Hydrofluoric acid: Difference between revisions
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==Background==
==Background==
*Used in both commercial and home setting
*Used in both commercial and home setting<ref>Cheong H, Kim J. Fatal hydrofluoric acid poisoning: histologic findings and review of the literature. Forensic Sci Med Pathol. 2023 Mar;19(1):67-71. PMID 36334175</ref>
**Rust remover (most common home use)
**Rust remover (most common home use)
**Glass etching, chrome and other metal cleaning, petroleum processing
**Glass etching, chrome and other metal cleaning, petroleum processing
*Oral ingestion has very high mortality rate
*Oral ingestion has very high mortality rate
 
*Onset and severity of symptoms correlated with concentration
==Clinical Features==
*Onset and severity of symptoms correlated w/ concentration
**Dilute solutions (<20%) may have delayed onset up to 24hr post-exposure
**Dilute solutions (<20%) may have delayed onset up to 24hr post-exposure
**Moderate solutions (20-50%) develop symptoms w/in 1-8hr
**Moderate solutions (20-50%) develop symptoms within 1-8hr
**Concentrated solutions (>50%) develop symptoms immediately
**Concentrated solutions (>50%) develop symptoms immediately
***These pts are at highest risk for systemic toxicity/death
***These patients are at highest risk for systemic toxicity/death
***Pain immediately (even if wound appears minor) implies severe injury
***Pain immediately (even if wound appears minor) implies severe injury
*Burn itself is usually relatively minor
*Burn itself may appear relatively minor
*Toxicity caused by binding of calcium
*Toxicity caused by binding of calcium and magnesium leading to electrolyte derangement and myocardial dysfunction<ref>McKee D, et al. A review of hydrofluoric acid burn management. Plast Surg (Oakv). 2014 Summer;22(2):95-8. PMID 25114621</ref>
 
==Clinical Features==
[[File:HF burned hands.jpg|thumb|Hydrofluoric acid (HF) burns, which were not evident until a day after exposure.]]
[[File:Hydrofluoric_acid_burn.png|thumb|Hydrofluoric acid burn]]
*Skin exposure
**[[Burns]]
**Pain out of proportion to extent of burn
*Ophthalmic exposure
**[[Eye pain]]
**Erythema
*Ingestion
**[[Nausea and vomiting]]
**[[Abdominal pain]]
*Inhalation
**[[Shortness of breath]]
**[[Throat pain]]/burning
*Signs/symptoms of [[hypocalcemia]] and  [[hypomagnesemia]]
**Can lead to QTc interval prolongation and cardiac arrhythmias, the primary cause of death in HF burns


==Differential Diagnosis==
==Differential Diagnosis==
{{Caustic burn types}}
{{Caustic burn types}}


==Diagnosis==
==Evaluation==
*Trend calcium and potassium levels
*Clinical diagnosis
**HF acid chelates calcium and poisons the Na+/K+ pump
*Trend calcium, magnesium, and potassium levels
**Order serial chemistries, EKGs
**Hydrofluoric acid chelates calcium and poisons the Na+/K+ pump
**Expect [[hypocalcemia]], [[hypomagnesemia]], and [[hyperkalemia]]
*Monitor EKG for signs of electrolyte abnormality
**[[QTc prolongation]]
**[[Ventricular tachycardia]]


==Management==
==Management==
*Minor injuries (<50 cm2 from dilute solutions <20%)
*Decontamination: remove soiled clothing and irrigate thoroughly.
#Copious irrigation
*Mainstay of treatment is application of calcium to affected area.
#Application of gel paste of Ca gluconate or benzalkonium Cl
 
##Rub into affected area for 10-15min w/ pain relief being used as end-point of tx
===Cutaneous Burns===
##Calcium gel is commercially available (found in industrial first-aid kits)
====Minor injuries (<50 cm2 from dilute solutions <20%)====
##Calcium gel can be made:
*Application of gel paste of Ca gluconate or benzalkonium Cl
###Mix calcium gluconate powder 3.5gm w/ 150mL water-soluble lubricant OR
**Rub into affected area for 10-15min with pain relief being used as end-point of treatment
###Mix 25mL 10% calcium gluconate solution w/ 75mL water-soluble lubricant
**Calcium gel is commercially available (found in industrial first-aid kits)
##Benzalkonium Cl is commercially available
**Calcium gel can be made:
##If calcium gluconate is not available calcium chloride can be used
***Mix calcium gluconate powder 3.5gm with 150mL water-soluble lubricant (KY-Jelly) '''OR'''
*Severe injuries
***Mix 25mL 10% calcium gluconate solution with 75mL water-soluble lubricant (KY-Jelly)
#Treat w/ intradermal injections of 5% calcium gluconate
**Benzalkonium Cl is commercially available
##Prepare by diluting conventional 10% Ca gluconate w/ sterile NS in 1:1 ratio
**If calcium gluconate is not available calcium chloride can be used
##Inject in and around the burned area in amount not to exceed 0.5mL per cm2
 
*Refractory injuries
====Severe injuries====
#Treat w/ intra-arterial infusion of calcium gluconate
*Treat with intradermal injections of 5% calcium gluconate
##Deliver via arterial line placed proximal to injury in the same limb
**Prepare by diluting conventional 10% Ca gluconate with sterile NS in 1:1 ratio
##Infuse 10mL of 10% Ca gluconate dilued in 40mL of NS or D5water over 4 hr
**Inject in and around the burned area in amount not to exceed 0.5mL per cm2
*Ingestion
 
#If <1hr of ingestion place NG tube, suction, gastric lavage
====Refractory injuries====
##Follow lavage by 300mL 10% Ca gluconate down NGT
*Treat with intravenous infusion of calcium gluconate using Bier block
##Provide aggressive IV supplementation if ECG signs of hypoCa or hyperK
**Place tourniquet proximal to exposure site on affected extremity and inject though IV distal to tourniquet
*[[Hyperkalemia]] and [[Hypocalcemia]]
**Inject 10 mL of 10% Ca gluconate diluted in 40 mL of saline and remove tourniquet after 20 min of dwell time
#Treat medically as needed
*In severe refractory cases may also infuse intra-arterial calcium gluconate
**Deliver via arterial line placed proximal to injury in the same limb
**Infuse 10 mL of 10% Ca gluconate diluted in 40mL of saline over 4 hr
 
===Ocular burns===
*Irrigate with saline for at least 5 min
*If persistent pain administer 1% calcium gluconate to eye (dilute 10% calcium gluconate with normal saline)
**Consult ophthalmology due to irritation effect of calcium salts to eye
 
===Ingestion===
*If <1hr of ingestion, may consider NG tube for suction and gastric lavage
**Follow lavage by 300mL 10% Ca gluconate down NGT
*Consider intubation for airway protection
 
===Inhalation===
*Consider in any patient with facial burns or exposure to HF in confined space
*Oxygen via NRB
*Nebulized 2.5% calcium gluconate
*Intubation may be required in severe cases
 
===Systemic toxicity===
*Administer [[calcium gluconate]] 100mg IV (10 mL of a 10% solution) over 2-3 minutes
*May also need to replete [[magnesium]] (4g IV over 20 minutes)
*May see [[QTc prolongation]], [[cardiac arrhythmia]], or obvious systemic illness
*Treat [[hyperkalemia]] as needed
 
 
==Medication Dosing==
{{MedicationDose
| drug = Calcium gluconate
| dose = Topical gel (3.5g powder in 150mL lubricant or 25mL 10% soln in 75mL lubricant)
| route = Topical
| context = Minor cutaneous burns (<50 cm2 from <20% solutions)
| indication = Hydrofluoric acid
| population = Adult
| notes = Rub into affected area 10-15min; pain relief is treatment endpoint
}}
{{MedicationDose
| drug = Calcium gluconate
| dose = 5% intradermal injection (max 0.5mL/cm2)
| route = Intradermal
| context = Severe cutaneous burns
| indication = Hydrofluoric acid
| population = Adult
| notes = Dilute 10% calcium gluconate 1:1 with sterile NS
}}
{{MedicationDose
| drug = Calcium gluconate
| dose = 10mL of 10% in 40mL NS via Bier block (20min dwell time)
| route = IV regional (Bier block)
| context = Refractory cutaneous burns
| indication = Hydrofluoric acid
| population = Adult
}}
 
==Disposition==
*Consultation with poison center and burn center transfer per [[Burn center criteria]]
*Admission for all patients with arrhythmia on ECG or severe electrolyte disturbance


==See Also==
==See Also==
*[[Caustics]]
*[[Caustics]]
*[[Burn]]


==References==
==References==
<references/>
<references/>


[[Category:Tox]]
[[Category:Toxicology]]

Latest revision as of 10:43, 22 March 2026

Background

  • Used in both commercial and home setting[1]
    • Rust remover (most common home use)
    • Glass etching, chrome and other metal cleaning, petroleum processing
  • Oral ingestion has very high mortality rate
  • Onset and severity of symptoms correlated with concentration
    • Dilute solutions (<20%) may have delayed onset up to 24hr post-exposure
    • Moderate solutions (20-50%) develop symptoms within 1-8hr
    • Concentrated solutions (>50%) develop symptoms immediately
      • These patients are at highest risk for systemic toxicity/death
      • Pain immediately (even if wound appears minor) implies severe injury
  • Burn itself may appear relatively minor
  • Toxicity caused by binding of calcium and magnesium leading to electrolyte derangement and myocardial dysfunction[2]

Clinical Features

Hydrofluoric acid (HF) burns, which were not evident until a day after exposure.
Hydrofluoric acid burn

Differential Diagnosis

Caustic Burns

Evaluation

Management

  • Decontamination: remove soiled clothing and irrigate thoroughly.
  • Mainstay of treatment is application of calcium to affected area.

Cutaneous Burns

Minor injuries (<50 cm2 from dilute solutions <20%)

  • Application of gel paste of Ca gluconate or benzalkonium Cl
    • Rub into affected area for 10-15min with pain relief being used as end-point of treatment
    • Calcium gel is commercially available (found in industrial first-aid kits)
    • Calcium gel can be made:
      • Mix calcium gluconate powder 3.5gm with 150mL water-soluble lubricant (KY-Jelly) OR
      • Mix 25mL 10% calcium gluconate solution with 75mL water-soluble lubricant (KY-Jelly)
    • Benzalkonium Cl is commercially available
    • If calcium gluconate is not available calcium chloride can be used

Severe injuries

  • Treat with intradermal injections of 5% calcium gluconate
    • Prepare by diluting conventional 10% Ca gluconate with sterile NS in 1:1 ratio
    • Inject in and around the burned area in amount not to exceed 0.5mL per cm2

Refractory injuries

  • Treat with intravenous infusion of calcium gluconate using Bier block
    • Place tourniquet proximal to exposure site on affected extremity and inject though IV distal to tourniquet
    • Inject 10 mL of 10% Ca gluconate diluted in 40 mL of saline and remove tourniquet after 20 min of dwell time
  • In severe refractory cases may also infuse intra-arterial calcium gluconate
    • Deliver via arterial line placed proximal to injury in the same limb
    • Infuse 10 mL of 10% Ca gluconate diluted in 40mL of saline over 4 hr

Ocular burns

  • Irrigate with saline for at least 5 min
  • If persistent pain administer 1% calcium gluconate to eye (dilute 10% calcium gluconate with normal saline)
    • Consult ophthalmology due to irritation effect of calcium salts to eye

Ingestion

  • If <1hr of ingestion, may consider NG tube for suction and gastric lavage
    • Follow lavage by 300mL 10% Ca gluconate down NGT
  • Consider intubation for airway protection

Inhalation

  • Consider in any patient with facial burns or exposure to HF in confined space
  • Oxygen via NRB
  • Nebulized 2.5% calcium gluconate
  • Intubation may be required in severe cases

Systemic toxicity


Medication Dosing

Calcium gluconate Topical gel (3.5g powder in 150mL lubricant or 25mL 10% soln in 75mL lubricant) Topical — Rub into affected area 10-15min; pain relief is treatment endpoint Calcium gluconate 5% intradermal injection (max 0.5mL/cm2) Intradermal — Dilute 10% calcium gluconate 1:1 with sterile NS Calcium gluconate 10mL of 10% in 40mL NS via Bier block (20min dwell time) IV regional (Bier block)

Disposition

  • Consultation with poison center and burn center transfer per Burn center criteria
  • Admission for all patients with arrhythmia on ECG or severe electrolyte disturbance

See Also

References

  1. ↑ Cheong H, Kim J. Fatal hydrofluoric acid poisoning: histologic findings and review of the literature. Forensic Sci Med Pathol. 2023 Mar;19(1):67-71. PMID 36334175
  2. ↑ McKee D, et al. A review of hydrofluoric acid burn management. Plast Surg (Oakv). 2014 Summer;22(2):95-8. PMID 25114621
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