II. Background

  1. Hydrofluoric Acid Industrial Uses
    1. Electroplating
    2. Glass Etching
    3. Rust Removal
    4. Brick Cleaning
    5. Semiconductor Manufacturing
  2. Mechanism of Injury
    1. Skin contact injury results in both local Burn Injury from Hydrogen Ions
    2. Systemic effects occur due to fluoride ion movement from weak surface acids to deep spaces (subcutaneous fat, vessels, nerves)
      1. Results in liquefaction necrosis
      2. Myocardial toxicity via increased cAMP (risk of refractory Ventricular Fibrillation)
    3. Fluoride chelates Calcium and Magnesium
      1. Results in Hypocalcemia and Hypomagnesemia
    4. Other Electrolyte abnormalities
      1. Hyperkalemia

III. Symptoms

  1. Onset of symptoms within hours to 24 hours after exposure
  2. Local vasospasm (pallor)
  3. Pain out of proportion

IV. Signs

  1. Cardiovascular
    1. Cardiac Arrhythmia
    2. Hypotension
  2. Neurologic
    1. Confusion
    2. Cerebral edema
    3. Tetany
    4. Seizures
    5. Paresis

V. Grading: Indications of Significant Hydrofluoric Acid Exposure

  1. Hydrofluoric Acid concentration >50% and burn of any size
  2. Hydrofluoric Acid burn affecting >5% Body Surface Area (BSA)
  3. Hydrofluoric Acid injury to the eyes, face, genitalia or mucosa
  4. Ingestion of Hydrofluoric Acid
  5. Inhalation Injury associated with Hydrofluoric Acid

VII. Diagnostics

  1. Electrocardiogram (EKG) Findings of HFA-related Myocardial Effects (esp. Electrolyte abnormalities)
    1. Prolonged QRS interval
    2. Prolonged PR Interval (first degree AV Block)
    3. QTc Prolongation
    4. T Wave Inversion or Peaked T Waves
    5. ST Segment Elevation or depression

VIII. Management

  1. General
    1. Personal Protective Equipment for all with patient contact
    2. ABC Management and evaluate for hemodynamic stability
    3. Early Consultation with poison control
    4. Burn Center coordination for any significant Burn Injury
  2. Decontamination
    1. Remove all clothing
    2. Copious Irrigation of contaminated regions
      1. Use saline or water for continuous 20 minute flush of burn area
      2. Saline and water have equivalent efficacy to chelating agents
  3. Antidote
    1. Topical Calcium Gluconate 2.5% gel
      1. Preprepared or mix 1 gram of 10% Calcium Gluconate IV solution in lubricant jelly
      2. Apply to all areas of Burn Injury to neutralize acid
      3. Calcium Gluconate in contact with Hydrofluoric Acid will form white Calcium fluoride crystals
      4. Replace the topical solution or gel every 15-30 minutes (after it has turned to a white color)
      5. Hand burns may be inserted into a Calcium Gluconate filled HFA-resistant glove
      6. Expect pain relief after serial applications of Calcium Gluconate (except in severe deep burns)
    2. Advanced measures for severe refractory cases
      1. Parenteral Calcium Gluconate (controversial)
        1. Subcutaneous into affected region
        2. Intravenously via regional block at affected area
        3. Distal arterial injection (e.g. radial artery, dorsalis pedis artery)
      2. Burn Center or Surgical Interventions
        1. Vasodilator infusion (e.g. alprostadil)
        2. Escharotomy
  4. Monitoring of severe exposure
    1. Vital Signs for hemodynamic instability
    2. Telemetry and serial EKG as needed
    3. Electrolyte abnormalities
    4. Renal dysfunction
      1. Hemodialysis may be needed in severe Poisonings for Renal Failure (not for HFA removal)

IX. Complications

  1. Congestive Heart Failure
  2. Chronic Kidney Disease
  3. Fluoride-induced osteolysis

X. References

  1. Kinker and Glauser (2021) Crit Dec Emerg Med 35(9): 19-27

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Related Studies

Ontology: Hydrofluoric Acid (C0020274)

Definition (MSH) Hydrofluoric acid. A solution of hydrogen fluoride in water. It is a colorless fuming liquid which can cause painful burns.
Concepts Hazardous or Poisonous Substance (T131) , Inorganic Chemical (T197)
MSH D006858
SnomedCT 42757007
English Acid, Hydrofluoric, Hydrofluoric Acid, Fluohydric Acid, Fluorhydric Acid, Acid, Fluohydric, Acid, Fluorhydric, Hydrofluoric Acid [Chemical/Ingredient], fluohydric acid, hydrofluoric acid, fluorhydric acid, acids hydrofluoric, acid fluorhydric, HYDROFLUORIC ACID, Hydrogen Fluoride, Hydrofluoric acid, Hydrofluoric acid (substance)
French Acide hydrofluorique, Acide fluorhydrique
Swedish Fluorvätesyra
Czech kyselina fluorovodíková
Finnish Fluorivetyhappo
Italian Acido fluoidrico, Acido fluoridrico
Japanese ふっ化水素, 弗酸, ふっ酸, フッ酸, ふっ化水素酸, 弗化水素酸, フッ化水素酸, フッ化水素
Croatian Not Translated[Hydrofluoric Acid]
Polish Kwas fluorowodorowy
Norwegian Flussyre, Hydrogenfluorid
Spanish Ácido Hidrofluorico, Fluoruro de Hidrógeno, ácido fluorhídrico (sustancia), ácido fluorhídrico, Ácido Fluorhídrico
German Fluorwasserstoffsäure
Portuguese Ácido Fluorídrico

Ontology: Hydrofluoric acid burn antidote (C0360300)

Concepts Pharmacologic Substance (T121)
SnomedCT 350078004, 419517004
English Hydrofluoric acid burn antid., Hydrofluoric acid burn antidote, Hydrofluoric acid burn antidote (product), Hydrofluoric acid burn antidote (substance)
Spanish antídoto para quemadura por ácido fluorhídrico (sustancia), antídoto para quemadura por ácido fluorhídrico, antídoto para quemaduras por ácido fluorhídrico (producto), antídoto para quemaduras por ácido fluorhídrico