burns 41 (2015) 761–763

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Chemical burns revisited: What is the most

appropriate method of decontamination?

Teresa Tan *, David S.Y. Wong

Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, Prince of Wales Hospital, Shatin, Hong Kong
Special Administrative Region

article info abstract

Article history: The purpose of this study is to investigate the efficacy of decontamination by immediate
Accepted 8 October 2014 surgical debridement in the acute management of chemical burns as compared to conven-
tional dilutional approaches by irrigation or wetting.
Keywords: A retrospective review of the medical records of patients admitted to the Burns Centre of
Chemical burns the Prince of Wales Hospital, Hong Kong, between 2001 and 2012, was performed. The time
Burn management to recovery as reflected by the hospital stay for patients who had received immediate
Decontamination debridement, continuous irrigation, and wet packs was calculated and compared.
Burn surgery A total of 99 patients were admitted for chemical burns (3.3% of total admissions). There
Irrigation were three mortalities. Immediate surgical debridement failed to achieve a faster recovery
Immediate debridement than irrigation or wet packs. Continuous water irrigation was better than wet packs in
achieving earlier recovery.
Continuous water irrigation remains the most preferred method of decontamination in
acute chemical burn management.
# 2014 Elsevier Ltd and ISBI. All rights reserved.

1. Introduction 2. Aim of study

Chemical burns represent the second most common cause of
hospital admission for patients with burns after thermally
related injuries [1,2]. The initial management is critical in that
the injuring chemical on the skin leads to on-going and
continuing damage. The conventional approach is a dilutional
approach by irrigating the affected parts of the body with
lukewarm running tap water [3–7]. The efficacy of this
approach was long established since the 80s [8–10]. A more
recent school of thought proposed the use of actual acute
surgical debridement to reduce the chemical load [11,12].
However it is uncertain as to whether immediate surgery
actually benefits the patient.
The aim of this study was to assess whether immediate
surgical debridement done within 24 h of admission in
patients with chemical burns resulted in earlier discharge
from hospital. In addition, the question as to whether different
ways of dilution would affect recovery was examined.
3. Patients and method
The medical records of patients afflicted with chemical burns
admitted to the Burns Unit of the Prince of Wales Hospital over
the 12-year period from January 2001 to December 2012 were

* Corresponding author at: Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, Prince of Wales Hospital, 30-32 Ngan
Shing Road, Shatin, Hong Kong Special Administrative Region. Tel.: +852 2632 2639; fax: +852 2637 7974.
E-mail addresses: teresa@surgery.cuhk.edu.hk, yellowbirdie@gmail.com (T. Tan).
http://dx.doi.org/10.1016/j.burns.2014.10.004
0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
762 burns 41 (2015) 761–763
reviewed retrospectively. Additional relevant data were also
captured from the CMS system of the Hospital Authority’s
computers. Parameters including patient demographics,
mechanism of injury, chemical agent involved, percentage
of body surface area involved, regions affected, in-hospital
irrigation and wetting method, immediate debridement
surgery (defined as surgery within 24 h of admission), surgery
during first hospital admission, and outcome in terms of
length of the first hospital stay and mortality were recorded.
The hospital stay for patients who underwent emergency
debridement and those that did not was first compared. In the
latter group, the hospital stay for those who received
continuous irrigation and those that had wetting by regular
soaked gauze application was again compared.
Data was entered into SPSS (IBM1 SPSS1 Statistics v21,
IBM) for statistical analysis. To take into account the effect of
possible confounding factors which would affect the duration
of hospital stay such as percentage of total body surface area
involved, age and also sex of the patient, a propensity score
matching was first performed on the data. The Mann Whitney
U and the Chi-square tests were then applied to test for
significant difference, if any. Statistical significance was taken
as P  0.05.
4. Results
As the outcome measure was the length of hospital stay,
patients who died during the first hospital stay (n = 3) or who
discharged themselves against medical advice (n = 1) were
excluded. In addition, patients who were admitted to the
Burns Centre with a more than 24-h delay after injury (n = 8)
were also not included in the analysis.
During the 12-year period, a total of 2965 patients were
admitted to the Burns Centre of the Prince of Wales Hospital,
with 99 (i.e. 3.3%) due to chemical burns. There were 65 males
and 34 females, with a M:F ratio of roughly 2:1. Significantly
more men have injuries on duty and accidents while more
women suffered from assaults ( p = 0.007). Age ranged from 2
to 87 (mean = 41.9, S.D. = 14.3). The total body surface area of
involvement (TBSA) ranged from 1 to 83 (mean = 8.4,
S.D. = 11.2). Body parts injured were: head and neck 59%,
upper extremities 72%, torso 51%, lower extremities, 47%.
Causes for the chemical injury included home accident
(n = 32), industrial (n = 38) and assault (n = 29) but aetiology
was not statistically related to hospital stay. More head and
neck involvement were seen with assault attacks ( p = 0.001).
The chemical agent was known to be acidic in nature in 22,
alkaline in 15, and unknown in 62. The pH upon arrival was not
useful as it was already neutral most of the time (n = 85). No
difference in hospital stay was demonstrated with the acid or
alkaline nature of the chemical agent ( p = 0.345).
The mean hospital stay of the immediate debridement
group and the pure dilutional group were 17.0 days (S.D. = 14.7)
and 17.8 days (S.D. = 14.8) respectively. Immediate surgical
debridement failed to achieve a faster recovery than irrigation
or wetting ( p = 0.529).
The mean hospital stay of the continuous irrigation group
and the wet gauze packs group were 10.8 days (S.D. = 9.2)
and 20.5 days (S.D. = 17.6) respectively. The difference was
significant and continuous water irrigation was better than
wetting with gauze in achieving a shorter hospital stay
( p = 0.021).
5. Discussion
The characteristic feature of chemical burns is the prolonged
period during which the burning effect continues after the
initial injury. A mainstay in the management of chemical
burns is to minimize the time when the chemical is with
contact with skin.
This study examined the immediate to early management
of patients afflicted with chemical burns in order to identify
factors after admission which could improve treatment
outcome. Falder [13] has explore the complexities of measur-
ing health outcome in burns populations due to the heteroge-
neity of factors. The policy adopted in our institution has been
to discharge patients from their first admission after injury
only after complete wound epithelialization so that patients
can be cared for outside the hospital. This could be regarded as
the ‘‘early recovery period’’ and therefore in the population
under study, the first hospital stay could be taken as a
parameter reflecting outcome of treatment.
The severity of injury from chemicals is dependent on
various factors including the chemical’s mechanism of action,
quantity, concentration, strength of penetration and the
duration of contact [14]. It is universally agreed that the effect
of the injury could be reduced by immediate decontamination
of the injuring agent [3–7]. The conventional approach is to
take off all soaked clothes and ornaments from the body, wipe
away undissolved particulate injuring agent if any, and
continuous irrigation to wash away as much of the injuring
agent as possible. Current evidence supports the use of
aggressive water irrigation or lavage in dermal corrosive
decontamination and this approach has been demonstrated to
be associated with improved clinical outcomes [15,16]. There
is also a suggestion that water irrigation helps to reverse the
hygroscopic effect of chemicals [17]. Although time is a matter
of utmost importance here, most patients came to the hospital
inadequately decontaminated owing to various reasons but
most often it was a lack of a ready source of running water
whilst on the way. This experience has also been reported in
other series [1,18]. The latter explains why decontamination is
necessary when patients are admitted.
Our data showed that it is more effective to employ the
running tap in a bath tub to flush with lukewarm water than to
use saline soaked gauze. Both of these methods work in theory
to allow dilution and diffusion of the injuring agent away from
the tissues. It is not difficult to understand why running water
is more efficient because a much larger amount of diluent is
being used. Moreover, considering the additional nursing work
involved in changing the gauze and to keep them wet, the
restriction to movements of the patient, the potential
contamination of the beddings, and costs, there is very little
justification to advocate this method of decontamination.
The concept of test shaving of affected areas for the purpose
of initial decontamination has been proposed before [14,17].
The rationale of this approach appears to be to achieve
the purpose of decontamination by actual removal of the
 burns 41 (2015) 761–763
superficial layers of the affected skin. We have demonstrated
from our data that this approach did not produce a better result
in terms of earlier discharge, i.e. recovery, compared to the use
of continuous irrigation. The data did not say that surgical
debridement was not useful as a decontamination strategy. It
only says that it was no better than ordinary wetting
techniques. However, the argument for the use of the ‘‘surgical
debridement’’ approach as an equally viable alternative is at
best non-convincing. The concern of intervention of course is
always to achieve the best outcome and to incur the least harm.
The means, i.e. surgical debridement, to achieve the end, i.e.
better cosmetic outcome and faster recovery, using this
approach seems to be contradictory in that tissues are
condemned even before the necessity to do so is confirmed.
It must be emphasized that the present discussion is on
emergency surgical debridement and no extrapolation should
be made to the practice of early excision and debridement upon
patient stabilization for wounds that need surgery which has
always been the policy of the Burns Centre.
The issue of whether the injuring agent is acid or alkali in
nature deserves elaboration. We do not find any difference in
outcome with the current set of data. Acid burns in general are
known to have a tendency to form a proteinaceous coagulum
on contact with skin which may be additionally contributed to
by the effect of dehydration in some cases. This coagulum is
believed to impair the further influx of the acidic agent into the
tissues and thus reducing the full damage potential if
decontamination is started early. Alkalis are caustics and
they dissolve protein and collagen causing saponification and
dehydration. The caustic tends to diffuse deeply into the
tissues and often causes deeper burns than initially estimated.
The finding of no significant difference in the hospital stay
between patients suffering from these 2 categories of injuring
agent is therefore unexpected. A possible reason could be that
the effectiveness of decontamination had nullified the
continuing damage which would otherwise have been present
in the caustic injury situation.
It is equally unexpected to find no difference in the
outcome between accident cases and assault cases. It was
the impression that accident cases are more often less severe
as many are related to chemicals used in the home or at work.
Assault cases are totally different and involve deliberate
infliction of grievous harm at another person for either facial
disfigurement or for taking lives. The observation from the
data could have been prejudiced by the exclusion of mortality
cases so as to avoid an infinity in hospital stay in calculations.
The opportunity is taken here also to keep in mind specific
instances such as hydrofluoric acid [19] or phosphorus burns
where additional chemical agents are known to be helpful in
treatment.
There are short comings in this paper. The retrospective
nature of the review means that its validity lacks the vigour of
a controlled trial. Nevertheless, the same argument prevails in
similar instances where there is evidence of superiority of one
modality of treatment over others that it would be difficult to
justify continuation of those alternative treatments in an
ethical sense, not to say subjecting patients to a prescribed
limb for the purpose of clinical study. Another possible bias is
the geographical difference in the pattern of etiologies of
chemical injuries, which is affected by the state of economic
763
development of the target population of an institution and, in
some instances, cultural beliefs.
6. Conclusion
The information derived from the data in this series confirmed
the conventional approach in the employment of continuous
water irrigation as the most preferred method in the initial
decontamination of chemical injury as evidenced by its
superior efficacy and safe nature in achieving its effect.
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