Burn, Baby, Burn

     Attack One responds to a report of a "person having trouble breathing." There is a female on the front porch of the house to which they've been sent, and she appears in moderate distress. She has an inhaler in her hand, and her left arm is wrapped in a towel. "My asthma's been set off," she tells the crew.

     She has audible wheezing, so the crew prepares the nebulizer for a treatment with albuterol. As the first crew member obtains vital signs, he asks the patient to remove the towel on her arm.

     "It hurts too much when I take it off," she says.
     "It hurts? From what?" he asks.
     "I splashed something on it."
     "What was it?"
     "Don't know. Somebody gave me some stuff."
     "I need you to tell me what happened."

     The lady describes a clogged kitchen drain, no relief using a home drain solvent, and a coworker who suggested a "stronger chemical" to which he had access at work. He subsequently gave her a clear glass bottle of "industrial lye" and told her to pour the entire contents into the clogged sink. She followed those instructions, but when she dumped the liquid in the sink, some splashed onto her left arm. It burned immediately, so she grabbed a wet kitchen washcloth and placed it over the affected area.

     She then gives an interesting description of a "stinging vapor" that came off her arm when the wet cloth was placed there. The irritant gas caused her to begin wheezing. Becoming more concerned about her shortness of breath, she took a towel and wrapped it around her arm and the wet cloth.

     When the Attack One crew member removes the towel, the patient's arm is severely burned, and the washcloth has disintegrated to shreds of cloth. The burned area has already turned a slight yellow color, and the patient has sloughed the skin off.

     The crew decides to continue the nebulizer treatment and quickly decontaminate the patient outside. The nebulizer, attached to a mask, will treat the patient's bronchospasm and protect her airway from any further fumes. The treatment for an alkali exposure is prolonged irrigation, and on a warm day, the garden hose will be an effective water source. There are likely more fumes coming from the patient's clothing, so they need to be removed. The crew has not been inside the house, so the area of the clogged sink might be an ongoing issue. The jar of "industrial lye" obviously needs to be secured as well. The hazardous-materials team and an engine and truck are called for assistance in cleanup and ventilation.

     Decontaminating the patient quickly, with a two-person crew, in the front yard of the patient's house, requires some deft maneuvering and the assistance of the patient. The crew has a clean hospital gown and some sheets in their vehicle. The nebulizer mask is secured to the patient's head, and the crew holds up the sheets to protect her modesty. She is asked to remove all clothing and don the gown, leaving her left arm completely exposed. The clothing is to be left outside. They move the patient away from the clothing, to a place where her arm can be irrigated with the hose and the runoff can flow away from her, into the yard. Irrigation with a continuous soft water flow is begun promptly over the burned arm, with care taken not to splash the patient. An IV line is placed for pain control, and medical control orders pain medication and a continuous albuterol nebulizer. The patient's arm is irrigated continuously for 20 minutes on the scene. The nebulizer treatment continues, but the wheezing persists. Transportation to the burn center follows, and irrigation continues, utilizing bags of IV fluid and a bucket to catch the runoff.

Hospital Course
     The emergency physician meets the crew outside, and evaluation reveals ongoing respiratory distress and wheezing. The burn on the arm has spread no further, but an area about 8 by 8 centimeters has progressed to very deep full-thickness involvement. The surrounding skin, matching the area almost exactly where the towel was in place when the crew arrived, is blistered and painful. Irrigation with warm water continues in the ED. There has now been 45 minutes of continuous irrigation.

     The patient's distress continues, so a decision is made to intubate her and administer anesthesia to reverse the bronchospasm. She is admitted to the ICU, and when her respiratory compromise resolves 48 hours later, she's moved to the burn unit for prolonged treatment. She eventually recovers with significant scarring to her arm.

Case Discussion
     This patient had a major complication from an incident involving industrial chemicals in the home. This is not uncommon. Many, if not most, household chemical preparations are formulated specifically in diluted or modified concentrations to mitigate severe hazards. When individuals bring home chemicals from work, the scenario can change significantly.

     This individual had a major full-thickness burn related to a concentrated alkali: sodium hydroxide. This substance will produce a severe burn on the skin or, if inhaled, airway compromise. The patient sustained a classic alkali skin reaction, with a progressive erosion of the layers of skin. She also demonstrated a complication that is all too common: When a concentrated alkali (or acid) is not flushed off the skin with large quantities of water, the chemical burn area will enlarge, and the damage will continue. Decontamination of a concentrated hazardous material should only be done with large quantities of water. This patient also had a further complication in that the vapor released from the small amount of water placed on the alkali produced severe airway swelling and bronchospasm.

     As soon as possible, concentrated chemicals should be flushed off the body with large quantities of water, and the airway isolated to prevent secondary exposure. Alkali exposures require prolonged irrigation. For large body exposures, the water will need to be warm, or the victim can get severely hypothermic. Rescuers must be concerned about the initial runoff, as it still may be potent enough to release a chemical vapor or cause a direct burn to skin.

     Rapid decontamination must include removing all clothes, jewelry and shoes. Having rescuers, fellow employees or bystanders shield the patient with plain stretcher sheets gives a modest amount of privacy in a crisis situation, and then clean sheets or gowns can allow the victim to cover up. Cold-weather situations present difficulty no matter what.

     Continuous albuterol aerosol treatment is an effective method of treating severe bronchospasm, and using a mask allows isolation of the patient's airway.