General Surgery · Year 3 · from General Surgery
Case 3: Chemical Burn
Patient Demographics
- Age: 28 years
- Sex: Female
- Occupation: Laboratory technician
Chief Complaint
"Acid spilled on my arm and face during an experiment."
History of Present Illness
The patient was working in a chemistry laboratory when a container of concentrated sulfuric acid (98%) broke, splashing onto her right arm, chest, and face. Coworkers immediately initiated emergency eyewash and shower protocols. She was under running water for approximately 20 minutes before EMS arrival. She reports severe pain in the affected areas. She was wearing safety glasses, which partially protected her eyes.
Prehospital Care
- Continued water irrigation during transport
- Removal of contaminated clothing
- Dry chemical brushed off before water (standard protocol)
Primary Survey
- A: Patent, speaking clearly, no oral involvement
- B: Normal respiratory effort, no chest involvement affecting breathing
- C: BP 142/88, HR 108 (pain response), stable
- D: GCS 15, alert and oriented
- E: Chemical burns to right arm, right chest, right face
Burn Assessment
Areas Affected:
- Right forearm and hand: 4.5% TBSA
- Right chest (lateral): 4.5% TBSA
- Right face: 2% TBSA (spared central face/eyes due to glasses)
- Total TBSA: ~11%
Burn Depth:
- Face: Superficial partial thickness
- Chest: Deep partial thickness
- Forearm: Mixed partial and full thickness
Chemical Identification:
- Agent: Sulfuric acid (strong acid)
- Concentration: 98%
- Mechanism: Coagulation necrosis (acids cause protein denaturation)
Eye Examination
- Visual acuity: Intact bilaterally
- Slit lamp: Minor conjunctival irritation, no corneal burns
- Continued irrigation with normal saline
Decontamination
- Continued copious water irrigation in ED
- pH monitoring of skin surface
- Irrigation until pH normalizes (approximately 30 minutes additional)
- No neutralizing agents used (exothermic reaction risk)
Wound Care
- After adequate decontamination:
- Gentle cleansing
- Debridement of loose tissue
- Topical antimicrobial (silver sulfadiazine)
- Sterile dressings
Pain Management
- IV opioids for initial pain control
- Tetanus prophylaxis updated
Hospital Admission
- Burn unit admission for wound monitoring
- Fluid resuscitation (modified Parkland - smaller TBSA)
- Daily wound assessments
Wound Evolution
- Day 3: Face burns healing well (superficial)
- Day 5: Chest burns showing epithelialization
- Day 7: Forearm burns delineating - areas of full thickness confirmed
Surgical Management (Day 10)
- Forearm: Tangential excision of full-thickness areas
- Split-thickness skin grafting
- Face and chest: Healed with conservative management
Hospital Course
- No infection
- Grafts take: 100%
- Physical therapy for hand function
- Scar management education
- Discharged Day 14
Follow-up Care
- Compression garments for hypertrophic scar prevention
- Silicone gel sheets
- Moisturization
- Sun protection
- Scar massage
Long-term Considerations
- Psychological support (facial scarring)
- Occupational safety review
- Return to work planning with safety modifications
Teaching Points
- Immediate copious water irrigation is the priority for chemical burns
- Continue irrigation until pH normalizes (may take hours)
- Do NOT use neutralizing agents (risk of exothermic reaction)
- Acids cause coagulation necrosis (limits depth of penetration somewhat)
- Alkali burns often more severe (liquefaction necrosis, deeper penetration)
- Identify the chemical agent when possible
- Eye involvement requires aggressive irrigation and ophthalmology consult
- Chemical burns may evolve over 24-72 hours
Clinical Image
Image Description: Clinical photograph demonstrating a chemical burn with characteristic demarcated borders following the splash pattern of the caustic agent. The wound shows coagulation necrosis typical of acid burns with varying depths of tissue injury.
Attribution: Image from Wikimedia Commons, Category:Chemical burns. Source: https://commons.wikimedia.org/wiki/Category:Chemical_burns