium, and potassium levels | ||
**Hydrofluoric acid chelates calcium and poisons the Na+/K+ pump | **Hydrofluoric acid chelates calcium and poisons the Na+/K+ pump | ||
**Expect [[hypocalcemia]] and [[hyperkalemia]] | **Expect [[hypocalcemia]], [[hypomagnesemia]], and [[hyperkalemia]] | ||
*Monitor EKG for signs of electrolyte abnormality | *Monitor EKG for signs of electrolyte abnormality | ||
**[[QTc prolongation]] | |||
**[[Ventricular tachycardia]] | |||
==Management== | ==Management== | ||
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**Calcium gel is commercially available (found in industrial first-aid kits) | **Calcium gel is commercially available (found in industrial first-aid kits) | ||
**Calcium gel can be made: | **Calcium gel can be made: | ||
***Mix calcium gluconate powder 3.5gm with 150mL water-soluble lubricant '''OR''' | ***Mix calcium gluconate powder 3.5gm with 150mL water-soluble lubricant (KY-Jelly) '''OR''' | ||
***Mix 25mL 10% calcium gluconate solution with 75mL water-soluble lubricant | ***Mix 25mL 10% calcium gluconate solution with 75mL water-soluble lubricant (KY-Jelly) | ||
**Benzalkonium Cl is commercially available | **Benzalkonium Cl is commercially available | ||
**If calcium gluconate is not available calcium chloride can be used | **If calcium gluconate is not available calcium chloride can be used | ||
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====Refractory injuries==== | ====Refractory injuries==== | ||
*Treat with intra-arterial | *Treat with intravenous infusion of calcium gluconate using Bier block | ||
**Place tourniquet proximal to exposure site on affected extremity and inject though IV distal to tourniquet | |||
**Inject 10 mL of 10% Ca gluconate diluted in 40 mL of saline and remove tourniquet after 20 min of dwell time | |||
*In severe refractory cases may also infuse intra-arterial calcium gluconate | |||
**Deliver via arterial line placed proximal to injury in the same limb | **Deliver via arterial line placed proximal to injury in the same limb | ||
**Infuse | **Infuse 10 mL of 10% Ca gluconate diluted in 40mL of saline over 4 hr | ||
===Ocular burns=== | ===Ocular burns=== | ||
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===Inhalation=== | ===Inhalation=== | ||
*Consider in any patient with facial burns or exposure to HF in confined space | |||
*Oxygen via NRB | *Oxygen via NRB | ||
*Nebulized 2.5% calcium gluconate | *Nebulized 2.5% calcium gluconate | ||
*Intubation may be required in severe cases | |||
===Systemic toxicity=== | ===Systemic toxicity=== | ||
*Administer [[calcium gluconate]] 100mg IV (10 mL of a 10 | *Administer [[calcium gluconate]] 100mg IV (10 mL of a 10% solution) over 2-3 minutes | ||
*May also need to replete [[magnesium]] (4g IV over 20 minutes) | *May also need to replete [[magnesium]] (4g IV over 20 minutes) | ||
*May see [[QTc prolongation]], [[cardiac arrhythmia]], or obvious systemic illness | *May see [[QTc prolongation]], [[cardiac arrhythmia]], or obvious systemic illness | ||
*Treat [[hyperkalemia]] as needed | *Treat [[hyperkalemia]] as needed | ||
==Medication Dosing== | |||
{{MedicationDose | |||
| drug = Calcium gluconate | |||
| dose = Topical gel (3.5g powder in 150mL lubricant or 25mL 10% soln in 75mL lubricant) | |||
| route = Topical | |||
| context = Minor cutaneous burns (<50 cm2 from <20% solutions) | |||
| indication = Hydrofluoric acid | |||
| population = Adult | |||
| notes = Rub into affected area 10-15min; pain relief is treatment endpoint | |||
}} | |||
{{MedicationDose | |||
| drug = Calcium gluconate | |||
| dose = 5% intradermal injection (max 0.5mL/cm2) | |||
| route = Intradermal | |||
| context = Severe cutaneous burns | |||
| indication = Hydrofluoric acid | |||
| population = Adult | |||
| notes = Dilute 10% calcium gluconate 1:1 with sterile NS | |||
}} | |||
{{MedicationDose | |||
| drug = Calcium gluconate | |||
| dose = 10mL of 10% in 40mL NS via Bier block (20min dwell time) | |||
| route = IV regional (Bier block) | |||
| context = Refractory cutaneous burns | |||
| indication = Hydrofluoric acid | |||
| population = Adult | |||
}} | |||
==Disposition== | ==Disposition== | ||
Latest revision as of 10:43, 22 March 2026
Background
- Used in both commercial and home setting[1]
- Rust remover (most common home use)
- Glass etching, chrome and other metal cleaning, petroleum processing
- Oral ingestion has very high mortality rate
- Onset and severity of symptoms correlated with concentration
- Dilute solutions (<20%) may have delayed onset up to 24hr post-exposure
- Moderate solutions (20-50%) develop symptoms within 1-8hr
- Concentrated solutions (>50%) develop symptoms immediately
- These patients are at highest risk for systemic toxicity/death
- Pain immediately (even if wound appears minor) implies severe injury
- Burn itself may appear relatively minor
- Toxicity caused by binding of calcium and magnesium leading to electrolyte derangement and myocardial dysfunction[2]
Clinical Features
- Skin exposure
- Burns
- Pain out of proportion to extent of burn
- Ophthalmic exposure
- Eye pain
- Erythema
- Ingestion
- Inhalation
- Shortness of breath
- Throat pain/burning
- Signs/symptoms of hypocalcemia and hypomagnesemia
- Can lead to QTc interval prolongation and cardiac arrhythmias, the primary cause of death in HF burns
Differential Diagnosis
Caustic Burns
- Caustic ingestion
- Caustic eye exposure (Caustic keratoconjunctivitis)
- Caustic dermal burn
- Airbag-related burns
- Hydrofluoric acid
- Tar burn
- Cement burn
Evaluation
- Clinical diagnosis
- Trend calcium, magnesium, and potassium levels
- Hydrofluoric acid chelates calcium and poisons the Na+/K+ pump
- Expect hypocalcemia, hypomagnesemia, and hyperkalemia
- Monitor EKG for signs of electrolyte abnormality
Management
- Decontamination: remove soiled clothing and irrigate thoroughly.
- Mainstay of treatment is application of calcium to affected area.
Cutaneous Burns
Minor injuries (<50 cm2 from dilute solutions <20%)
- Application of gel paste of Ca gluconate or benzalkonium Cl
- Rub into affected area for 10-15min with pain relief being used as end-point of treatment
- Calcium gel is commercially available (found in industrial first-aid kits)
- Calcium gel can be made:
- Mix calcium gluconate powder 3.5gm with 150mL water-soluble lubricant (KY-Jelly) OR
- Mix 25mL 10% calcium gluconate solution with 75mL water-soluble lubricant (KY-Jelly)
- Benzalkonium Cl is commercially available
- If calcium gluconate is not available calcium chloride can be used
Severe injuries
- Treat with intradermal injections of 5% calcium gluconate
- Prepare by diluting conventional 10% Ca gluconate with sterile NS in 1:1 ratio
- Inject in and around the burned area in amount not to exceed 0.5mL per cm2
Refractory injuries
- Treat with intravenous infusion of calcium gluconate using Bier block
- Place tourniquet proximal to exposure site on affected extremity and inject though IV distal to tourniquet
- Inject 10 mL of 10% Ca gluconate diluted in 40 mL of saline and remove tourniquet after 20 min of dwell time
- In severe refractory cases may also infuse intra-arterial calcium gluconate
- Deliver via arterial line placed proximal to injury in the same limb
- Infuse 10 mL of 10% Ca gluconate diluted in 40mL of saline over 4 hr
Ocular burns
- Irrigate with saline for at least 5 min
- If persistent pain administer 1% calcium gluconate to eye (dilute 10% calcium gluconate with normal saline)
- Consult ophthalmology due to irritation effect of calcium salts to eye
Ingestion
- If <1hr of ingestion, may consider NG tube for suction and gastric lavage
- Follow lavage by 300mL 10% Ca gluconate down NGT
- Consider intubation for airway protection
Inhalation
- Consider in any patient with facial burns or exposure to HF in confined space
- Oxygen via NRB
- Nebulized 2.5% calcium gluconate
- Intubation may be required in severe cases
Systemic toxicity
- Administer calcium gluconate 100mg IV (10 mL of a 10% solution) over 2-3 minutes
- May also need to replete magnesium (4g IV over 20 minutes)
- May see QTc prolongation, cardiac arrhythmia, or obvious systemic illness
- Treat hyperkalemia as needed
Medication Dosing
Calcium gluconate Topical gel (3.5g powder in 150mL lubricant or 25mL 10% soln in 75mL lubricant) Topical — Rub into affected area 10-15min; pain relief is treatment endpoint Calcium gluconate 5% intradermal injection (max 0.5mL/cm2) Intradermal — Dilute 10% calcium gluconate 1:1 with sterile NS Calcium gluconate 10mL of 10% in 40mL NS via Bier block (20min dwell time) IV regional (Bier block)
Disposition
- Consultation with poison center and burn center transfer per Burn center criteria
- Admission for all patients with arrhythmia on ECG or severe electrolyte disturbance