Annals of Burns and Fire Disasters - vol. XVI - n. 3 - September 2003
NITRIC ACID BURNS (CASE REPORT)
Çelik E.1, Erog×lu S.1, Dinçler M.1, Karacaog×lan N.2 Uzunismail A.3
Haydarpas¸a Numune Education and Research Hospital, Department of Plastic and Reconstructive Surgery, Istanbul, Turkey
SUMMARY. Chemical burn injuries, including nitric acid injuries, are rarely encountered in routine daily practice. In this paper we wish to present two nitric acid burn cases in which the histories were not of accidental injury but of planned assault on the victim. In such cases, the victims are generally good-looking women. Nitric acid burns are frequently reported in the national and local press, especially in third-world countries.
Chemical burn injuries constitute a type of burn injury that we may come across in our daily practice, although not as frequently as thermal and electrical injuries. The chemical agents involved are alkalis, acids, or organic compounds. Alkalis such as hydroxides, carbonates or caustic soda are commonly found in oven and drain cleaners, fertilizers, and industrial cleaners. Acids such as sulphuric acid, nitric acid, hydrochloric acid, tannic acid, and formic acid are widely used in many areas. More than 65,000 chemicals are available on the market, and an estimated 60,000 new chemicals are produced every year. However, the potentially deleterious effects on human health of many of these chemicals are largely unknown. They are contained in bathroom cleaners and rust removers and are routinely used by automobile battery manufacturers, in the dyeing industry, in tanneries, and in jewellery workshops.
Although rare, occupationally and accidentally induced acid burns have been reported in the literature.1-3 This paper presents two nitric acid burn cases in which the histories are not of accidental injury but of planned assault on the victim.
Case report 1
A 40-year-old woman who had received nitric acid burns on the left side of the face and upper extremities was admitted to our clinic with second- to third-degree burns in the face, neck, chest wall, abdomen, and upper extremities in body areas where the chemical had been splashed (Figs. 1a,b). The woman attacked had been divorced two years previously and was having a new relationship. The assault was performed by her former husband. The burn wound was treated with topical antibiotic ointments and daily limited eschar debridement. After formation of healthy granulation tissue the open wounds were covered with split-thickness skin grafts harvested from the anterior and lateral thigh. No post-operative complications were observed.
Case report 2
This 27-year-old woman received nitric acid burns on the right side of the face, neck, right upper extremity, and the upper anterior chest wall. The extent of the burn injury was between second and third degree (Figs. 2a,b).
The assault in this case was perpetrated by the woman’s ex-boyfriend, who could not bear her marrying someone else. The eschar tissue was debrided. Following daily dressing changes and formation of granulation tissue, the patient was operated upon. Split-thickness skin grafts were harvested from the anterior and lateral thigh. No post-operative complications were observed.
Chemical burn injuries, including nitric acid injuries, are rarely encountered in routine daily practice. They usually occur as occupational and accidental injuries. Nitric acid is a chemical that is important in industry. It is a very strong acid and a powerful oxidizing agent with the ability to nitrate organic materials, thus making it essential in the production of numerous chemicals. Skin contact with nitric acid leads to severe burns, and its vapours can cause severe acid burns to the eyes, respiratory tract, and lungs. Delayed pulmonary oedema can be expected after vapour inhalation.
Most chemical agents damage the skin by producing a chemical reaction rather than hyperthermic injury. Although some chemicals produce considerable heat as a result of an exothermic reaction when they come into contact with water, their ability to produce direct chemical changes in the skin accounts for more significant injuries. The pathophysiology depends on the type of concentration, the strength, quality, and duration of contact, and the penetration power of the acids concerned. Superficial burns occur after only 5 sec of contact and full-thickness burns after 30 sec. Acids cause coagulation necrosis of the tissues with thrombus formation in the microvasculature of the lesion. Rapid loss of collagen and mucopolysaccharides occur. If these acids are absorbed through the skin, they may cause systemic effects such as metabolic acidosis or renal failure.
In all chemical injuries, the primary concern is the removal of the offending agent because the longer the offending agent is in contact with the skin, the severer the injury becomes.
There are specific antidotes for certain chemical agent injuries but, whatever the agent, initial treatment consists of the removal of saturated clothing (including underwear, gloves, and shoes), brushing of the skin if the agent is a powder, and irrigation with copious amounts of water.
Irrigation should be continuous from the time of discovery of the injury until emergency evaluation in hospital. Irrigation should continue until definitive treatment is begun or until the patient experiences a decrease in the pain. The burn wounds are managed after the initial intervention with proper wound care and reconstructive procedures.
With regard to the kind of case that we present here, apart from occupational and accidental injuries, acid burn injuries are usually planned as an assault on the victim for reasons of revenge. The victim is generally a good-looking woman - males are relatively less affected. Common causes are love affairs, enmity, and personal reasons. The aim of the attack is not to kill the victim but to make her live with a sequela, a mark she will always be left with. The incidence is greater in rural than urban areas. Another remarkable feature is that despite the limited number of cases presented in the medical literature, nitric acid burns are widely reported in national and local newspapers, especially in third-world countries.
In conclusion, it may be said that acid burn injuries represent only a small percentage of total burn injuries, but they cause a particular type of lesion in which disability is high and aesthetic sequelae are very important.
RESUME. Dans la pratique clinique quotidienne on encontre rarement les lésions causées par les brûlures chimiques, y inclus les lésions dues à l’acide nitrique. Les Auteurs présentent deux cas de brûlures par acide nitrique où la cause n’était pas une lésion accidentelle mais un assaut délibéré sur la victime. En ce type de cas, les victimes sont généralement des femmes d’aspect avenant. Les brûlures causées par l’acide nitrique reçoivent une vaste couverture dans la presse nationale et locale, particulièrement dans les pays du Tiers Monde.