Application of calcium nebulization for mass exposure to an accidental hydrofluoric acid spill.

PURPOSE: To determine the long-term prevalence and characteristics of acute hydrofluoric acid (HF) exposure in 2223 patients during the first 30 months after a mass-casualty exposure, and to confirm the antidotal effect of nebulized calcium on inhalation burns caused by HF. METHODS: This observational cohort study included patients after an HF spill in the Republic of Korea on September 27, 2012; registered patients were followed until April 2015. We assessed toxic effects, distance from spill, degree of acute poisoning, and the effect of nebulized calcium in HF-exposed individuals. RESULTS: Overall, 2223 patients received emergency management or antidote therapy for 20 days. Seventy-four of 134 patients with dermal toxicity received calcium-lidocaine gel, and 368 individuals with bronchial irritation signs received calcium gluconate via nebulizer nCG. A total 377 ampoules 786 g of calcium gluconate were used in the nCG formulation. Calcium administration did not cause adverse reactions during the observation period. Long-term cohort observation showed that 120 patients (120/2233, 5.4%) returned to medical facilities for management of HF-related symptoms within 1 month; 18 persons (18/1660, 1.1%) returned 1-3 months later with chronic cough and respiratory symptoms; and 3 patients (3/1660, 0.2%) underwent medical treatment due to upper-airway toxic symptoms more than 2 years after HF exposure. CONCLUSION: Respiratory toxicity after mass exposure to an HF spill was successfully treated by calcium nebulizer. Based on our experience, detoxification processes and the amounts of antidote stocked are important when planning for future chemical disasters at the community level.

Fatal Refractory Ventricular Fibrillation Due to Ingestion of Hydrofluoric Acid.

Hydrofluoric acid (HF) is a colorless and odorless solution of the hydrogen fluoride in water. It is used in some household products. The rapid onset of severe toxicity and death after the ingestion of HF is not reported often. Also, there is no reported fatal pediatric case after HF ingestion. In this case report, we present a 3.5-year-old girls who unintentionally drunk a rust remover that contained 8% HF. She died in a short period as a result of refractory ventricular fibrillation, which was developed due to fluoride intoxication.

Clinical significance of urinary fluoride levels in patients with hydrofluoric acid burns.

OBJECTIVE: We investigated the urinary fluoride level in patients with hydrofluoric acid (HF) burns of different severities and explored the clinical significance of these levels in the diagnosis of acute HF burn. METHODS: Data from 260 patients with HF burns were collected from the Department of Burns, Zhejiang Quhua Hospital, between July 2006 and June 2016. According to burn severity, patients were divided into non-poisoning, mild poisoning, moderate poisoning, and severe poisoning groups. In addition, 25 healthy controls were recruited from fluorine chemical companies. The urinary fluoride level was measured using a fluoride-selective electrode and values were compared amongst groups. The urinary fluoride level was also measured periodically after exposure to investigate dynamic changes in the moderate and severe poisoning groups. RESULTS: Urinary fluoride levels were 0.32-520.0mg/L (n=260) on admission to the emergency department, and 182 patients had levels >1.7mg/L. The levels in controls and the non-poisoning group were lower than in the other two groups, and increased significantly with an increase in severity. Thirty-three patients were admitted 4h after injury; of these patients, fluoride levels were significantly higher in those with severe poisoning than in those with moderate poisoning. Levels peaked 4h after injury and then dropped and returned to normal 6days after injury. CONCLUSION: Urinary fluoride level can be used for the early diagnosis of HF burns and to determine the severity of fluoride poisoning, which is crucial for early treatment.

[Dermal and inhalation poisoning. Rare guests in our intensive care units?]. / Dermale und inhalative Intoxikationen. Seltene Gäste auf unseren Intensivstationen?

Patients with dermal and inhalation poisoning are uncommon in intensive care treatment. We describe the diagnostics and specific toxicological treatment of patients with hydrofluoric acid burns. For inhalation poisoning, we focus on smoke inhalation, especially the management of cyanide and carbon monoxide poisoning. Special attention is given to the use of hyperbaric oxygenation for the treatment of carbon monoxide poisoning.

[Hydrofluoric acid poisoning: case report]. / Intoxicación por ácido fluorhídrico. Presentación de un caso clínico.

Hydrofluoric acid is a highly dangerous substance with industrial and domestically appliances. Clinical manifestations of poisoning depend on exposure mechanism, acid concentration and exposed tissue penetrability. Gastrointestinal tract symptoms do not correlate with injury severity. Patients with history of hydrofluoric acid ingestion should undergo an endoscopy of the upper gastrointestinal tract. Intoxication requires immediate intervention because systemic toxicity can take place. We present a 5 year old girl who accidentally swallowed 5 ml of 20% hydrofluoric acid. We performed gastrointestinal tract endoscopy post ingestion, which revealed erythematous esophagus and stomach with erosive lesions. Two months later, same study was performed and revealed esophagus and stomach normal mucous membrane.

Intoxicación por ácido fluorhídrico: Presentación de un caso clínico / Hydrofluoric acid poisoning: Case report

El ácido fluorhídrico es una sustancia cáustica muy peligrosa, que tiene aplicaciones industriales y domésticas. Las manifestaciones clínicas asociadas a la intoxicación por este producto dependen de la vía de exposición, la concentración del ácido y la penetrabilidad en el tejido expuesto. En el tubo digestivo, la presencia o la ausencia de síntomas no se correlacionan con la gravedad de la lesión. Es necesario realizar una endoscopia digestiva alta en los pacientes con historia de ingestión de ácido fluorhídrico. Se requiere una inmediata intervención, ya que puede causar toxicidad sistémica. Se presenta el caso de una niña de 5 años que ingirió accidentalmente 5 ml de ácido fluorhídrico al 20%. En la videoendoscopia digestiva alta (VEDA), realizada dentro de las 24 horas, el esófago y el estómago estaban eritematosos, con lesiones erosivas. A los 2 meses se realizó una VEDA de control, que mostró una mucosa normal.

Hydrofluoric acid is a highly dangerous substance with industrial and domestically appliances. Clinical manifestations of poisoning depend on exposure mechanism, acid concentration and exposed tissue penetrability. Gastrointestinal tract symptoms do not correlate with injury severity. Patients with history of hydrofluoric acid ingestion should undergo an endoscopy of the upper gastrointestinal tract. Intoxication requires immediate intervention because systemic toxicity can take place. We present a 5 year old girl who accidentally swallowed 5 ml of 20% hydrofluoric acid. We performed gastrointestinal tract endoscopy post ingestion, which revealed erythematous esophagus and stomach with erosive lesions. Two months later, same study was performed and revealed esophagus and stomach normal mucous membrane.

Hydrofluoric acid poisoning: data from the Victorian Poisons Information Centre.

OBJECTIVE: To determine the epidemiology of hydrofluoric acid (HF) exposures, over an extended time period, in Victoria, Australia. METHODS: Retrospective case review of all HF exposures from calls to the Victorian Poisons Information Centre (VPIC) from June 2005 to February 2011. RESULTS: The VPIC received calls regarding 75 separate HF exposures (approximately 12 per year). The majority 68 (91%) of calls related to male patients. Sixty-nine (92%) calls related to adults, six (8%) to children (<12 years) and none to the elderly (>65 years age). Fifty-three per cent of exposures occurred at the workplace. Dermal exposures comprised 54 (72%). Forty-six (85%) of these resulted from hand contact, six (11%) arm and two (4%) legs. The second most common exposure was ocular 11 (15%). More than half of exposures involved HF concentrations of 10% or less. Of the dermal exposures treated in EDs, 16% required calcium treatment in a form other than gel. Overall poisoning severity was mild (79% of cases Poisoning Severity Score of 0 or 1). Health professionals were the most frequent callers (53% of all cases). CONCLUSIONS: Calls to the VPIC regarding HF are relatively rare, but almost all calls regarding HF taken by the VPIC required hospital evaluation. The majority of exposures were accidental occupational dermal exposures in male adults and most of these were minor, requiring topical calcium gel only. Small exposures with higher concentrated HF can be fatal; however, there were no cases of severe toxicity in the present study.

Hydrogen fluoride inhalation injury because of a fire suppression system.

Automatic fire suppression systems (FSSs) use hydrofluorocarbons (HFCs) to chemically extinguish fires. At high temperatures, HFC can release hydrogen fluoride (HF), a toxic and potentially lethal gas. We report the deaths of three U.S. military personnel at Bagram Air Base from acute respiratory failure after the FSS in their vehicle received a direct hit from a rocket-propelled grenade. Despite presenting with little to no additional signs of trauma, these individuals all died within 24 hours from HF-induced respiratory failure. When two patients later presented with similar symptoms after damage to their vehicle's FSS, they were aggressively treated with nebulized calcium and positive pressure ventilation. Both survived. The presence of HFC-containing FSSs in military vehicles may lead to future cases of HF inhalation injury, and further research must be done to help rapidly diagnose and effectively treat this injury.

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

Hydrofluoric acid (HF) is a highly toxic poison that can be rapidly fatal. Death usually results from the many systemic effects of dissociated fluoride ions, including hypocalcemia, hypomagnesemia, hyperkalemia, and direct cardiotoxicity. A patient is described who accidentally ingested a hydrofluoric acid-containing substance and who likely benefited from hemodialysis. His fluoride level post-dialysis was reduced by approximately 70% from a level drawn three hours prior to the initiation of hemodialysis. However, the single treatment did not reduce the fluoride level to normal. A review of the pathophysiology of hydrofluoric acid intoxication and the outcomes of prior exposures suggests that hemodialysis could play a vital role in the management of poisonings with fluoride-containing substances. However, the initial hemodialysis treatment should be prolonged beyond the standard four-hour session.

Survival after hypocalcemia, hypomagnesemia, hypokalemia and cardiac arrest following mild hydrofluoric acid burn.

BACKGROUND: Although hydrofluoric (HF) acid burns may cause extensive tissue damage, severe systemic toxicity is not common after mild dermal exposure. CASE: A 36-year-old worker suffered a first-degree burn of 3% of his total body surface area as a result of being splashed on the right thigh with 20% HF acid. Immediate irrigation and topical use of calcium gluconate gel prevented local injury. However, the patient developed hypocalcemia and hypomagnesemia, hypokalemia, bradycardia, and eventually had asystole at 16 h post-exposure, which were unusual findings. He was successfully resuscitated by administration of calcium, magnesium, and potassium. CONCLUSION: This report highlights a late risk of HF acid dermal exposure.

[Acute respiratory distress syndrome induced by hydrogen fluoride gas inhalation].

A 21-year old man was referred to our hospital with severe respiratory distress and diffuse infiltrative shadows on chest radiograph. He had been exposed to irritant gas when polishing the inside of a stainless tank using a chemical cleaner containing hydrofluoric acid and nitric acid. He felt sick immediately after exposure and experienced respiratory distress within a few hours. He was successfully treated with intensive care including mechanical ventilation and administration of high dose methylprednisolone. Later, his illness was diagnosed as acute lung damage induced by hydrogen fluoride gas inhalation based on the findings of increased fluoride concentration in serum and urine specimen, and decreased serum calcium level.

Hypocalcemia, hypomagnesemia, and hypokalemia following hydrofluoric acid chemical injury.

Dermal exposure to hydrofluoric acid could potentially result in severe serum calcium and magnesium depletion induced by binding with fluoride anion. This report describes the case of a 48-year-old man who developed hypocalcemia and hypomagnesemia accompanied by hypokalemia-an interesting finding-following a chemical injury with exposure to 70% hydrofluoric acid. Successful treatment included administration of calcium gluconate and magnesium both intravenously and topically.

Chemical colitis.

Chemical colitis can occur as a result of accidental contamination of endoscopes or by intentional or accidental administration of enemas containing various chemicals. Most cases have occurred after accidental contamination of endoscopes with glutaraldehyde and/or hydrogen peroxide. There have been multiple case reports of chemical colitis resulting from unintentional administration of caustic chemicals. Intentional administration of corrosive enemas has been implicated in sexual practices, bowel cleansing, or in suicide attempts. Patients present with nonspecific symptoms including abdominal pain, rectal bleeding, and/or diarrhea. As chemical colitis remains rare, the literature consists of scattered case reports and small series. Agents implicated in chemical colitis that are covered in this review include alcohol, radiocontrast agents, glutaraldehyde, formalin, ergotamine, hydrofluoric acid, sulfuric acid, acetic acid, ammonia, soap, sodium hydroxide, hydrogen peroxide, herbal medicines, chloro-m-xylenol, and potassium permanganate. Clinical, endoscopic, and histologic features are outlined for each agent in addition to the existing literature. Given the nonspecific presentation of many cases of chemically induced colitis, the diagnosis can be challenging if the pertinent history is not obtained. Most patients demonstrate the resolution of chemical-induced colitis after conservative or medical therapy. Depending on the depth and extent of injury, patients rarely require colectomy for ischemic colitis and/or peritonitis. Other postingestion complications include colonic strictures and rectovaginal fistulae. The benefits of medical therapy compared with conservative therapy are not known, as comparative clinical management trials have not been performed.

Toxic myocarditis due to oral ingestion of hydrofluoric acid.

We report the case of a 32-year-old man, admitted to cardiac care unit with congestive heart failure, caused by a reduced global cardiac function four months after oral hydrofluoric acid ingestion while attempting suicide. Biopsy results of left ventricular myocardium confirmed toxic myocarditis due to ingestion of hydrofluoric acid. This case represents an uncommon example of toxic myocarditis as a long-term complication of oral hydrofluoric acid ingestion. We recommend cardiological follow-up consultations in patients with hydrofluoric acid intoxication for early detection of cardiac deterioration.