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First aid measures for chemical burns and burns to the eyes

MEDICINE: The overview

Chemical burns and burns of the eyes represent a small group in the context of all eye injuries. Fortunately, minor accidents predominate, which usually cause neither therapeutic nor prognostic problems. Serious accidents are rare, but precisely because of this there are great uncertainties in the initial care and the further treatment measures to be initiated. Adequate first aid with rinsing therapy that starts immediately and continues has a decisive influence on the healing process and the prognosis of such eyes.
Keywords: cornea, conjunctiva, chemical burn, burn, first aid measure


Primary Management in Chemical and Thermal Eye Burns
Chemical and thermal eye burns are a small but significant fraction of ocular trauma. Most of these accidents are trivial, easy to treat, with no lasting adverse effects. Severe eye burns are rare, but result in unilateral or bilateral visual impairment. Unfortunately, primary management and subsequent therapy of acute eye burns are often ineffective and not appropriate. Adequate first aid with prompt and prolonged irrigation determines the healing course and the prognosis of such eyes.
Key words: Cornea, conjunctiva, chemical burn, thermal burn, first aid

The incidence of chemical burns and burns is given in the literature as 7.7 to 18 percent of all eye accidents (39, 41, 50, 78, 80). Fortunately, many accidents are trivial and do not cause permanent damage, but others lead to blindness (29). Most of the accident victims are young patients who suffer accidents at home, at work or in connection with criminal attacks (25, 45, 77). Chemical burns caused by alkali are much more common than damage caused by the action of acids (44, 50). Accidents caused by detergents, solvents, and burns, on the other hand, are much less common (30). The most common agents that cause alkaline burns are ammonia (NH3), caustic soda (NaOH), potassium hydroxide (KOH) and lime (CaO or Ca (OH) 2). Acid burns are mainly caused by sulfuric acid (H2SO4), sulphurous acid (H2SO3), hydrofluoric acid (HF) and hydrochloric acid (HCL). Table 1 shows the data of 191 patients (260 eyes) who were treated for severe chemical burns or burns between 1980 and 1995 at the RWTH Aachen Eye Clinic. A shockingly high percentage of the patients had suffered severe bilateral damage. The high proportion of accidents at home and during leisure time is also noteworthy.
Effect of alkalis and acids
In principle, the severity of the damage depends on the type and concentration of the agent, the amount, the duration of exposure and the pH value of the solution (20). Alkali penetrated faster than acids. The action of the hydroxyl ion (OH-) saponifies the lipid components of the cell membranes with subsequent cell disruption and cell death, while the cation is responsible for the penetration properties of the specific alkali. If the corneal epithelium is intact, calcium hydroxide, potassium hydroxide, sodium hydroxide and, most rapidly, ammonium hydroxide penetrate with increasing speed (42). Depending on the extent of penetration, the corneal and conjunctival epithelium, stromal keratocytes and endothelium are lost. The cornea becomes cloudy. Damage to the vascular endothelium of the conjunctival and episcleral vessels leads to thrombosis of these vessels with subsequent ischemia. The stronger the lye, the faster it can penetrate. Irreversible tissue damage occurs at a pH value of 11.5 and higher (10). The pH of the aqueous humor increases within a few seconds after a chemical burn with ammonium hydroxide (15). Intraocular structures such as the iris, the lens and the ciliary body are also quickly damaged.
With the exception of the oxidatively active hydrofluoric acid and sulfuric acid, acids penetrate more slowly. Protons (H +) cause precipitation and denaturation of the proteins in the cells and thus lead to irreversible, structure-related cell death. The proteins not only deform, they also network with one another. This change in proteins can also be observed when exposed to heat. The coagulation of the proteins on the surface of the globe provides a relative protection against the deeper penetration of the acids. However, strong acids penetrate just as quickly as alkalis. In the healing process and the prognosis of such eyes, no differences between severe caustic and acid burns could be determined on the basis of our own patient collective (26).
Clinical classification of chemical burns and burns
The severity is classified into four stages (57, 58). The healing process and prognosis depend on the area of ​​the destroyed conjunctiva, the involvement of the eyelids and the depth of the damage, in particular on the extent of the limbal and scleral ischemia (Table 2).
This classification is based on the fact that minor burns in stages I and II result in more superficial and less extensive damage. In severity stages III and IV, extensive destruction of the surface and deep structures also occurs. In the case of slight burns, hyperemia or chemosis of the conjunctiva and loss of epithelium in the cornea can be seen (Figure 1). In the case of slight acid burns, the coagulated epithelium often has a grayish-glassy appearance. If the epithelium is removed, the clear corneal stroma can be seen underneath. These mild cases have a good prognosis, do not cause any problems in therapy and experience has shown that they heal in a few days without any consequences.
Stages III and especially IV show more extensive and, above all, deeper damage. Characteristically, large parts of the conjunctiva and subconjunctival tissue are damaged and do not appear to be clinically perfused. The vessels that are still visible are thrombosed and appear brownish-black (Figure 2). The cornea loses its keratocytes, the denatured proteins swell and the cornea becomes cloudy. Chemical damage to the iris and lens manifests itself in a mydriasis with a dirty-gray discoloration of the iris and the development of rapid lens opacity. The breakdown of the blood-aqueous humor barrier often results in inflammatory anterior chamber exudation. In the areas of necrosis, inflammatory substances such as histamine, prostaglandins and leukotrienes develop (7, 34, 66). They cause reactive inflammation in the areas bordering healthy tissue. While this process quickly subsides in the case of minor damage, severe and long-lasting inflammation develops in the case of extensive damage (74, 79), which determines the further course of the disease (54, 56, 59, 60, 63).
Immediate flush therapy determines the extent of the damage
Any chemical burn or burn must be treated as an emergency until a specialist examination can take place. Immediately starting irrigation therapy of the eye with sufficient amounts of irrigation fluid is of crucial importance (2, 69). First aid in the form of intensive rinsing, if possible immediately after contact with the damaging agent, has a decisive influence on the course and prognosis, more than any later therapeutic approach (Tables 3 and 4). This applies to the visual acuity achieved later, which is significantly better if a professional, immediate flushing therapy is carried out (28). The visual acuity of two percent as the limit of legal blindness was chosen because it enables orientation in space without outside help. The number of operations required and the length of the inpatient stay are also significantly reduced by flushing therapy carried out immediately as part of first aid. !
First aid
Rinsing therapy that is started immediately after a chemical burn or burn is of the greatest prognostic importance. It should be borne in mind that in severe cases, the casualty himself may not be able to perform a flush, or at most ineffectively. The initial pain leads to reflex blepharospasm. In addition, the patient feels fear and panic. In such situations, if it is an accident in an industrial area, it is uncertain whether the patient can get to the nearest body or eye shower and can efficiently rinse the eyes. Measures such as prevention on the "man", working in groups of two in danger areas and, above all, intensive training in dealing with prepared initial measures are therefore of decisive importance. The first aider must have learned to overcome the blepharospasm by passively opening the eyelids and to carry out an effective eye wash. The casualty is asked to look one after the other in all directions so that the irrigation fluid can penetrate into every corner of the conjunctiva. A surface anesthetic can be instilled to relieve pain and make irrigation easier. According to the ANSI standard (ANSI, American National Standards Institute) (Z358.1-1990), this should be done for 15 minutes. Accordingly, sufficient quantities of flushing liquid of at least 1.5 liters must be available. The pH of the aqueous humor can be normalized within this time with amphoteric or buffered substances (70). In burns, it is not uncommon for the hot, liquid metal to solidify as a "cast" in the conjunctival sac or the upper eyelid (55, 61). Particulate constituents and dirt particles typically accumulate under the tarsus, often unnoticed. Therefore, every first aid measure includes ectropioning the upper eyelid and intensive cleaning of the conjunctiva. Calcium oxide, which is present in cement and mortar, for example, reacts to calcium hydroxide when rinsed with water and leads to continued chemical burns with a pH value of 12.4. A cotton swab soaked in a one percent Titriplex solution (EDTA = di-sodium-ethylene-diamine-tetra-acetate) can be used to facilitate the mechanical cleaning of the conjunctival sac from set calcium residues. Under no circumstances should EDTA be used with the intention of neutralizing a fresh burn with calcium, since the use of unbuffered EDTA in reaction with calcium hydroxide does not neutralize the alkali. In the special case of lime and cement burns, the conjunctiva and the fornices can be cleaned with oil (olive oil, sunflower oil, etc.) without water (18). Immediate rinsing is particularly important in the case of burns, as it cools the surface (71). Continued irrigation removes inflammatory substances and activated leukocytes from the surface of the globe (58, 62).
Selection of the flushing medium
So far, water has been recommended as the rinsing liquid. It has the advantage that it is usually available everywhere in sufficient quantities and that the desired dilution effect is achieved with intensive flushing. However, water is hypotonic to the intraocular environment. Since the epithelium is lost within a few seconds in the event of chemical burns, the water easily penetrates the ion-rich milieu of the corneal stroma due to the osmotic pressure and intensifies the edema induced by the chemical burn. This edema increases the permeability of the cornea. This means that alkali and acid particles can penetrate deeper into the corneal stroma, benefiting from the osmotic gradient. It is therefore more advisable to use a tear isotonic or even hypertonic solution. A flow of ions and water out of the tissue is used as a non-specific physico-chemical therapy. Dissolved ions are mobilized from the tissue. The physiological saline solution recommended as an eyewash solution is also only conditionally suitable as a rinsing medium in the context of such considerations, since this solution is also not tear-isotonic. New studies show that even after intensive rinsing with physiological saline solution, the pH value in the anterior chamber cannot be lowered sufficiently (Table 5). Exogenously added phosphate, together with the endogenously released calcium due to cell damage, can lead to considerable subtotal calcifications of the corneal stroma (62). In the case of experimental burns, these were irreversible with continued use. For this reason, the use of the phosphate buffer (isogutt = 4.48 percent sodium phosphate buffer), which is often recommended in the current literature and which is stored as a flushing medium in many companies, is prohibited (38, 53, 67, 76). Rinsing media preserved with benzalkonium chloride have their own high toxicity, so that they are not suitable for long-term rinsing of the eyes.
At the moment there is no flushing medium that is adapted to the milieu of the corneastroma in terms of electrolytes. Development work is in progress here to find more compatible flushing media.
Of the solutions currently available, the sterile, unpreserved lactated Ringer's solution and the Balanced Salt Solution (BSS) are ideal. According to studies by other authors, these solutions are better tolerated than a physiological saline solution (16). A lactated Ringer's solution is buffered and therefore more effective than a saline solution. The solutions mentioned are available everywhere and are inexpensive.
BSS has an osmolarity identical to the aqueous humor and has a neutral pH value. It has been specially developed for ophthalmic operations that require higher intraocular flow rates. After it was previously shown that saline and lactated Ringer's lactate damage the corneal endothelium (8). BSS is similar in composition to aqueous humor and contains sodium acetate and sodium citrate, among other things. According to Pfister's work, isotonic citrate buffer forms chelates and can therefore also bind non-specifically metal ions (51, 52). BSS prevents corneal edema and protects the endothelium. The related and considerably more expensive BSS Plus should not be used as a flushing medium due to the high concentration of phosphate. The pH value, the osmolarity and the buffer capacity of the aqueous humor, the corneal stroma and the rinsing media are summarized in Table 6. Information on the buffer capacity of Isogutt cannot be given because the preparation is no longer on the market. In our opinion, the requirements for an ideal rinsing medium are as follows: hyperosmolar, unpreserved, termination of the etching trauma, removal and chemical binding of the etching substance without exothermic or precipitating reactions from the cornea. When using rinsing liquids, it is essential to pay attention to the expiry date of the solution. Contaminated rinsing fluids represent a vital threat to severely burned and burned eyes. Due to the loss of the surface epithelia, which fulfill a barrier function, these eyes are extremely susceptible to infection. Within a few hours, a bacterial infection (e.g. by Pseudomonas) can lead to a meltdown of the cornea and endophthalmitis with loss of the eye.
About the use and benefits of the recently used Diphoterine (Previn), a hypertonic rinsing medium with an organic molecule with amphoteric and chelate properties, which binds alkalis as well as acids and lowers the pH value just as quickly as phosphate buffer in the conjunctival sac and corneal stroma, are available First clinical and experimental experience is available (35). Diphoterine is a completely newly synthesized substance, the composition of which can be obtained from the manufacturer Prevor GmbH, Cologne. The pH of the 0.4 percent Diphoterines is 7.4 and the osmolarity is 820 mosm / l. According to the experience of occupational physicians, the accident-related downtimes in patients who were flushed with Previn during emergency treatment are significantly shorter than after flushing with other flushing media (Schrage et al., Unpublished). Only the future will show to what extent this solution represents an improvement for emergency treatment. Testing the effectiveness of Previn as a solution with ideal physical and chemical properties is currently the subject of our own experimental investigations. It must be emphasized once again that a severe burn or burn of the eyes is an emergency in which no time should be lost. If none of the above-mentioned special rinsing liquids are available, rinsing with water can and must of course be carried out immediately. !
Eye rinsing during patient transport
The rinse must not be interrupted on the way to a specialist, as concentrated alkalis and acids penetrate within seconds or minutes and remain for hours (14). The recommendations for the minimum time for rinsing therapy for caustic and acid burns in the literature range from at least 15 minutes (ANSI standard) (40) to two to four hours (50, 68).We recommend the use of an infusion system for rinsing the eyes, consisting of one or more bottles with 500 ml of isotonic lactated Ringer's or BSS solution and an infusion set. As already described above, one helper holds the patient's eyelids open, while another helper carries out a mild rinse from the open infusion with a height difference of around 20 to 50 cm from the eye. If the patient is in pain, a surface anesthetic can be instilled repeatedly.
In addition, a large number of special flushing systems are widespread in the Anglo-Saxon language area. The principle of these irrigation systems consists of a polyethylene loop or a scleral lens made of polymethyl methacrylate (e.g. Morgan lens), which can be connected to an infusion system with irrigation solution (12, 37, 43, 47, 72, 75). These loops are inserted into the conjunctival sac or placed on the cornea. The irrigation solution escapes through openings in the loops or lenses and washes out the conjunctival sac. Although these systems ensure continuous rinsing of the eyes, based on our own experimental investigations, homogeneous rinsing of the entire surface of the globe and in particular of the fornices cannot be achieved. Rather, characteristic "rinsing routes" are also formed in the case of irrigation loops calculated using fluid dynamics, so that individual areas of the globe surface are not sufficiently reached by the irrigation solution. It is possible that solid particles such as lime and mortar remain undetected once the irrigation loop is applied as an "adequate measure". The care of the accident victim, as described above, however, requires the unrestricted attention of the first aiders and the careful execution of an efficient, consciously carried out rinsing until they arrive at an ophthalmic clinic. Once an irrigation sling has been applied, there is a risk that first aiders, knowing that they have done everything necessary, will no longer pay any attention to the burned eye and, at best, carry out systemic pain reliever therapy. In addition, first aiders who are inexperienced in handling such systems may lose important time trying to insert the irrigation slings or lenses and may cause additional mechanical trauma to the eye. Finally, damage patterns from the application of the flushing systems have also been found in healthy test persons (own investigations). To check the effectiveness of the irrigation therapy, the pH value in the conjunctival sac can be measured with indicator paper. As long as the pH value is not normal, rinsing must not be interrupted. If the pH value does not return to the normal range in spite of the continuous rinsing, one should make sure again by ectropioning that no particles of the etching substance in the fornices have been overlooked.
Follow-up treatment
The further measures to be taken after chemical burns depend on the severity of the accident. Therefore, the classification with regard to the severity of the burn is decisive for the further treatment measures. This is done by the ophthalmologist providing the first care. This should carry out a careful inspection and assessment. If it is a slight burn (stage I or II) and an immediate rinse therapy was carried out, the eye will normally heal without permanent damage (29). The supply is usually limited to the application of a combination preparation of corticosteroid and antibiotic in the form of drops or ointments and the application of an eye bandage. The patient should undergo an outpatient ophthalmological examination within 24 hours. Tolazoline (Priscol), a hyperaemic preparation, which is still used in some places, must not be prescribed under any circumstances because of an intensification of the reactive inflammation!
Severe burns (stage III and IV), on the other hand, are difficult to treat and often take months to heal. These cases require a precise assessment of the extent and depth of the damage. Such an examination should be done under the surgical microscope. If the patient experiences severe pain, this examination should be carried out under retrobulbar or general anesthesia.
Lighter cases (stage III) show only superficial ischemia with moderate opacity of the cornea. The extent of the limbal ischemia helps to estimate the severity of the burn. If the limbus is largely preserved, no fibrin exudation is visible in the anterior chamber, no discoloration of the iris and no ectropion uveae, the patient can receive mostly conservative care in a local eye department or clinic (62).
The most severe burns (stage IV) show extensive ischemia of the limbal region and the surface of the globe down to the depths of the folds of the envelope. In the case of superficial necrosis, perfused scleral vessels shimmer in the depth; in the case of deep necrosis, these are completely absent. In these cases there is usually a stronger primary corneal opacity. A dirty-gray iris discoloration with an ectropion uveae and a gray-white fibrin exudation in the anterior chamber can then be seen as an indication of the deep damage caused by the agent. It is not uncommon for the eyelids and the conjunctiva tarsi to be involved. In this acute phase of damage, in addition to other problems such as mastering secondary glaucoma, it is important to prevent melting of the eyes, which is particularly threatening when large parts of the conjunctiva and the eyelids are destroyed. This extensive damage to the conjunctiva leads to strong leukocyte secretion. This leukocyte secretion contains high levels of lysosomal enzymes. In particular, the matrix metallo-proteinases collagenase (MMP-8) (9, 19, 22, 23, 24, 35, 48), gelatinase (MMP-2, MMP-9) (6, 9, 11, 21, 46) and stromelysin (MMP-3) (4, 5) are responsible for the formation of corneoscleral and corneal ulcerations within four to six weeks after the accident.
These severely damaged eyes therefore require early, intensive drug anti-inflammatory therapy that alleviates the reactive inflammation and essentially consists of the application of eye drops containing corticosteroids (57, 64). The application of a local antibiotic is essential, as these severely damaged eyes are extremely susceptible to infection as long as the surface of the globe is not completely epithelialized again (27). Tetracycline preparations are playing an increasingly important role in this. These preparations not only have an antibiotic effect, but also act as non-specific inhibitors of metalloproteinases (1, 3, 13, 49, 73). In addition to conservative therapy, an early active surgical approach is essential in the first three days after the accident in order to remove the substrate from the reactive inflammation by removing the necrosis of the conjunctival and subconjunctival tissue and to cover the ischemic surface with plastic (31, 32, 33, 59, 61, 62, 63, 65). These cases should therefore be treated in a special eye clinic that has sufficient experience in the plastic reconstructive therapy of these ophthalmological problem cases.


How this article is cited:
Dt Ärztebl 2000; 97: A-104-109
[Issue 3]


The numbers in brackets refer to the bibliography, which is available from the author in an offprint and on the Internet (www.aerzteblatt.de).


Address for the authors
Priv.-Doz. Dr. med. Ralf Kuckelkorn
Wilhelmstrasse 8
52070 Aachen


Table 1
Severe chemical burns and burns at the RWTH Aachen Eye Clinic (1980 to 1995): 191 patients (260 eyes)
Number percent
Patient
one-sided 122 64
both sides 69 36
eyes
Occupational accidents 177 68.1
Private accidents 63 24.1
no information 20 7.8
eyes
Alkali 151 58.1
Acid 37 14.1
Combustion 42 16.2
other 30 11.6

Table 2
Severity of chemical burns and burns to the eyes
I II III IV
Erosio Erosio Erosio Like III
Hyperemia ischemia> 1/3 ischemia> 1/2 ischemia> 3/4
Regeneration Chemosis Chemosis dense corneal opacity
Recirculation opacity extensive necrosis
Regeneration ulcer persistent epithelial defects
Vascularization extensive ulceration
Proliferation fibrin exudation on iris
Scars cataract, glaucoma

Figure 1: Slight burns from lime. Hyperemia and circumscribed ischemia with vascular ruptures in the lower fold.

Figure 2: Severe burns from concentrated caustic soda. Diffuse opacity of the cornea, the pupil is vaguely visible. The conjunctiva is completely necrotic, and blackish discolored thrombosed episcleral vessels can be seen in the inner corner of the eyelid.

Table 3
Importance of first aid for the later therapeutic effort
(n = 101 patients, 131 severely burned or burned eyes)
Number of operations dwell time in
Hospital (months)
immediate rinsing 6.5 6 4.6 * 1 4.2 6 2.8 * 2
no or late irrigation 10.4 6 10.0 * 1 6.0 6 4.5 * 2
* 1 significant (P < 0,01,="" unverbundener="" t-test)="">
* 2 significant (P < 0,01,="" unverbundener="">

Table 4
Importance of first aid for the achieved visual acuity (n = 101 patients, 131 eyes)
Visual acuity immediate irrigation no or late irrigation
Number of eyes (%) Number of eyes (%)
> 1/50 45 (34) 22 (17)
< 1/50="" 31="" (24)="" 33="">
total 76 (58) 55 (42)
Significant: p = 0.0347 (Fisher test)

Table 5
pH value on the corneal surface and in the aqueous humor after rinsing with different
Media (experimental burns on rabbits' eyes for 30 sec with 1N NaOH)
PH value
Corneal surface aqueous humor
Immediately after burns 13 +/- 0 10 +/- 0
5 minutes after rinsing with 500 ml
NaCl 0.9% * 1 9 +/- 0 10 +/- 0
5 minutes after rinsing with 500 ml
Phosphate buffer * 2 7.5 +/- 0 9.25 +/- 0.44
5 minutes after rinsing with 500 ml
Diphoterine 7.5 +/- 0 9.34 +/- 0.59
* 1 p

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First aid measures for chemical burns and burns to the eyes