What is the management for a chemical burn caused by sulphuric acid?

Management of Sulfuric Acid Chemical Burns

Immediately irrigate the affected skin with copious running water for at least 15 minutes, remove all contaminated clothing and jewelry, and call EMS if there are respiratory symptoms, systemic symptoms, or large burn areas. 1

Immediate Decontamination (First Priority)

The single most critical intervention is rapid removal of the chemical agent through irrigation. 1, 2

• Begin continuous irrigation with running water within seconds to minutes of exposure - outcomes are directly dependent on how quickly decontamination begins, with irrigation within 10 minutes significantly reducing full-thickness burns and hospital length of stay 1
• Continue irrigation for a minimum of 15 minutes - this duration is specifically recommended for caustic chemical exposures including sulfuric acid 1, 2
• If dry sulfuric acid powder is present, brush it off before water irrigation to prevent exothermic reactions 1
• Remove all contaminated clothing, jewelry, shoes, and surrounding materials immediately to prevent the chemical from being trapped against the skin and causing continued injury 1, 2
• Use personal protective equipment during decontamination to avoid contaminating healthcare providers 1

The 2024 American Heart Association guidelines emphasize that patients receiving immediate irrigation within 10 minutes with large volumes of water for at least 15 minutes had decreased full-thickness burns, fewer total burns, and shorter hospital stays compared to delayed irrigation. 1

Assessment of Burn Severity and Systemic Impact

After initiating decontamination, rapidly assess for:

• Total body surface area (TBSA) burned - sulfuric acid typically causes deep second-degree and third-degree burns with brown-black, leather-like eschar formation 3
• Respiratory involvement - check for circumoral burns, oropharyngeal burns, carbonaceous sputum, or difficulty breathing, which indicate inhalation injury and significantly increase mortality 4, 2
• Ocular exposure - sulfuric acid eye contact requires immediate continuous irrigation and ophthalmology consultation 1, 5
• Systemic toxicity signs - sulfuric acid can cause life-threatening metabolic acidosis and electrolyte derangements requiring immediate correction 6, 5

Call EMS immediately if: respiratory symptoms are present, systemic symptoms develop, or the burn involves large areas, face, hands, feet, or genitals. 1, 2

Fluid Resuscitation Protocol

For adults with burns ≥10% TBSA or children with burns ≥5% TBSA, initiate aggressive fluid resuscitation immediately. 4

• Administer 20 mL/kg of balanced crystalloid solution (Ringer's Lactate preferred) within the first hour via IV or intraosseous access if IV cannot be obtained 1, 4
• Calculate 24-hour fluid requirements using the Parkland formula: 2-4 mL/kg/%TBSA 4
• Give half of the calculated 24-hour volume in the first 8 hours post-burn, with the remaining half over the next 16 hours 4
• Target urine output of 0.5-1 mL/kg/hour to guide ongoing fluid administration 4
• Avoid normal saline (0.9% NaCl) as primary resuscitation fluid - it increases risk of hyperchloremic metabolic acidosis and acute kidney injury compared to balanced crystalloids 1

For children, higher fluid volumes (approximately 6 mL/kg/%TBSA) may be required due to their higher surface area-to-weight ratio. 1, 4

Wound Management

Wound care is NOT a priority until after adequate resuscitation is established. 1

• Clean wounds with tap water, isotonic saline, or antiseptic solution in a sterile environment 1
• Apply appropriate dressings - while no single dressing type is proven superior, avoid prolonged use of silver sulfadiazine on superficial burns as it delays healing 1
• Do NOT apply ice, butter, oil, or other home remedies - ice causes additional tissue damage 2
• Monitor for compartment syndrome in circumferential third-degree burns, which can cause acute limb ischemia 1, 4
• Consider escharotomy within 48 hours if circumferential burns cause circulatory impairment or intra-abdominal hypertension, but this should ideally be performed at a specialized burn center 1

Sulfuric acid burns often appear deceptively superficial initially but progress to full-thickness injury with extensive underlying muscle and neurovascular damage, requiring serial assessment and potentially early radical excisional surgery. 7, 3

Pain Management

Titrate intravenous opioids (short-acting preferred) and ketamine based on validated pain assessment scales. 1

• Ketamine is particularly effective for burn-induced pain and can reduce morphine requirements 1
• Cooling burns <20% TBSA in adults or <10% TBSA in children (if no shock present) can reduce pain and limit burn deepening, but cooling should not exceed 40 minutes to prevent hypothermia 1
• For dressing changes, consider general anesthesia for highly painful procedures 1

Critical Pitfalls to Avoid

• Never delay irrigation - every minute counts, and delayed decontamination dramatically worsens outcomes 1
• Do not underestimate burn depth - sulfuric acid causes progressive tissue damage that may not be apparent initially, and histologic monitoring may be needed to assess true depth 8, 3
• Avoid "fluid creep" (excessive fluid administration beyond calculated needs) as it leads to compartment syndrome and other complications 4
• Do not delay transfer to a burn center for burns involving face, hands, feet, genitals, or those with >10% TBSA in adults or >5% TBSA in children 4, 2
• Never break blisters - this increases infection risk 2

Specialized Considerations

Consult a regional poison control center for chemical-specific treatment recommendations, as sulfuric acid may require specialized management beyond standard irrigation. 1, 2 Some concentrated sulfuric acid burns at high altitude or with massive exposure may require prolonged intensive care with organ protection, prevention of sepsis, and multiple surgical interventions. 3