Use of hemodialysis after ingestion of a mixture of acids containing hydrofluoric acid

Antar-Shultz, Marina; Si, Rifkin; McFarren, Christopher

doi:10.5414/cp201532

Cited by 5 publications

(8 citation statements)

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“…Because renal clearance of fluoride is only 50% in the 24 hours after ingestion, 11 it is plausible that even in the presence of normal renal function, high-flow HD would significantly improve clearance. Previously, the same approach has been used in cases of poisoning by 2 different fluoridecontaining products, hydrofluoric acid 12,13 and sodium fluoride, 14 which were successfully treated with HD. Conversely, in a case of fluoride poisoning from sodium silicofluoride, peritoneal dialysis was ineffective in enhancing elimination of fluoride.…”

Section: Discussionmentioning

confidence: 99%

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Treatment of Ventricular Fibrillation Due to Ammonium Bifluoride Poisoning With Hemodialysis

Farkas¹,

Wolf

Landzberg

et al. 2018

Pediatrics

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Ammonium bifluoride is an inorganic, fluoride-containing compound found in glass and metal etching products, as well as wheel cleaners. Fluoride toxicity is a common cause of preventable poisoning and has been reported to cause life-threatening ventricular dysrhythmias. Here, we report a case of recurrent ventricular fibrillation secondary to ingestion of ammonium bifluoride. The patient presented with vomiting and coma. She was intubated for altered mental status and respiratory failure and subsequently had 5 episodes of ventricular fibrillation, each resolving with a single defibrillation. She developed metabolic acidosis and hypocalcemia, which were treated with sodium bicarbonate and calcium gluconate, respectively. During transfer to a tertiary care children's hospital, ventricular fibrillation recurred despite electrolyte correction. Hemodialysis (HD) was initiated emergently. No further dysrhythmia occurred after initiation of HD. The result of a basic urine drug screen was negative, and a comprehensive drug screen (gas chromatography and mass spectroscopy) revealed only a nonsignificant peak for diphenhydramine. Subsequent laboratory evaluation revealed an elevated serum fluoride level. Diagnostic laryngoscopy and upper endoscopy did not reveal evidence of caustic injury. She was successfully extubated on hospital day 2 and discharged from the hospital on day 4 with no neurologic sequelae. With this example, we demonstrate a potential therapeutic approach to this potentially lethal poisoning. Fluoride toxicity is typically treated with calcium. However, dysrhythmia may result from calcium-independent direct myocardial toxicity. The kinetics of fluoride are amenable to HD, and renal clearance is slow. The potential use of HD in cases of fluoride poisoning refractory to other therapies warrants further study.

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Section: Discussionmentioning

confidence: 99%

“…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…”

Section: Discussionmentioning

confidence: 99%

Treatment of Ventricular Fibrillation Due to Ammonium Bifluoride Poisoning With Hemodialysis

Farkas¹,

Wolf

Landzberg

et al. 2018

Pediatrics

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“…However, the concentration of serum fluoride was still 6 times above the upper reference limit. Antar-Shultz et al [ 14 ] documented a case in which the patient received hemodialysis for 4 hours approximately 16 hours after ingestion of a mixture containing HF. In that case, the concentration of serum fluoride decreased from 688 to 36 μmol/L after hemodialysis.…”

Section: Discussionmentioning

confidence: 99%

“…These reports show that serum fluoride concentrations can be reduced by 30% to 70% after 1 standard hemodialysis. [ 12 – 14 ] Prolonged or repeated hemodialysis is recommended to avoid fluoride-related cardiac toxicity. Obviously, it is difficult to estimate how much fluoride ions are truly removed by hemodialysis, as the fluoride ions can transform rapidly into a nonionic form.…”

Section: Discussionmentioning

confidence: 99%

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

Qian²,

Tao³

et al. 2017

Medicine

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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.

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“…The most frequent exposure is by cutaneous contact with the aqueous solution, no matter if the skin is intact or damaged [ 28 ], [ 29 ], [ 30 ], [ 31 ], [ 32 ]; it could also be absorbed through eyes [ 33 ], [ 34 ]. Inhalation intoxication occurs not only from exposure to hydrogen fluoride gas [ 17 ], [ 35 ], but also from vapors arising from concentrated hydrogen fluoride liquid [ 20 ], [ 36 ], while ingestion [ 14 ], [ 37 ], [ 11 ] of even a small amount of this acid is likely to produce systemic effects and may be fatal [ 13 ], [ 16 ], [ 18 ], [ 38 ], [ 39 ].…”

Section: Corrosiveness and Toxicitymentioning

confidence: 99%

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

Valjakova

Korunoska-Stevkovska

Georgieva

et al. 2018

Open Access Maced J Med Sci

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BACKGROUND:Hydrofluoric acid is a commonly used chemical in many industrial branches, but it can also be found as an ingredient in household products such as cleaning agents. Possessing high corrosive potential, HF acid causes burns and tissue necrosis, while when absorbed and distributed through the bloodstream, its extremely high toxic potential is expressed. Acute symptoms are often followed by pain, particularly in the case of skin burns, which intensiveness does not often correlate with the expressiveness of the clinical findings. Even exposure to low-concentrated solutions or gasses, or low-doses of high-concentrated acid, may provoke delayed systemic disorder which may eventually have a lethal outcome.AIM:Therefore, having information regarding the possible hazardous effects of hydrofluoric acid usage, a variety of symptoms, as well as a treatment approach, is of great importance in the case of HF exposure.METHODS:Available scientific articles published in literature databases, scientific reports and governmental recommendations from the internet websites, written in English, using the following search terms “Hydrofluoric acid, skin burns, eye injury, ingestion, inhalation, systemic toxicity, decontamination, antidote, medical treatment” have been reviewed.RESULTS:This review is useful not only for physicians but for everyone who may come in contact with a person exposed to HF acid.CONCLUSION:It highlights the mechanism of action, presents the acute and chronic symptoms, personal and general protective measures and devices that should be used, as well as decontamination procedures, immediate, antidote and hospital medical treatment.

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Use of hemodialysis after ingestion of a mixture of acids containing hydrofluoric acid

Cited by 5 publications

References 0 publications

Treatment of Ventricular Fibrillation Due to Ammonium Bifluoride Poisoning With Hemodialysis

Treatment of Ventricular Fibrillation Due to Ammonium Bifluoride Poisoning With Hemodialysis

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

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

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