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Hydrofluoric acid is a caustic compound found in a wide variety of items for household and industrial uses. Dermal exposures can be visually unimpressive on presentation but still have fatal complications. This case review includes a description of a patient presenting with a dermal hydrofluoric acid burn that was effectively treated with topical calcium gluconate gel. Also highlighted are the challenges faced with recognizing the severity and appropriately treating dermal hydrofluoric acid burns in the emergency department., (Copyright © 2020 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved.)

A chemical alkali burn caused by ash and soot is quite rare, resulting from its high pH-value, and underestimated in its potential to cause injury. In folkloric medicine, ash was purportedly used to relieve pain. We present an unusual case of a 27-year-old man who used a self-mixed cream of soot of wooden pellets, milking grease and baby oil to blacken his face and hands for a traditional Krampus procession.

Objective: to report the experience of the Division of Plastic Surgery of the Hospital das Clínicas of the Medical School of the University of São Paulo in the treatment of cutaneous lesions due to accidental extravasation of drugs., Methods: we included patients with lesions due to extravasation of drugs over a period of 18 months. We retrospectively evaluated the following parameters: age, diagnoses during hospitalization and comorbidities, serum levels of albumin and hemoglobin, place of hospitalization, drug involved, anatomic segment affected, therapeutic management and death during hospitalization., Results: we followed-up 14 patients. The main drug involved was noradrenaline (21%). All patients underwent debridement of tissue necrosis. Three patients were submitted to flaps after preparation of the wound bed with negative pressure therapy, with good results. Seven patients had no definitive treatment of their lesions due to lack of clinical conditions., Conclusion: in patients with favorable clinical conditions, the definitive treatment with flaps was adequate for cases of wounds due to extravasation of drugs in the subcutaneous tissue when there was exposure of noble structures.

According to the Centers for Disease Control and Prevention, up to 40 percent of workers will suffer from occupational dermatitis at some point in their working lives.

Extravasation injuries are common emergencies in clinical practice. If they are not recognized and treated promptly, they can lead to deleterious functional and cosmetic outcomes. There is a vast range of agents involved in these injuries and marked paucity of evidence to support their specific management. Following an extensive literature review, we outline management principles for clinicians involved in the care of patients with extravasation injuries. Key parameters in deciding appropriate management plans include the volume/toxicity of the agent, the necrosis interval of the injury, patient-related factors, as well as the facilities and expertise available in the setting of individual cases of extravasation., (© The Author(s) 2014.)

The broad market penetration of products with components used primarily in the industrial sector requires the precise knowledge of their mechanism of action in order to perform a correct therapeutic approach. The article reports on three cases of domestic hydrofluoric acid burn that came to our Plastic Surgery Unit over the last three years. The treatment options are discussed in detail with emphasis on the importance of a constant update about such emerging diseases.

The authors report two cases of patients presenting with chemical frostbite-like injuries to the hands and wrists after contact exposure to Freon liquid. Although the history and initial physical presentations were quite similar, the severity of these injuries varied widely from superficial bullae to deep tissue injuries, requiring skin grafting and amputation of several digits. Freon is a widely used coolant in refrigerators, air conditioners, freezers, and water coolers, with a boiling point of -41°C. Although several cases of Freon-induced inhalational injury have been reported, few case reports of Freon-associated contact skin injury exist in the literature. The authors detail the broad diversity of injuries resulting from Freon contact as well as the first report of severe Freon injury necessitating skin grafting and amputation of multiple digits.

Hydrofluoric acid (HF) is a colorless corrosive acid used in different industrial branches. Exposure to HF typically results from spills, and most often the hand or fingers are involved. Tissue damage through cutaneous HF exposure occurs through corrosive burns due to the free hydrogen ions and through skin penetration of the fluoride ions, causing a depletion of calcium in the deep tissue layers, ultimately leading to cell death and tissue necrosis. Treatment of HF burns consists of thoroughly flushing the exposed area with water and applying calcium gluconate gel to the skin. If topical treatment does not suffice, subcutaneous injections, as well as intravascular--both intravenous and intra-arterial--calcium gluconate therapy, have been advocated. We report for the first time a case of HF burn of the hand and digits associated with vasospasm. Pain and vasospasm were successfully treated by repeated intra-arterial calcium gluconate injection. We conclude that intra-arterial calcium gluconate injection is a successful and well-tolerated therapy for HF burn associated with Raynaud's syndrome. Intra-arterial injection allows for well-controlled delivery of therapy as well as assessment of the vascular status.

White phosphorus is an incendiary agent used in particular types of ammunition. Exposure to phosphorus-containing compounds may cause severe burn injuries. Systemic effects may be fatal for the casualty even though only a small surface of the body is burned. We report 4 cases of white phosphorus burn injuries due to an exceptional accident mechanism. All casualties were holidaymakers in a coastal area at the Baltic Sea and confused white phosphorus ammunition residues with amber on a beachwalk. The supposed treasure was taken into the pants pocket. The phosphorus substances ignited spontaneously when they dried because of the body heat. Injury patterns combined simultaneous full thickness burn injuries of both hands with a burn injury of one thigh or the abdominal region. The acute treatment and the controversy surrounding decontamination of such patients are discussed. In addition, pathology of tissue damage and systemic injury are elucidated.

Systemic treatment with chemotherapeutic agents is often applied by infusions over peripheral vein cannulae located on the hands and lower arms. Dislocation of the cannulae or vein perforation causes an extravasation of the cytostatic agent. This complication occurs in approximately 0.1 - 6 % of intravenous treatments and is rarely noticed before administration of greater volumes. Depending on the tissue toxicity of the administered substances, the extravasation results in tissue damage of different extents. In a few cases, only conservative therapy is required. The majority of patients, however, needs immediate surgical therapy. The reason for this is the severe tissue damage caused by the chemotherapeutic agent that accumulates in the subcutaneous fat where it destroys the connective and fat tissue, nerves, vessels, tendons and muscles, impairing the functionality of the entire hand and arm. In very severe cases, partial or complete amputation of the extremity is the only treatment. The application of antidotes has been discussed controversially and is not a standard procedure. In the past 11 years, 18 patients with extravasations of chemotherapeutics on the dorsum of the hand were admitted to our department. After radical debridement no primary closure of the resulting defect was advisable in the first operation. In all cases we could later perform a stable wound closure. In our opinion, this two-step procedure with primary radical debridement, temporary wound coverage and later wound closure should be performed regularly.

Introduction: Capecitabine (Xeloda) is a systemic prodrug of 5-fluorouracil (5-FU), which is administered in an oral formulation. Hand-foot syndrome (HFS) has proven to be a chronic dose-limiting toxicity of capecitabine, leading to significant morbidity in patients receiving this agent. The purpose of this review is to define the pathophysiology, risk factors, incidence and management of capecitabine-induced HFS., Methods: Literature for this review article was collected from the following databases: PubMed, CINAHL, and the proceedings of the American Society of Clinical Oncology (ASCO) confined to the years 1995-2006. The following key terms were used in the search: hand-foot syndrome, palmar-plantar erythrodysesthesia, capecitabine, Xeloda, colorectal cancer, and metastatic breast cancer., Results: HFS associated with capecitabine is a serious dose-limiting toxicity. Incidence of grade 3/4 toxicity is of extreme significance, and introduces the need for dose reductions and/or interruptions in capecitabine therapy. Drug-related therapies studied include topical emollients and creams, systemic and topical corticosteroids, nicotine patch, vitamin E, pyridoxine, and COX-2 inhibitors. However, due to the lack of randomized, controlled trials with these therapies, the current mainstay of treatment for the management of this toxicity is interruption of therapy and, if necessary, dose reduction., Conclusion: Treatment interruption or dose reduction remain the only methods shown to effectively manage HFS, but supportive measures to reduce pain and discomfort and prevent secondary infection are very important. Many other prophylactic and treatment strategies have been investigated, with pyridoxine and COX-2 inhibitors being the most promising in case reports and retrospective studies; therefore, prospective, randomized, controlled trials are needed to prove their efficacy.

This case report discusses a patient who injected 20 mL of metallic mercury subcutaneously in his left hand during an attempted suicide. The blood mercury level was 118 microg/L and the urinary mercury level was 43 microg/L, which confirmed the diagnosis of metallic mercury poisoning. A good result was obtained in this patient and the local and systemic toxicity and its management are discussed. A chelation therapy with dimercaprol and early surgical excision of injected material are recommended because this treatment effectively lowers mercury blood levels and controls the local inflammatory reaction. Intraoperative fluoroscopy is useful to confirm the extent of removal.

With the expanded use of fluoroquinolones and increasing number of reports of tendon injury linked to these agents, clinicians must be aware of the frequency and strength of this association. In the past, pefloxacin and ciprofloxacin were most frequently implicated, but tendon injury is reported with most fluoroquinolones. As many as half of patients with fluoroquinolone-associated tendinopathy experience tendon rupture, and almost one third have received long-term corticosteroids. Tendon injury is mostly reported in the lower extremities, but injury in the upper extremities, including the hand, has also been reported. Management is similar regardless of the location of the injury. Use of fluoroquinolones requires careful patient assessment and follow-up in view of this complication with potential for sequelae.

Objective: To document the occurrence and consequences of accidental self-inoculation of vaccinators (producers, farm employees, contractors) with the recently registered Gudair vaccine for the control of ovine paratuberculosis in Australia., Design and Procedure: A survey of the first 50 primary producers permitted to use the vaccine in sheep and a description of six cases of accidental self-inoculation for which medical attention was sought, and which occurred after the vaccine became widely available., Results: The survey recorded that, of 37 respondents vaccinating 155,523 sheep, there were 21 incidents of exposure to the vaccine, an overall rate of one incident per 7406 vaccinations. In five of these incidents there was only superficial skin contact with vaccine; in 16 there was needle penetration without vaccine injection. There were no reports of self-inoculation with vaccine. Six cases of self-inoculation with Gudair vaccine that required medical intervention are described. Of these five were in males and one in a female; four involved injection of vaccine into the leg and single cases involved a foot or hand. Most cases required surgical removal of the injected vaccine to allow wound repair; three required extensive surgery and open drainage. Even with surgery recovery took as long as 9 months. Possible risk factors for self-inoculation and the resulting outcome are discussed., Conclusions: Gudair ovine paratuberculosis vaccine can cause prolonged granulomatous inflammation if inadvertently injected into human tissue. After.self-inoculation, early surgical debridement of the damaged tissue and drainage to remove the vaccine material are advised to avoid progression to extensive necrosis.

We report 7 cases of chemical burns due to hydrofluoric acid (HF). The patients suffered from severe pain. However, the pain was relieved after treatment with calcium gluconate. 6 out of the 7 cases were men. At the accidental exposures, all the patients had been engaged in washing or cleaning work and received burns on their hands and/or fingers. In one case, the forearm was also involved. During such work, all the patients had used rubber gloves, but the gloves had pinholes. For the treatments, 4% calcium gluconate jelly was applied in 5 cases and 4 of 7 were subcutaneously injected with 8.5% calcium gluconate. The involved nails were removed in 5 cases. It is concluded that physicians should provide calcium gluconate jelly and subcutaneous injections to treat an HF burn and should not hesitate to remove the involved nails. To prevent chemical burn due to HF, education and reeducation of workers regarding the hazard of this chemical are necessary.

A case of a 33-years-old aquarist admitted to the Clinic with a painful wound caused by a Stinging Catfish (Heteropneustes fossilis) was presented. While cleaning the aquarium the fish actively stung him in the hand. After irrigating and debriding of the wound the patient was given tetanus anatoxin and antibiotic course. The opioid analgesia and local anesthesia had to be provided to relieve the pain. The follow up after 2 weeks showed healed wound of the hand and the patient had no subjective complaints. There is an urgent need for a bill about venomous and poisonous animals which will be allowed to be kept at home. The registration of venomous and poisonous animals in the Regional Poison Control Centers should be compulsory. There is a need for initiating educational activity among people who keep dangerous animals at home as their pets.

Two men, aged 32 and 40, had a high-pressure paint injection injury to the left index and middle finger respectively. The first patient's finger became inflamed within a week, after which the paint was removed operatively; there was complete recovery of function. In the other patient the paint was removed immediately; however the finger was amputated a week later because of gangrene. High-pressure injection injuries should not be underestimated. High-pressure injection injuries to the hand often lead to severe and irreversible loss of function. Acknowledging the severity of this type of injury is the key to adequate treatment. Mostly this means immediate operative intervention. Only injuries with clean water, air or a small amount of vaccine can be treated conservatively under close observation.

Malayan cobra (Naja naja sputatrix) is the venomous snake of the Elapidae family which involves at least three species of Asian spitting cobras, according to the new taxonomy. This snake occurs naturally in southeastern Asia and in Poland it is kept only in the private breedings. Its venom mainly contains neurotoxins which have paralyzing activities to the nervous system and cardiotoxins which act cytolytically. The present study shows a case of the forty-one-year-old man professionally engaging in venomous reptiles who was bitten in his left ring finger by the Malayan cobra. No general symptoms, especially neurotoxic, were observed in the patient after the snake bite, but there was a significant local tissue injury including necrosis. In the bite site the infection with Morganella morganii developed with consequent phlegmon within the hand and the forearm. Additionally, features of haemolysis and injury of muscles with elevated level of serum creatine phosphokinase (CPK) were present. The local injuries of tissues were treated surgically including the amputation of the bitten finger which has undergone the necrosis. No specific antivenom was used in the treatment.

Background: Chemical burns account for relatively few admissions to a burns unit. These injuries, however, deserve separate consideration because of their ability to cause continuing tissue destruction, their potential to cause systemic toxicity and the value of early treatment with copious lavage. Widespread inexperience in the treatment of chemical burns highlights the potential for greater levels of general awareness and knowledge., Methods: A review of 31 patients with chemical injuries admitted to the Tasmanian Burns Unit at the Royal Hobart Hospital (RHH) was carried out for the years 1989-1999., Results: The majority of patients were men aged 20-49 years (mean age: 32 years). Fifty-one per cent of injuries occurred in a domestic and 38% in an industrial setting. The more common aetiological agents were cement (25%), sulphuric acid (16%) and hydrofluoric acid (16%). The upper and lower extremities were involved in all but four patients and the mean total body surface area affected was 3.4%. The mean length of hospital stay was 9 days with a range of 1-30 days. Management of injuries consisted of either surgical or conservative treatment. The former included debridement and split-thickness skin grafting or primary closure and the latter of topical treatment with 1% silver sulfadiazine cream and appropriate dressings., Conclusion: Widespread inexperience in the treatment of chemical injuries highlights the potential for greater levels of knowledge. This is particularly apparent in the early management of these injuries.

Extravasations of chemotherapeutic drugs may lead to large soft-tissue losses in the hand and forearm and necessitating surgical excision with secondary flap coverage. Unfortunately, a delayed referral to a hand and plastic surgical unit with an already established soft-tissue defect is most common. Nevertheless, in our unit the method of choice is early emergency subcutaneous "wash-out", which facilitates dilution and reduction of concentration of the extravasation and therefore reliably avoids the development of soft-tissue defects. The aim of this paper is to present the surgical technique.

Summary.High-pressure injection injuries are rare and the extent of tissue damage is often underestimated. They usually have devastating effects on tissues and result in poor functional outcome of the involved hand. The severity of these injuries is related to the nature, pressure, volume and toxicity of the injected substance. The major problem of this injury is a toxic edema followed by ischemia, causing a gangrene of the involved finger, which may require amputation. The pathogenesis is characterized by different, but often synchronous onsets, leading to an apparent chain of events that occur once the material has been injected. Increase of pressure within the closed space leads to tamponade, intravascular thrombosis and spasm of vessels create circulatory embarrassment, a chemical irritation provokes an acute inflammation. Three stages of progress are described. Timing is an important factor influencing the results. An early, wide decompression and aggressive debridement with complete removal of foreign substances and necrosectomy is recommended in the acute stage and will improve prognosis and outcome. Open wound treatment and second-look operations during the intermediate stage are followed by secondary wound closure with local or free flaps, if necessary. We emphasize the role of early active motion during this time. Reconstructive surgery is reserved for the late stage.43 patients were treated surgically in our department over the last 28 years (1972 to 2000). 12 of them (28 %) required amputation at different levels of the involved finger. Only nine patients healed without any functional loss. Most frequent injuries were of the paint or paint-solvent and grease-gun type.

A 50-year-old fisherman was stung in his right hand by a Great Weever fish (Trachinus draco). The crew did not have sufficient medical knowledge to adequately treat him on board. Severe pain, oedema of the hand, fever, vomiting and syncope occurred. Treatment with antibiotics, on board, after disembarkation and later in hospital for six days reduced the severity of the symptoms. However, two years after the accident, the patient still suffered from a dysfunction of the right hand as well as extreme fatigue and intermittent joint complaints. The symptoms mostly commonly arising from a Weever fish sting are: severe pain, local erythema and oedema. Systemic symptoms may sometimes occur: headache, syncope, bradycardia, fever and hypotension. The symptoms of continuous joint pain and severe fatigue following a Weever sting have not been previously described. The Weever fish venom contains a mixture of biogenous amines, of which some are known: 5-hydroxytryptamine, epinephrine, norepinephrine and histamine. The venom's composition has yet to be fully elucidated. In the event of a Weever fish sting, the first aid which should be given is: clean the wound and immerse the affected part of the body for at least 30 minutes in water which is as hot as the victim can tolerate (40-45 degrees C). Persons at risk from Weever fish stings are bathers, especially from the Lesser Weever fish (Echiichthys vipera), and sea fishermen. General practitioners and first aiders in coastal areas as well as sea fishermen should be informed about the first aid to be given in the event of a Weever sting.

The,Marjolin's ulcer" is a malignant lesion which is developed especially at chronic wounds after burn trauma. The latency from primary trauma to the malignant transformation is about 30 years. The lesion is more aggressive than other squamous cell carcinomas. We report on the combined radiation and surgical therapy of an 65-year-old patient with this lesion on the right hand and regional lymph node metastases. The extensive tissue defect after wide excision was reconstructed with a reversal radial forearm flap.

We report a case in which quick freeze injury occurred to both hands by helium vapour at extremely low temperatures. At the time of injury the victim was wearing protective gloves which were removed quickly after the accident. This prompt removal of gloves reduced the depth and severity of the injury. Initially he was treated by rapid thawing by immersing the hands in luke warm water (37 degrees C) and administering heparin by drip to prevent microvascular thrombosis. Delayed skin grafting was performed with good functional recovery. The circumstances accompanying this injury and preventive measures are discussed.

Phenolic disinfectants (e.g. Meytol, Dettol, etc.) are widely used for domestic purposes. Instructions on the bottles are clearly given with regards to the dilutions that should be used. In domestic cleaning, these instructions are often ignored and higher concentrations are used with the thinking that 'the more I pour, the cleaner it gets!'. Furthermore, cleaning equipment is sometimes stored without prior rinsing with fresh water. As water evaporates much faster than phenol, the solution on stored mops/ brushes, etc. becomes progressively more and more concentrated and can cause chemical burns when these utensils are handled at a later time. We therefore suggest that two further instructions should be added to the usual instructions on bottles of household phenolic disinfectants, namely: 'wear gloves when performing domestic cleaning' and 'wash all cleaning equipment with plenty of fresh water after use'. We support this by a case report of a 65-year-old man who sustained full-thickness, painless chemical burns to his right hand after handling a moist mop which had been used for cleaning a carpet with a phenolic household disinfectant solution 2 days earlier.

A term baby with neonatal convulsions secondary to birth asphyxia was given i.v. phenytoin via a cannula in the dorsum of the hand at 17 h of age. She developed a blue discolouration in the tissues surrounding the i.v. site. The infusion was aborted but the discolouration gradually spread to the rest of the hand. Twenty hours later, improvement could be detected although a blister appeared near the i.v. site. A further attempt two days later to administer phenytoin via an i.v. cannula sited in the left foot was aborted after the appearance of a similar reaction.

Hydrofluoric acid has widespread uses in industry and at home. Its mechanism of toxicity is the basis of a specific treatment. Cutaneous burns are the most common form of toxicity and the consequences can be catastrophic. Its insidious presentation can delay any therapeutic action, except if the physician is aware about it. A case report underlines the beneficial action of the intra-arterial infusion of calcium gluconate.

Hydrofluoric acid is used extensively as an industrial cleaning agent for metals and glass. Many workers are injured by cutaneous contact of the acid with exposed skin surfaces, particularly hands. Hydrofluoric acid burns are characterized by delayed onset of symptomatology with skin ulceration, and severe pain may be of extended duration. Treatment of hydrofluoric acid burns traditionally has consisted of local infiltration or intraarterial injections of calcium solutions. These injections are painful and frequently require retreatment. A new treatment utilizing a topical gel of calcium carbonate is described. Nine patients have been treated for hydrofluoric acid burns of the hand with calcium carbonate gel applied topically and covered with occlusive glove dressings. A gel slurry is compounded from calcium carbonate tablets and K-Y Jelly. Fingernails of the affected fingers are removed if a subungual burn is obvious. The gel is put into a surgeon's glove and placed over the burned hand. The patient replaces the glove and slurry every 4 hours for 24 hours. After the first day, the glove is discontinued unless there is resumption of painful symptoms. Full range of motion is encouraged during this interval. The calcium carbonate gel technique was successfully utilized in nine patients with no further need for injection therapy. In these patients, pain relief was obtained within 4 hours of treatment, with no further progression of skin ulceration. No reconstructive procedures were required in any patient, and only one patient did not return to full-duty work within 1 week. There were no long-term sequelae from burns treated with this topical therapy, except one patient, who presenting 24 hours after the burn, developed a digital tip neuroma that was excised.

A case report of accidental hydrofluoric acid burns that involve dermal tissue of the hand is presented. Prompt medical treatment for this accident resulted in minimal disfigurement and minimal paresthesia and disability. Protocols for essential treatment and precautions for personnel working in dental laboratories where hydrofluoric acid is used have been discussed.

Airless gun injection injuries of the hand are a surgical emergency. The injection of paint or paint solvents are the most pernicious, whereas grease or diesel fuel injections have a better prognosis for the victim. Tissue necrosis and subsequent morbidity results from the diffusion of the noxious substance. Solvents and paint generate the most severe inflammatory response. Prompt major surgical treatment can minimize morbidity.