Chemical and Electrical Burns: Specialized Field Protocols

Chemical Burns

The Core Principle: Dilute, Don't Neutralize

Every chemical burn protocol starts with one action: water irrigation. The impulse to apply a neutralizing agent (acid on base burns, base on acid burns) is wrong and dangerous. Neutralization reactions are exothermic — they generate heat — which deepens the burn. The correct response to all chemical burns is:

Copious water irrigation for at least 20-30 minutes.

More water, more time. That is the treatment.

Decontamination: The First Steps

1. Remove yourself and the patient from the chemical source. Do not become a casualty yourself. If the chemical is a gas or vapor, move upwind. If it is on the ground, move the patient without walking through it.

2. Remove contaminated clothing. Cut off clothing quickly — pulling it over the face spreads contamination. Remove jewelry, belts, shoes. Bag contaminated clothing in plastic.

3. Brush off dry chemicals first. If the chemical is a dry powder (lime, calcium carbide, some bleaching agents), brush as much off as possible with a dry brush or cloth before water contact. Water activates some dry chemicals and causes them to generate heat or create a caustic solution.

4. Begin water irrigation. Use the largest, most comfortable volume of clean water available. Running water is preferred. Remove contact lenses if eye involvement.

5. Duration: 20-30 minutes for most acids and bases. 60 minutes for hydrofluoric acid and cement lime. 45 minutes for concentrated alkalis.

6. Test pH. If litmus paper or pH strips are available, test the wound surface periodically during irrigation. Continue until pH is between 7 and 7.5. Acid burns reach neutral quickly. Alkali burns (bases) may take significantly longer.

Common Chemical Agents

Acid burns (sulfuric, hydrochloric, nitric acid):

• Cause coagulative necrosis — the protein denatures and forms a hard eschar that somewhat limits penetration depth
• Burns appear dry, brown, or black
• Irrigate with water for 20-30 minutes minimum

Alkali burns (lye/sodium hydroxide, lime, cement, ammonia):

• Cause liquefactive necrosis — penetrate tissue much more deeply than acids
• Burns look wet and soapy
• Significantly worse than equivalent acid burns
• Irrigate for 45-60 minutes minimum

Hydrofluoric acid (HF): The most dangerous chemical burn agent. HF penetrates through skin into muscle and bone, chelating calcium. Death from systemic hypocalcemia (low calcium) has occurred from burns covering as little as 2.5% TBSA.

Signs: burning pain hours after apparently minor exposure, systemic symptoms (cardiac arrhythmia, tetany, hypocalcemia).

Specific treatment: After 30-minute water irrigation, apply calcium gluconate gel — 3.5g calcium gluconate in 150ml water-soluble lubricant (like K-Y Jelly). This binds the fluoride ion, terminating the tissue damage. If gel is unavailable, IV calcium gluconate or intra-arterial calcium gluconate may be required. HF burns to the face, genitalia, or any burn greater than 1% TBSA require immediate emergency evacuation.

Cement burns: Concrete and wet cement are caustic — pH can exceed 12. The insidious danger is that concrete burns often go unnoticed because cement feels cool and damp. By the time pain develops, significant tissue damage has occurred. Workers sitting in wet concrete or kneeling on fresh concrete can develop severe burns over large areas.

Treatment: Remove from contact, irrigate for 60 minutes, treat as alkali burn.

Eye Chemical Burns

Eye exposure to any chemical is an emergency.

1. Immediately irrigate with large volumes of water. Hold eyelids open — this will be difficult with the patient's reflex to close them.
2. If available, Morgan lens or IV tubing threaded under the eyelids allows continuous irrigation
3. Normal saline is ideal; clean water is acceptable
4. Irrigate for minimum 20-30 minutes, 60 minutes for alkali exposure
5. Check visual acuity after irrigation
6. Evacuate for any chemical eye exposure — even if the patient feels better after irrigation, delayed complications can cause permanent vision loss

Chemical Burn Dressing

After thorough irrigation, treat chemical burns similar to thermal burns of equivalent depth. The critical difference: chemical burns may continue to cause tissue damage if irrigation was incomplete. Watch for symptoms recurring hours after the initial injury, which suggests inadequate decontamination.

Cover with non-adherent dressings. Do not apply neutralizing agents. Evacuate for burns greater than small areas (more than 1-2% TBSA), burns to face or hands, or any exposure to hydrofluoric acid or concentrated alkali.

Electrical Burns

Assessment First: Is It Safe?

Before approaching a victim of electrical injury, confirm the power source is off. Do not touch the patient if they may still be in contact with a live electrical source. A person in contact with household current can transmit lethal current to a rescuer. Turn off the breaker or use a non-conductive object (dry wood, plastic) to move the patient away from the source if absolutely necessary.

High-voltage lines (power lines, railway lines) require professionals. Stay at least 10 meters from the patient and source. Call for emergency services.

Types of Electrical Burns

Low-voltage (under 1,000 volts, household current):

• Entry wound at the point of contact, often the hand
• Exit wound at the ground contact, often the foot or buttock
• The primary danger is cardiac arrhythmia, particularly ventricular fibrillation
• The external burn may be small — this does not indicate low risk
• Any victim of household electrical shock should have cardiac monitoring

High-voltage (over 1,000 volts, power lines, industrial equipment):

• Massive tissue destruction along the current path
• Flash burn (caused by electrical arc, essentially a thermal burn from radiated heat) may also be present
• Entry and exit wounds may be large, deep, charred
• Internal damage to muscle, bone, and vessels far exceeds visible external damage
• Rhabdomyolysis (muscle breakdown) and acute kidney failure are common
• Risk of delayed tissue necrosis days after initial injury

Lightning strikes: A lightning strike is a brief, massive-amperage DC current followed immediately by a reverse current pulse. It differs from AC electrical injury.

• "Flashover": current often travels over the body surface rather than through it — many victims survive with less internal damage than equivalent AC injury
• Entry and exit wounds may be absent or subtle
• Ferning pattern burns (Lichtenberg figures) — branching red marks on skin — are pathognomonic for lightning injury
• Risk of respiratory arrest and cardiac arrest. Start CPR immediately if unresponsive.
• Contrary to intuition, lightning victims are safe to touch — they carry no residual charge

Initial Assessment and Field Treatment

1. Scene safety. Power off, no lightning risk, no downed wires.

2. Check for cardiac arrest. Lightning and low-voltage AC injuries can cause immediate cardiac arrest. Start CPR if no pulse.

3. Spinal precautions. High-voltage and lightning injuries frequently involve falls or blast effect. Treat as potential spinal injury until proven otherwise.

4. Assess entry and exit wounds. Document location. Entry wounds are typically smaller and more well-defined; exit wounds are often larger, more irregular.

5. Treat external burns. Clean and dress the entry and exit wounds like thermal burns of similar appearance.

6. Fluid replacement is critical. Electrical injury causes massive muscle breakdown (rhabdomyolysis). Myoglobin from destroyed muscle is filtered through the kidneys. If urine output drops or urine appears dark brown (like tea or cola) without dehydration, the kidneys are being damaged. Aggressive fluid replacement is essential.

Urine color is your guide: Pale yellow = adequate hydration. Dark or tea-colored without dehydration = rhabdomyolysis occurring, increase fluids dramatically.

Target: urine output of 100ml per hour in a high-voltage electrical injury patient. This requires oral hydration approaching 1-2 liters per hour in the early hours.

7. Monitor for compartment syndrome. Electrical burns to the extremities cause massive swelling. If the forearm or leg feels rock-hard, if the patient complains of severe pain with passive stretch of the fingers or toes, or if pulses are diminishing distally, compartment syndrome may be developing. This requires emergency fasciotomy (surgical release of pressure) — a skill beyond field scope. Evacuate urgently.

What to Watch For: Delayed Complications

Electrical burns have more late complications than thermal burns of equivalent appearance.

Wound progression: Electrical wounds often look stable initially, then demarcate (edges become clear, tissue dies) over days 3-7. A wound that looks manageable day one may require amputation by day seven. This is not a management failure — it is the nature of electrical tissue death.

Cardiac arrhythmia: Can occur hours after the initial injury. Any victim of significant electrical shock needs monitoring for at least 24 hours for cardiac rhythm changes.

Neurological: Peripheral nerve damage (paresthesias, weakness), spinal cord syndromes, and delayed central nervous system effects have all been reported after electrical injury.

Cataracts: Late complication of lightning and high-voltage injury. Occurs months to years later.

Evacuation Criteria

Evacuate immediately for:

• High-voltage electrical injury regardless of visible burn size
• Lightning strike regardless of apparent severity
• Any loss of consciousness
• Cardiac arrhythmia or cardiac arrest at scene
• Dark urine (myoglobinuria)
• Signs of compartment syndrome
• Entry/exit wound on the head or torso
• Any burn to hands, feet, or face

Low-voltage household injury with a very small burn, no loss of consciousness, and cardiac rhythm confirmed normal for 2-4 hours may be managed locally with close monitoring. The risk period extends 24-48 hours.