What is the appropriate management for a patient with a Freon (refrigerant) burn?

Management of Freon (Refrigerant) Burns

Freon burns are deceptive cold-contact injuries that initially appear superficial but frequently progress to full-thickness burns requiring surgical intervention within days—immediate cooling with water, aggressive pain control, and close monitoring with early burn center consultation are essential. 1, 2

Immediate First Aid and Cooling

• Remove the patient from exposure and remove all contaminated clothing immediately to prevent continued cold injury 3
• Cool the affected area with clean running water (15-25°C) for 20-40 minutes as soon as possible, as this is effective for up to 3 hours after injury and significantly reduces tissue damage 4, 5, 6
• Never apply ice directly to the burn, as this causes additional tissue ischemia and damage 4, 5, 3
• Only perform cooling if the patient shows no signs of shock and the total body surface area (TBSA) is <20% in adults or <10% in children 4, 5

Critical Understanding of Freon Injury Pathophysiology

Freon burns evolve in two distinct phases that make early assessment unreliable:

• Phase 1 (Initial presentation): The burn appears deceptively superficial with minimal tissue damage, often presenting as simple bullae or erythema 1, 2
• Phase 2 (Days 2-7): Spontaneous progression to full-thickness burns occurs, revealing the true depth of injury and necessitating surgical excision and skin grafting 1, 2
• Freon is maintained at temperatures below -41°C, causing severe frostbite-type chemical burns on contact 1, 2
• The severity of injury varies widely from superficial bullae to deep tissue necrosis requiring amputation of digits, despite similar initial presentations 2

Aggressive Pain Management

• Provide titrated intravenous opioids and ketamine for severe burn-induced pain, using validated pain assessment scales to guide dosing 4, 3
• Short-acting opioids and ketamine are the most effective drugs for burn-induced pain 4, 5
• Inhaled nitrous oxide can be used when intravenous access is unavailable 4, 5
• For highly painful procedures or injuries, general anesthesia is an effective option 7, 5

Wound Assessment and Cleaning

• Assess the affected TBSA using the Lund-Browder chart (the gold standard method) rather than the rule of nines, which significantly overestimates TBSA 4
• Clean the burn wound in a clean environment with tap water, isotonic saline, or an antiseptic solution after proper pain control is established 4, 5, 3
• Document the initial appearance but recognize that the true depth will not be apparent for several days 1, 2
• Thorough irrigation is essential to remove any residual chemical contamination 4, 3

Wound Dressing and Monitoring

• Apply a moist dressing such as petrolatum-based ointment, petrolatum-based antibiotic ointment, medical-grade honey, or aloe vera with a clean nonadherent dressing 4, 5, 3
• Moist dressings significantly reduce complications including hypertrophic scarring compared to dry dressings 4
• Re-evaluate dressings daily to monitor for the characteristic delayed progression to full-thickness injury 5, 1
• When applying dressings on limbs, prevent bandages from inducing a tourniquet effect and monitor distal perfusion 5

Infection Prevention

• Topical antibiotics should not be used as first-line treatment but reserved for infected wounds only 4, 5, 3
• Systemic antibiotic prophylaxis should not be administered routinely 4, 5, 3
• Monitor for signs of infection including increasing pain, redness, swelling, or purulent discharge 4, 3
• Check tetanus immunization status as burns are tetanus-prone injuries 6

Mandatory Burn Center Consultation

Contact a burn specialist immediately for all Freon burns, regardless of initial appearance:

• All Freon burns affecting the hands require specialized burn center treatment, as these are occupational injuries with high functional importance 1, 2
• Burns covering >10% TBSA in adults or >5% in children require burn center referral 4, 5, 3
• All full-thickness burns (which will likely develop within days) require immediate medical attention 4, 5
• Chemical burns should be assessed by a burn unit regardless of initial severity 6, 8
• Specialist management is associated with better survival, reduced complications, shorter hospital stays, and lower costs 4

Anticipated Surgical Management

• Prepare the patient and family for likely surgical intervention including excision and skin grafting within 3-7 days as the injury declares its true depth 1, 2
• In severe cases, amputation of digits may be necessary 2
• Early excision may be indicated once the full extent of tissue necrosis becomes apparent 8

Critical Pitfalls to Avoid

• Do not be reassured by benign initial appearance—Freon burns characteristically progress to full-thickness injury over several days 1, 2
• Do not discharge patients with hand burns without burn center consultation and close follow-up arrangements 1, 2
• Do not apply butter, oil, or other home remedies as they increase infection risk and delay healing 5, 3
• Do not break blisters, as this increases infection risk 5, 3
• Do not delay wound care in favor of imaging studies unless there is concern for deeper structural injury 3