Skin/eye decontaminationSkin/eye decontaminationPast and PresentPast and Present

Eileen SegalSegal ConsultsEaston, PA 18045ebsegal@aol.com

Past

Present

Case Study

Past

• History of organized first aid goes back 120 years

• Training in first aid began in 1903

• Clara Bow, President of the American Red Cross

Exception to the rule

In 1998

“First aid for a unique acid: HF”

Limit flush to 5 minutes

Past

• K.I.S.S.

Keep It Simple and Straightforward

Past

Many treatments recommended in the past are simply based on practical experience and the consensus of experts.

Present

In 2000 the American Heart Association in collaboration with the International Liaison Committee on Resuscitation began the first step to evaluate guidelines in first aid.

NFASAB

In 2004, the American Heart Association and the American Red Cross co-founded the

National First Aid Science Advisory Board

(NFASAB) to review and evaluate the scientific literature on first aid to develop “evidence-based medicine”.

Evidenced-Based Medicine

A movement to apply the scientific method to the practice of medicine, especially to long-established practices that never have been subjected to adequate scientific study

NFASAB Organizations

• American Academy of Orthopaedic Surgeons

• American Academy of Pediatrics• American Association of Poison

Control Centers• American Burn Association• American College of Emergency

Physicians• American College of

Occupational and Environmental Medicine

• American College of Surgeons• American Heart Association• The American Pediatric Surgical

Association• American Red Cross• American Safety and Health

Institute• Army Medical Command

• Australian Resuscitation Council• Canadian Red Cross• International Association of Fire

Chiefs• International Association of Fire

Fighters• Medic First Aid International• Military Training Network• National Association of EMS

Educators• National Association EMS

Physicians• National Association of EMTs• National Safety Council• Occupational Safety and Health

Administration• Save a Life Foundation

Goals of NFASAB

Goals are to analyze the scientific data and answer the following questions:

• 1. What are the most common emergency conditions that lead to significant morbidity and mortality?

• 2. In which of these emergency conditions can morbidity or mortality be reduced by the intervention of a first-aid provider?

• 3. How strong is the scientific evidence that interventions performed by a first-aid provider are safe, effective, and feasible?

NFASAB

• NFASAB considered a wide range of emergencies, e.g.

• Allergic reactions, contusions, fractures, how to position a victim, oxygen delivery, seizures, severe bleeding, snake bites, spinal injuries, sprains, etc., as well as chemical and thermal burns.

An exampleAn example

• Emergency treatment of poisoning:

• Syrup of ipecac

NFASAB new guidelines state:Do NOT give water, milk, or syrup of ipecac to

someone who has ingested poison.

Important References

• (1) A special supplement to Circulation [Dec. 12, 2005]Part 14: First Aid, 2005, 112, IV-196—IV-203, freely available at

http://www.circulationaha.orgor

http://www.redcross.org/static/file_cont4913_lang0_1727.pdf

(2) The Canadian Centre for Occupational Health and Safety, “TheMSDS—A Practical Guide for First Aid.” CCOHS encourages the widest possible distribution. Call 1-800-668-4284 or visit

http://www.ccohs.ca/products/publications/firstaid/

NFASAB statement for chemical burns

In their review of the science behind first-aid practices, the American Heart Association advises flushing chemical burns with large amounts of cool running water and to continue flushing until EMS personnel arrive.

N.B.

• This recommendation does not address the question of how long flushing should continue.

• However, it makes sense to tailor the duration of flushing to the known effects of the chemical or product.

○Adequate irrigation is difficult to define and depends on the amount of exposure and the agent involved.

○The first priority in treatment is to ensure complete removal of the offending agent.

New Guidelines

• Flushing should start immediately following skin or eye contact with a chemical.

• Longer flushing is required for corrosive chemicals:60 min for strong alkalies30 min for other corrosives

• A moderate or severe irritant requires 15-20 min.

• A mild irritant needs only 5 min.

Some considerations

• Using litmus paper to measure the pH of the affected area or the irrigating solution is helpful.

• Tap water is adequate for irrigation.

• Low-pressure irrigation is desired; high pressure may exacerbate the tissue injury.

• It is preferable that complete decontamination of the skin and eyes occur on site.

More considerations

• Each emergency is unique.

• First-aid provider must be trained.

• It is important to know the physical and reactivity properties of the chemicals involved.

• The MSDS is only a starting point for developing a work-site first-aid program.

Physical Properties

• Is the chemical involved a solid, liquid, or gas?This information helps determine which exposure routes and first-aid measures are relevant for a particular substance. E.g., first aid for a solid particle in the eye may not be the same as for a liquid in the eye.

• Is the involved chemical soluble in water?Substances that are not water soluble should be quickly blotted or brushed from the skin before flushing with water.

Reactivity Data

• Does the substance react with water to produce heat or a more toxic substance?This information allows modification of the

recommendation to reduce contact of the chemical with water by quickly blotting or brushing the chemical away, prior to flushing.

• Is the substance an oxidizer?Oxidizers create a fire hazard. Care must be taken

with contaminated clothing.

Knowledge of the properties of chemicals involved determines the first-aid intervention.

MSDSs

• The MSDS should not exclusively describe first- aid recommendations written for the "worst case" exposure imaginable.

• Usually, first aid is given for mild to moderate exposures. If the MSDS places too much emphasis on extreme exposures, which rarely occur, the first-aid procedures will be overstated.

• Inappropriate first aid could further harm the victim.

Because of their properties, the following chemicals need special consideration..

• Hydrofluoric Acid*Because HF can penetrate tissues deeply and can cause fatal systemic toxicity even in small burns, exposures need special attention.

• Flushing with water should be limited to no more than 5 min. Then treatment with benzalkoniumchloride or calcium gluconate gel should begin.

• For eye contact: Immediately flush the contaminated eye(s) with lukewarm, gently flowing water for 15-20 min., while holding the eyelid(s) open. Do NOT use benzalkonium chloride (Zephiran®) for eye contact.

• *Details can be found in the updated “Recommended Medical Treatment for Hydrofluoric Acid Exposure.”

PhenolPhenol

•• Phenol is not water-soluble and is difficult to remove with water alone. Dilution of phenol with water may enhance skin absorption .

• If available, immediately and repeatedly wipe the affected area with a 50% water solution of PEG 300 or PEG 400 (polyethylene glycol of average molecular weight 300 or 400). If PEG is not available, quickly blot or brush away excess chemical. Then flush affected area with lukewarm water at a high flow rate for at least 30 min. Quickly transport victim to an emergency care facility.

Sodium and Potassium

• These metals can ignite spontaneously on contactwith moisture and react with water to form very corrosive sodium and potassium hydroxides.

• Do NOT flush with water. Use forceps to carefully remove any metal fragments embedded in the skin and submerse them in mineral oil. If all particles cannot be removed, cover affected area with nontoxic mineral oil or cooking oil (Na) / tert-butyl alcohol (K) and transport victim to an emergency care facility. If all particles have been removed, flush the affected area with lukewarm, gently flowing water for at least 30 min. Then, immediately transport victim to an emergency care facility

White Phosphorus

• White phosphorus is spontaneously oxidized in air to P2O5 which reacts violently with water to evolve heat.

• Keep the area immersed in water and manually remove any P particles seen.

Are other flushing solutions effective?

Four eye-irrigating solutions were evaluated for comfort as flushing solutions:

• normal saline• lactated Ringer’s• normal saline with bicarbonate, and• Balanced Saline Solution Plus

• Diphoterine

• Neutralizing agents

Neutralization

• Neutralization of a chemical on the skin seems logical; • e.g., treat an acid with a base or a base with an acid.

There are, however, consequences which could increase the injury:

• a delay in flushing while first-aid personnel search for neutralizing agents

• thermal burns from the heat of reaction of the chemicals involved

• further injury due to contact with the neutralizing agent

Evidence-based medicine

• The conclusion is that there is no clear benefit in using neutralizing agents instead of water following exposure to acids or bases.

An Admonition

• Delays of even seconds can dramatically affect the outcome following contact with a corrosive chemical. There is no justification for waiting for another solution if water is the first available agent.

Help is available

• Decision trees: decision-making processes presented in flowcharts, one for each route of exposure.

• Use of the decision trees allows a step-by-step determination or evaluation of first-aid recommendations for a specific product.

• A worksheet is provided to gather the information required for making first-aid decisions.

Decision Tree

NFASAB Statement

• NFASAB strongly believes that education in first aid should be universal; everyone can and should learn first aid.

Next Step

• Every major national and international training organization is in the process of developing evidence-based training materials to reflect the new treatment recommendations.

• Training material revision, publication, and rollout are expected to continue to the end of the year.

Conclusion

Very little research on first aid for chemical exposure is being done

Thus, there is a lack of evidence-based medicine on skin/eye first aid

Extrapolations by health professionals are being made

More research must be undertaken

Conclusion

• However, what we do learn as scientific fact should be accepted.

• Life would be much simpler if the K.I.S.S. principle were in effect,

• Our world is not simple

• NFASAB strongly believes that education in first aid should be universal; everyone can and should learn first aid.

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