What is the emergency management of an acute sulfuric acid burn?

Emergency Management of Sulfuric Acid Burns

Immediately irrigate the burn with copious amounts of cold tap water (15-25°C) for at least 20-40 minutes while simultaneously removing all contaminated clothing to prevent ongoing tissue destruction and life-threatening metabolic acidosis. 1, 2, 3

Immediate Decontamination (First Priority)

• Begin copious water irrigation within seconds of exposure and continue for a minimum of 20-40 minutes, as sulfuric acid causes progressive tissue destruction until completely removed 2, 3, 4
• Remove all clothing and jewelry immediately during irrigation, as acid trapped under fabric continues burning the skin and can cause systemic absorption leading to severe metabolic acidosis (pH as low as 6.92 has been documented) 3, 5
• Have the patient take a complete shower if possible to avoid missing areas of contamination that may be overlooked 5
• Do not apply ice directly to the burn as this causes additional tissue ischemia 2
• Cooling is effective up to 3 hours post-injury and significantly reduces the need for skin grafting when performed for 20-40 minutes 2

Airway Assessment (Simultaneous Priority)

• Immediately assess for obstructive dyspnea, stridor, or facial/oropharyngeal burns, as sulfuric acid exposure can cause rapid airway compromise 3, 4
• Prepare for emergency intubation with all airway equipment immediately available if any signs of inhalation injury or facial burns are present 6, 4
• Monitor continuously with pulse oximetry and be prepared for surgical airway if needed 6

Metabolic Stabilization

• Obtain immediate arterial blood gas, as sulfuric acid burns commonly cause severe life-threatening metabolic acidosis (pH <7.0, base deficit >20 mEq/L) requiring aggressive bicarbonate and lactate buffer administration 3, 4
• Establish large-bore IV access and initiate Ringer's Lactate at 20 mL/kg within the first hour for burns >15% TBSA in adults or >10% TBSA in children 1, 2
• Target urine output of 0.5-1 mL/kg/h as the primary resuscitation endpoint 2
• Monitor serum creatinine closely, as admission creatinine ≥1.21 mg/dL predicts markedly higher rates of sepsis, pneumonia, and mortality 2

Pain Management

• Administer titrated IV ketamine at 1-2 mg/kg over 60 seconds combined with short-acting opioids for severe burn pain during ongoing decontamination and initial wound care 6, 7
• Use validated pain assessment scales to guide dosing and prevent under-treatment 6
• Continuous monitoring (ECG, pulse oximetry, blood pressure every 5 minutes) is mandatory during ketamine administration 6

Wound Care (After Stabilization)

• Clean the burn thoroughly with tap water, isotonic saline, or antiseptic solution in a clean environment after completing initial irrigation 2
• Apply moist dressings (petrolatum-based ointment, medical-grade honey, or aloe vera) with non-adherent secondary dressing, as moist dressings significantly reduce hypertrophic scarring (RR 0.13; 95% CI 0.03-0.52) 2
• Do not apply topical antibiotics prophylactically; reserve them only for confirmed wound infections 2
• Re-evaluate dressings daily to detect early complications 2

Burn Center Transfer

• Contact a burn specialist immediately for all sulfuric acid burns, as direct admission to a burn center improves survival, reduces complications, and shortens hospital stays 2
• Mandatory transfer criteria include: TBSA >10% in adults or >5% in children, any full-thickness burns, facial/hand/foot/perineal involvement, signs of inhalation injury, or metabolic acidosis 1, 2
• Sulfuric acid burns are typically third-degree and often meet transfer criteria due to depth and systemic complications 3, 8

Escharotomy Considerations

• Perform escharotomy within 48 hours if deep circumferential burns cause compartment syndrome threatening limb perfusion or respiratory compromise 1, 2
• This procedure should ideally be performed at a burn center; if transfer is impossible, obtain specialist consultation before proceeding 1, 2

Critical Pitfalls to Avoid

• Never delay irrigation to search for neutralizing agents—water irrigation is the definitive treatment and must begin immediately 1, 2
• Do not underestimate the severity based on initial appearance, as sulfuric acid causes progressive tissue destruction and third-degree burns are the rule 3, 8
• Do not overlook systemic toxicity—monitor for severe metabolic acidosis requiring hours of buffer therapy 3, 4
• Avoid prolonged external cooling devices in large burns (>20% TBSA adults, >10% children) due to hypothermia risk 2
• Do not miss hidden areas of contamination under clothing or protective equipment—complete decontamination is essential 5