A young man who works in a glass etching factory is rushed to ED for severe pain to his hand after a high concentration chemical solution spilled onto it. He complains of severe pain to the hand in the area of his injury, diffuse abdominal pain and intermittent twitching of several different muscles. On exam there is destruction of the skin tissue in the area of exposure and the beginning of tissue necrosis. After initiating irrigation with tap water, what should you do?
ANSWER: Apply calcium gluconate either as gel or local infiltration
Glass etching, home rust remover, metal cleaning and electronic manufacturing are key activities that question stems like to use to tip you off that the patient has been exposed to hydrofluoric acid. It is an acidic solution used in several areas: petroleum industry for high-octane gasoline, production of microelectronics, etching glass, removing rust, and cleaning cement and bricks. Dermal exposure is most common and the pain is typically very severe. Untreated skin will eventually become coagulated and may form an eschar. The fluoride ion binds to calcium and magnesium ions. If tap water irrigation is not successful, infiltration of calcium gluconate or application of a topical calcium gluconate gel can be considered. In this patient we could coat a glove in the gel and have the patient wear the glove. In severe cases, calcium gluconate in lactated ringers can be injected intra-arterially with a tourniquet in place isolating the limb and allowing the ca to concentrate. Systemic toxicity may occur leading to hypocalcemia demonstrated in this patient by his muscle fasciculations and abdominal pain.
Levine MD, Zane R: Chemical Injuries, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 64: pp 818-822.