Weak Acid, Strong Consequences

In Urgent Care, we are supposed to receive patients that triage nurses deem to have minor problems. Because triage nurses are not omniscient, however, occasionally we get something that is very serious. For example, we had a "minor motor vehicle accident" victim arrive, whose symptoms started and worsened while she was being treated, eventually leading to one-sided numbness and tingling. I transferred her to the trauma room soon after as a full-trauma so they could do a full work-up for spinal cord/nerve damage.

The other day, I saw that we had a "chemical burn" coming. The man and his relative were non-English speaking, but handed me a materials safety sheet that listed concentrated "Hydrogen Fluoride". He had accidentally submerged an index finger at work while cleaning masonry. I saw that the finger was inflamed with small, dark, funnel-like holes. HF, as I learned in high school and college chemistry, is a relatively weaker inorganic acid. Neither the PA nor I knew much more before we looked it up online.

Apparently, HF burns of less than 3% of a person's body can cause systemic failure and kill a person.

According to medscape, these are mechanisms behind how that can happen:

"The 2 mechanisms that cause tissue damage are corrosive burn from the free hydrogen ions and chemical burn from tissue penetration of the fluoride ions.

Fluoride ions penetrate and form insoluble salts with calcium and magnesium. Soluble salts also are formed with other cations but dissociate rapidly. Consequently, fluoride ions release, and further tissue destruction occurs.

Systemic toxicity occurs secondary to depletion of total body stores of calcium and magnesium, resulting in enzymatic and cellular dysfunction, and ultimately in cell death. Majority of deaths are resulting from cardiac arrhythmias that were precipitated by hypocalcaemia and consequent hyperkalemia."

http://emedicine.medscape.com/article/773304-overview

Yikes!! How long had it been since he was exposed? A day and a half ago! The inflammation might have been from the acid already etching away at the bones in his hand. That's much too long to not have been treated, so we sent him immediately to critical care. Our critical care physician deemed it serious enough to be immediately sent to the burn unit at a nearby hospital and the man was sent there by ambulance.

However, we found that the other hospital, through a serious oversight, did not look up how to treat HF burns and ignored the suggestions by our own physician to treat him immediately with intravenous calcium gluconate... and discharged him with bacitracin ointment and a few band-aids.

I've been thinking of him for the past few days, hoping that the polite young man will be able to keep his finger/life. It's a dangerous world we live in....

S