Burns Open 3 (2019) 96–98

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Burns Open
journal homepage: www.burnsopen.com

Beware of household remedies. You may get burned!

Marcus Sng a,⇑, Jeremy Wiseman a,b, Julian Liew a, Rodrigo P Teixeira a,c
a
Plastic and Hand Surgery Unit, Northern Health, Epping, Victoria, Australia
b
Honorary Clinical Lecturer University of Melbourne, Australia
c
Honorary Clinical Senior Lecturer, Division of Surgery, University of Melbourne, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Burns are a common injury presenting with a broad spectrum of severity. The mechanism of
Received 23 March 2019 burn injuries is generally of a single modality, i.e. thermal, chemical or electrical.
Received in revised form 18 May 2019 Objectives: Herein, we report a case of a burn injury involving, a scald burn injury followed by a super-
Accepted 23 May 2019
imposed chemical burn injury that aggravated the initial injury and lead to unplanned return to theatre.
Available online 30 May 2019
To our knowledge a unique case like this has not been previously reported in the literature.
Case: The patient a fit and healthy 5-year-old male who presented 24 h post-injury to the emergency
Keywords:
department. Immediately following the thermal burn injury from hot tea, a slurry of baking soda (sodium
Burns
Burn management
bicarbonate) was applied as a first-aid measure and left overnight. The domestic treatment resulted in a
Thermal burns full thickness burn of the skin on the chest wall. It is uncommon for scald burns to present acutely with a
Chemical burns well demarcated full thickness burn. Presumably, sodium bicarbonate, normally a mild alkali and seem-
Sodium bicarbonate burns ingly innocuous household product, caused additional chemical injury in the setting of partial thickness
Mixed modality burns thermal burn and lead to full thickness skin necrosis after. Furthermore, after debridement to viable tis-
Skin graft in burns sues, the first attempt at reconstruction with split skin graft was complicated by near total graft failure.
We present this case to highlight the danger of domestic treatment with alternative home-made reme-
dies. In addition, we hope that it will provide insight into an unique and rare clinical presentation, as well
as provide guidance in the management of such injuries.
Ó 2019 Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

1. Background with the aim to ensure that the wound is neutralized. The principle
of delayed reconstruction should be considered in chemical burns
Burns are commonly preventable injuries, ranging in clinical [1].
severity, and have the potential to severely affect patients’ lives. Multi-modal burn injury is a unique and rare clinical presenta-
Effective and appropriate management of burns is entirely depen- tion, the authors were unable to identify a similar case report in
dent on accurate clinical assessment and based on thorough his- the current literature and report a multi-modal thermal – chemical
tory and examination. Attention and consideration must be given injury, discussing the relevant pitfalls of management.
to the mechanism of burn injury. Regardless of the mechanism of
injury, first aid is paramount in the management of burns (i.e. copi-
2. Case report
ous irrigation with cold running water for 20 min within the first
3 h of injury). Further management may vary from regular dress-
2.1. Patient
ings to surgical debridement and skin grafting. Particular attention
must be paid where there is chemical insult. Generally speaking,
The patient was a 5-year-old male fit and healthy. All immuni-
caustic agents such as alkali or acids can cause inconspicuous
sations were up to date and there was no history previous injury to
and ongoing tissue destruction. Alkali agents are more penetrative
the burn site.
then acids and tend to liquefy tissues causing more extensive
injury.[1,2] Litmus paper can be used to measure wound pH to
guide irrigation and duration of the first aid for chemical injuries, 2.2. Presentation

The patient sustained a scald burn from tea made with boiled
⇑ Corresponding author. water. First-aid was attended with cool running tap water for five
E-mail address: marcussngc@gmail.com (M. Sng). minutes and a cool compress with a towel. His parents conducted

https://doi.org/10.1016/j.burnso.2019.05.004
2468-9122/Ó 2019 Published by Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 M. Sng et al. / Burns Open 3 (2019) 96–98 97

an internet search for pain remedies for scalds on the search provided no further insight into this clinical presentation.
engine, GoogleTM Mountain View, CA, United States. They chose to Literature review on PubMed, Cochrane, OVID and Medline only
proceed with an alternative treatment that they had previously revealed 2 case reports of chemical injury from sodium
heard about and made a paste from baking soda and water. The bicarbonate both extravasation injuries with little application to
paste was applied to the burn and covered with an occlusive dress- this clinical scenario [3,4]. There were no case reports identified
ing made of cellophane wrapping. This was left overnight on the of chemical injury in the setting of concurrent thermal burn.
burn site. On the following morning, his parents removed the The guardians of our patient reported the application of baking
dressing and were surprised at how much worse the burn looked. soda to burns as a commonly used home remedy, and indeed gen-
They immediately took him to the Emergency Department (ED). eral internet search using the terms ‘‘baking soda” and ‘‘sodium
After initial triage in ED, the patient was referred to specialist bicarbonate” AND ‘‘burns” using the search engine GOOGLETM, did
care with the Plastic and Hand Surgery Unit. reveal various sources identifying baking soda as useful in the
first-aid of burns. With claims that it can relieve heat and pain,
2.3. Treatment when applied as a paste or slurry.
It is our hypothesis that damage to the epidermal barrier from
Examination under general anaesthetic revealed a TBSA of 3% partial thickness thermal injury rendered the relatively mild alkali
with approximately 2% full thickness injury on the chest. There agent, sodium bicarbonate, when applied for an extended duration
were small burns to the neck and chin predominantly superficial under occlusive dressings, extremely damaging to the tissues lead-
partial thickness that were not treated with the baking soda paste. ing to full thickness skin damage and progressive fat necrosis.
The burn to the neck was debrided, cleaned and dressed with silver This case reminds us of the importance for public education
impregnated dressings, ActicoatTM, Smith-Nephew, London, UK. The regarding burn injuries. It highlights the potential hazard of using
full thickness burn over the chest was excised to healthy underly- alternative home-made remedies. It also illustrates a rare clinical
ing fat tissue. The decision was made intra-operatively to graft the presentation of a potential chemical burn superimposed to a ther-
defect primarily with a split thickness skin graft as the wound bed mal injury that if not recognised presents as a pitfall in early recon-
was deemed to be fine. The graft was secured with a negative pres- struction. We would recommend that any clinician encountering
sure dressing. The patient remained admitted post-operatively. similar superimposed burn injury obtains a thorough history
On day 7 the patient was returned to theatre for graft check. His including any possible interventions, no matter how seemingly
neck wound was healing well. However, the graft on the chest was benign, and consider a more cautious approach with delayed
non-viable and required a second sharp debridement and dressings reconstruction.
with ActicoatTM. Due to the unexpected outcome and further tissue
necrosis, it was decided to proceed cautiously and delay recon-
struction until the wound was stable with no further tissue loss.
The patient was discharged with outpatient follow-up.
We were perplexed by the graft failure and realised that the
sodium bicarbonate in the baking soda could have resulted in an
underlying insidious chemical burn. A second opinion was sought
with the state paediatric burns centre. They were also surprised
by the outcome and reported that they had not experienced a sim-
ilar case of potential thermal injury aggravated by a chemical burn
from home-made medicine. On Day 9, progression of fat necrosis
was seen during dressing change and was treated with further
debridement and dressings, delaying reconstruction once more.
On day 14 the wound was examined in theatre and no further
tissue loss was seen. After minor debridement a split thickness skin
graft was placed over the wound and dressed with non-adhesive
interface dressing layer and negative pressure dressing. At graft
check on day 21, the second skin graft had taken fully. The patient
was followed up in our outpatients’ department closely. There
were no further complications and the patient has subsequently
been discharged with scar management advice.

2.4. Outcome and discussion points

This was a particularly troubling case being a paediatric patient.

What was thought to be a relatively simple soft tissue defect, was
complicated, and required multiple debridements and repeat skin
grafting. Consultation with the state paediatric burns centre
98 M. Sng et al. / Burns Open 3 (2019) 96–98

Declarations

Funding

This case report did not receive any funding from any public,
private, commercial or non-profit organisations.

Authors’ contributions

All authors collaborated to write the case report. The senior

authors, Mr J Liew and Mr R Teixeira edited, reviewed and
approved the paper for submission.

Consent

The patient’s mother was consented for the publication of the

case and the patient’s photos.

Declaration of Competing Interest

The authors declare that they have no competing interests.

Appendix A. Supplementary data

Supplementary data to this article can be found online at

https://doi.org/10.1016/j.burnso.2019.05.004.

References

[1] Téot LGU. Chemical burns management. Surgery in wounds. Berlin,

Heidelberg: Springer; 2004.
[2] Dunne JA, Rawlins JM. Management of Burns. Surgery (Oxford) 32: 477-484.
[3] Huang L, Li J, Yao Y, Zhang Z, Li W. Burn-like Skin Necrosis in a patient following
infusion of sodium bicarbonate. JSM Burns Trauma 2016;1:1002.
[4] Kumar RJ, Pegg SP, Kimble RM. Management of extravasation injuries. ANZ J
Surg 2001;71:285–9.