What is the management for a non-circumferential chemical burn to the heel from floor stripping chemical, presenting 1 week after injury?

Management of Non-Circumferential Chemical Burn to Heel from Floor Stripping Chemical, Presenting 1 Week Post-Injury

For this delayed-presentation chemical burn, immediately irrigate the wound with copious running water or saline for at least 15 minutes (even at 1 week post-injury if any residual chemical is suspected), then clean thoroughly, apply a petrolatum-based antibiotic ointment with non-adherent dressing, provide adequate pain control, and monitor closely for infection given the delayed presentation. 1, 2

Immediate Wound Assessment and Decontamination

Even though this patient presents 1 week after injury, you must first assess whether any residual chemical remains on the wound surface:

• If any chemical residue is visible or suspected, immediately irrigate with copious running water or saline for at least 15 minutes, as floor stripping chemicals (typically alkaline agents) can continue causing tissue damage if not completely removed 1, 2
• Floor stripping chemicals commonly contain strong alkalis (sodium hydroxide, potassium hydroxide) which cause liquefactive necrosis and can penetrate deeply into tissue over time 3, 4
• The delayed presentation is concerning because alkaline burns characteristically deepen over days to weeks, making initial depth assessment unreliable 5, 4

Wound Cleaning and Preparation

After ensuring complete decontamination:

• Clean the wound thoroughly with tap water, isotonic saline, or antiseptic solution in a clean environment to remove any debris, necrotic tissue, or foreign matter 6, 2
• This thorough irrigation is essential even at 1 week post-injury to prepare the wound bed for appropriate dressing 6
• Assess burn depth carefully: look for areas of white/gray eschar (full-thickness), blistering with pink base (partial-thickness), or superficial erythema 5, 7

Pain Management

Given that this is a heel burn presenting 1 week later, pain control is essential:

• Provide adequate analgesia before and during wound care - this may require oral opioids or parenteral medications depending on pain severity 8, 2
• Short-acting opioids and ketamine are most effective for severe burn-induced pain during dressing changes 8, 2
• For ongoing pain management, acetaminophen or NSAIDs may suffice for mild burns, but escalate to opioids if needed 2

Wound Dressing Selection

The choice of dressing depends on burn depth assessment:

For Partial-Thickness Burns:

• Apply petrolatum-based antibiotic ointment and cover with non-adherent dressing 2, 7
• Avoid silver sulfadiazine on superficial burns as it delays healing when used long-term, though it can be applied to partial-thickness burns at 1/16 inch thickness once to twice daily if infection is a concern 1, 9, 7
• Modern occlusive dressings provide faster healing and are more cost-effective than silver sulfadiazine 7
• Re-evaluate dressings daily given the delayed presentation and risk of infection 2

For Full-Thickness Burns:

• Cover with clean, dry, non-adherent dressing 2
• All full-thickness chemical burns require immediate evaluation by burn surgery 2

Infection Monitoring - Critical at 1 Week Post-Injury

The 1-week delay significantly increases infection risk:

• Monitor closely for signs of infection: increasing pain, redness, swelling, purulent discharge, or fever 6
• Do not use topical antibiotics prophylactically - reserve them only for infected wounds to prevent antimicrobial resistance 6, 1
• If infection develops, consider appropriate topical antimicrobial treatment after proper wound cleansing 6
• Systemic antibiotic prophylaxis should not be administered routinely 6

Referral Criteria and Follow-Up

Determine if this patient requires burn center referral:

• Burns involving the feet require specialized burn center treatment 6, 1
• Any full-thickness burn requires immediate burn surgery evaluation 2
• Partial-thickness burns covering >10% TBSA in adults require burn center referral 6
• Given the heel location (weight-bearing surface) and delayed presentation, strongly consider burn surgery consultation regardless of size 6, 2

Special Considerations for Floor Stripping Chemicals

• Contact your regional poison control center for specific recommendations if the exact chemical composition is known, as some alkaline agents may require specialized treatment 1, 2
• Alkaline burns characteristically continue to deepen over time, so what appears superficial now may progress to deeper injury 3, 4
• The heel location poses functional concerns for ambulation and weight-bearing during healing 6

Critical Pitfalls to Avoid

• Do not apply ice directly to the burn - this causes additional tissue damage 1, 2
• Do not break any blisters - this increases infection risk 1
• Do not delay medical attention further if the burn shows signs of full-thickness injury, infection, or involves significant surface area 1, 2
• Do not underestimate burn depth - chemical burns, especially alkaline, often appear deceptively superficial initially but deepen over days to weeks 5, 4