A short post…but a relevant one. We are interested in other perspectives here. Please post comments below.
Firstly – Don’t use a blog like this to dictate clinical care. For direct patient care seek toxicology and expert advice. Use this post to help you prepare and plan.
Unfortunately the UK is seeing a surge in acid attacks on its streets. They are sometimes gang-related, sometimes racially motivated, and sometimes as part of a mugging. They are uniformly horrible and frequently devastating to the individual. Whilst historically they were associated with honour crimes in some communities and predominantly targeted females, there is now a trend towards male victims. The increase isn’t a blip; there is a definite trend which is only getting worse.
Whilst horrendous, the increase is sadly unsurprising. There are big crackdowns on knife crime (which is awesome), however it forces would be offenders to consider other options…enter acid/alkali. It is very difficult to prove intent in an individual walking down the street with a bottle of strong bleach or acid on their person. It is even harder to identify someone who has distilled a substance into a sports bottle. The way the law currently handles it also makes things difficult; a knife attack can equal attempted murder, whereas an acid attack can equal GBH (grievous bodily harm). The problem is scarily hard to tackle. Corrosive agent attacks are not intended to kill. The purpose of acid attacks are to inflict pain, cause disfigurement, humiliation, and psychological torment. As the crackdown of knives continue, it is likely that we will continue to see an increase in these attacks.
As a point of nomenclature, the term corrosive substance is probably better than acid. For the most part we are not aware of the chemical being used, and whilst people say acid it may well be a strong alkaline that has been used. However, in common parlance and certainly in the media the term ‘acid attack’ appears to be used irrespective of the actual pH. The point is that the intent is to cause harm with a corrosive substance.
As emergency physicians we should not forget that a key aspect of treatment is going to occur in the pre-hospital phase of care. In a small single-centre case series it was suggested that irrigation within the first 10 minutes caused a 5-times decrease in full-thickness injury1. The key is to irrigate with clean water as soon as possible (dirty water increases risk of infection, but if that’s all you have it is better than nothing). Remove clothes, jewellery….anything that may have the corrosive substance on it.
Water water water water
— John McKenna (@DrJEMcK) July 14, 2017
Ideally the irrigated fluid should not spread the chemical to unaffected areas (so try and lower the affected part to encourage run off). Analgesia is going to be needed, and what form that takes depends on the resource available on scene, but the patient will likely be in significant pain. Like thermal burns, cling film is an option to keep affected areas clean and covered once they have been decontaminated.
— Michael Maybin (@MichaelMaybin) July 16, 2017
ED management may get messy depending on the extent of the burn. Be prepared to irrigate the wound for as long as it takes to return the pH to normal. Use litmus paper, which is likely found in your ophthalmology room and check it, immediately after irrigation and again after 5,10,30 minutes to ensure that you really have removed the agent. Frequently the face is targeted in these attacks so be careful to thoroughly assess for airway involvement being mindful that there will not be all the same signs we associate with thermal burns (for example you would not expect soot in the airway). In Virchester these patients activate the trauma team and receive a thorough primary/secondary/tertiary survey. BE SURE TO DO A STAB CHECK. The pain of the chemical may distract from other injuries, and we have seen many with concurrent stab sounds. If the burns are extensive then they will need fluid replacement using the Parkland formula (or equivalent) and specialist involvement.
Special mention should be given to the eyes. These attacks can prove catastrophic to victims vision. The principles remain the same…irrigate, irrigate, irrigate. Beware leaving the eyes as the last place to irrigate, it can happen as patients have ocular pain, blepharospasm and fear. They are arguably the most sensitive area and thus you may want to prioritise them. Consider using topical tetracaine if needed to facilitate irrigation if available (Ed – consider it briefly and then use it). Victims will usually subsequently need a cocktail of eye medications including topical antibiotics and steroids plus artificial tears, but one should be guided by your on call ophthalmology service.
As a rule of thumb the chemicals used do not affect the management strategy. Irrigation is always the sensible first step. There are some exceptions, namely hydrofluoric acid which warrants topical calcium gluconate gel (but if you don’t have that then copious water may still be the thing to use). Sulphuric acid may feel warm when washed with water, however one should focus on removing the acid over intellectual debate whether to use a different solution or not.
These patients will potentially need plastic surgical involvement, ophthalmology involvement, psychology involvement. They may never live the life they had before the attack. They have potentially sustained a life changing injury. Be kind. Support for victims can be found in numerous places, such as the Acid Survivors Trust International2 3.
Lastly. You’ve read the blog and had a think, now go back to your units to plan and prepare. Look at your local/national guidance and if there is none – create it. Make the links to expert colleagues now and maybe run a Sim to see how you would perform in practice.
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