What is the management for an alkaline burn on the shoulder?

Management of Alkaline Burn on the Shoulder

Immediately irrigate the alkaline burn with copious running water for at least 15 minutes, starting within seconds to minutes of exposure, as outcomes are directly dependent on how quickly decontamination begins. 1

Immediate Decontamination (First Priority)

• Begin continuous irrigation with running water immediately upon contact with the alkaline substance, as alkalis cause liquefactive necrosis through saponification of lipids and protein denaturation, which continues until the chemical is completely removed 2, 3
• Continue irrigation for a minimum of 15 minutes, though alkaline burns may require longer irrigation than acid burns due to their tendency to penetrate deeper into tissues 4, 1
• If dry alkaline powder is present, brush it off before water irrigation to prevent exothermic reactions 1
• Remove all contaminated clothing immediately to prevent the chemical from being trapped against the skin and causing continued injury 1

Important caveat: While one animal study suggested that neutralization with 5% acetic acid (household vinegar) may reduce alkaline burn depth compared to water alone 5, current international consensus guidelines do not recommend neutralization as first-line treatment 4, 3. Water irrigation remains the gold standard because it is universally available, safe, and effective 3.

Initial Cooling and Assessment

• After thorough irrigation, cool the burn with clean running water (15-25°C) for 5-20 minutes if the burn area is small (<20% TBSA in adults) to limit burn depth and reduce pain 6, 7
• Avoid cooling if the patient shows signs of shock or if the burn covers >20% TBSA in adults or >10% in children, as this increases hypothermia risk 4
• Assess burn depth, size, and location to determine whether specialized burn center referral is needed 6

Pain Management

• Provide adequate analgesia during wound care, as alkaline burns are typically very painful 4
• Use short-acting opioids and titrated intravenous ketamine for severe pain, as ketamine is particularly effective for burn-induced pain and can reduce morphine requirements 4, 1
• Consider inhaled nitrous oxide when intravenous access is unavailable 4

Wound Care

• Clean the wound with tap water, isotonic saline, or an antiseptic solution in a clean environment after proper pain control is established 4, 6
• Apply a moist dressing such as petrolatum-based ointment or antibiotic ointment with a clean nonadherent dressing 6
• If using silver sulfadiazine, apply to a thickness of approximately 1/16 inch once to twice daily, but avoid prolonged use on superficial burns as it may delay healing 6, 8
• Do not use topical antibiotics as first-line treatment—reserve them only for infected wounds to prevent antimicrobial resistance 4, 6

Referral Criteria

Refer to a burn center or emergency department if: 6, 1

• The burn involves the face, hands, feet, or genitals
• The burn covers >10% TBSA in adults or >5% in children
• Any full-thickness (third-degree) burn is present
• Signs of respiratory involvement (circumoral burns, oropharyngeal burns, difficulty breathing) are present
• Signs of infection develop (increasing pain, redness, swelling, purulent discharge)

Critical Pitfalls to Avoid

• Never delay irrigation—every minute counts, as alkaline substances continue to cause tissue damage until completely removed 1, 2
• Do not apply ice directly to burns, as this causes additional tissue damage 6, 7
• Do not apply butter, oil, or other home remedies 7
• Do not break blisters, as this increases infection risk 1, 7
• Avoid attempting chemical neutralization in the field, as water irrigation is safer and more effective 3