Extracorporeal membrane oxygenation combined with continuous renal replacement therapy in cutaneous burn and inhalation injury caused by hydrofluoric acid and nitric acid

Abstract

Rationale:Hydrofluoric acid (HF) is a highly corrosive agent and can cause corrosive burns. HF can penetrate deeply into tissues through intact skin and the lipid barrier, leading to painful liquefactive necrosis, and inducing hypocalcemia and hypomagnesemia. In this study, we hypothesize that continuous renal replacement therapy (CRRT) may be beneficial in addressing hemodynamic instability in cases of HF poisoning.Patient concerns:A 25-year-old man fell into an electroplating pool containing 10% HF and 50% nitric acid.Diagnoses:He had severe cutaneous injuries involving approximately 60% of his total body surface area including the head, face, neck, right upper arm, right hand, trunk, perineum, and both lower limbs and feet. Examination at admission showed the following electrolyte concentrations: ionic calcium 0.192 mmol/L, total calcium 0.72 mmol/L, magnesium 0.4 mmol/L, potassium 5.49 mmol/L, and sodium 136.8 mmol/L.Interventions:An initial 20 mL intravenous bolus of 10% calcium gluconate was followed by a continuous infusion at 6 g/h plus continuous intravenous drip 25% magnesium sulfate at 1.5 g/h. Continuous cardiac monitoring was performed in the intensive care unit. Extracorporeal membrane oxygenation (ECMO) was used to improve oxygenation function at 38 hours post exposure. Antibiotic therapy using imipenem/cilastin plus vancomycin was required.Outcomes:After treatment for 12 hours, electrolyte concentrations returned to normal. On day 11, the hemodynamic parameters were stable and oxygenation function had improved. On day 26, the patient was weaned off CRRT. One month later, the patient twice received skin grafting, then was discharged from the hospital without pulmonary, cardiac, or neurological complications 3 months later.Lessons:The present case study demonstrates that CRRT may be an effective and potentially lifesaving therapy after severe exposure to HF. Prolonged hemodialysis is recommended to remove delayed release fluoride ions to avoid delayed systemic injury. When conventional therapy can not improve oxygenation and/or carbon dioxide retention, ECMO should be performed as soon as possible.

Treatment of Ventricular Fibrillation Due to Ammonium Bifluoride Poisoning With Hemodialysis

“…16 However, in cases of poisoning with persistent hemodynamic instability, extracorporeal membrane oxygenation combined with continuous renal replacement therapy can be considered. 17 The lack of a postdialysis fluoride level is a limitation of this report; however, there is historical and theoretical basis for the efficacy of fluoride removal via HD. 13…”

Hydrofluoric Acid: Burns and Systemic Toxicity, Protective Measures, Immediate and Hospital Medical Treatment

“…A 10-year [ 1 ], a 11-year [ 20 ], a 15-year [ 30 ], a 20-year [ 2 ] and a 22-year [ 29 ] retrospective epidemiological studies revealed that chemical burns encountered in a Burn centres caused by hydrofluoric acid are one with the most frequent occurrence, especially in the regions with highly developed industry. The most common sites of injury are the head and neck, hands, legs and arms [ 1 ], [ 45 ]. HF burns might be accompanied by ocular injuries, respiratory and digestive tract disorders [ 1 ].…”

“…Irritation and immediate severe pain, followed by lacrimation are first signs after eye exposure. Conjunctivitis followed by oedema and congestion [ 45 ], oedema of other structures of the eye, mydriasis, nystagmus, and corneal erosion and ulceration, with corneal opacification and non-visible iris as complications, may result from even minor hydrofluoric acid splashes [ 33 ], [ 55 ]. Prolonged HF exposure can lead to loss of vision and total eye destruction.…”

“…Symptoms from respiratory system may occur when exposed to HF gas, fumes or vapours which arise when liquid acid evaporates on increased ambient temperature; in the case of a pulmonary aspiration while ingesting [ 1 ]; as a systemic toxicity symptom after HF acid ingestion [ 16 ], [ 18 ]; as a respiratory complication after HF splashes on the skin [ 24 ], or after severe dermal burns [ 45 ].…”

“…The presence of pale bronchial mucus on the bronchial membrane and congested, edematous mucosa several days after skin exposure have been confirmed by fiberoptic bronchoscopy [ 45 ]. Extravasations and hemorrhagic infarcts have been detected in the lungs after fatal accidental ingestion of a mixture of hydrochloric and hydrofluoric acid [ 18 ].…”