Do Primary Care Physicians (PCPs) treat severe chemical burns?

Primary Care Physicians Should Not Treat Severe Chemical Burns

Primary Care Physicians (PCPs) should not treat severe chemical burns and should instead refer these patients to specialized burn centers for optimal outcomes. 1

Rationale for Specialized Care

Severe chemical burns require specialized management that is typically beyond the scope of primary care settings for several reasons:

1. Specialized Assessment Required: Chemical burns often require expert evaluation to determine severity, measure the total burned surface area (TBSA), and initiate appropriate fluid resuscitation 1

2. Improved Outcomes with Specialist Care: Evidence shows that management by specialized multidisciplinary teams is associated with better survival, reduced complications, shorter hospital stays, and improved long-term functional outcomes 1

3. Complex Wound Management: Chemical burns may require surgical interventions like debridement, escharotomy, or skin grafting that cannot be performed in primary care settings 2

4. Risk of Systemic Toxicity: Certain chemicals can cause substantial systemic toxicity beyond local tissue damage, requiring specialized monitoring and treatment 2

Initial Management Before Referral

While PCPs should not manage severe chemical burns, they may need to provide initial care before transfer:

• Immediate Water Lavage: Copious irrigation with water should begin immediately and continue for up to 60 minutes 3, 4

• Remove Contaminated Clothing: If not stuck to the skin 3

• Pain Control: Provide appropriate analgesia

• Urgent Specialist Consultation: Contact burn specialists immediately, using telemedicine if available 1

When to Refer to a Burn Center

PCPs should refer chemical burn patients to specialized burn centers when:

• Burns involve special anatomical areas (face, hands, feet, flexure lines, genitals, perineum) 1

• Deep or extensive burns are present

• There are signs of compartment syndrome requiring escharotomy 1

• Systemic toxicity is suspected

• The chemical agent is known to cause severe tissue damage or systemic effects 2

Importance of Prompt Referral

Early referral to specialized burn centers significantly improves outcomes:

• Direct admission to burn centers is associated with decreased morbidity, even long-term 1

• Patients receiving prompt specialist care have significantly less full-thickness injury and more than twofold shorter hospital stays 4

• Early surgical interventions available at burn centers (excision and skin grafting) significantly reduce morbidity, mortality, and length of hospital stay 1

Medication Considerations

If PCPs must provide temporary care before transfer:

• Silver sulfadiazine cream may be applied to thermal burns but has limited utility for chemical burns 5

• Mafenide acetate may be used in certain cases but carries risk of adverse reactions including pain, burning sensation, and metabolic acidosis 6

• Specific antidotes may be needed for certain chemical exposures, but their use should be limited and guided by specialist consultation 7

Common Pitfalls to Avoid

• Delayed Irrigation: Failure to immediately irrigate chemical burns can lead to deeper tissue damage 4

• Underestimating Severity: Chemical burns can appear deceptively superficial initially but continue to cause damage over time

• Overlooking Systemic Effects: Some chemicals can be absorbed and cause systemic toxicity 4

• Inappropriate Use of Antidotes: Using incorrect neutralizing agents can sometimes worsen tissue damage 7

• Delayed Referral: Attempting to manage severe chemical burns in primary care settings can lead to worse outcomes and longer hospital stays 1, 4