Langerman

Water

Advanced Chemical Safety
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Is Water Effective?
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Is Water Effective?

Is Water Effective?

Neal Langerman
Sharron Sussman

Is Water Effective?
A thorough rinse with water, lasting at least 15
minutes is the accepted procedure for the first
response to skin/eye decontamination.

Is this procedure based on fact or fancy?

Is Water Effective?

Is Water Effective?
Acetic acid

Is Water Effective?

Is Water Effective?
Sodium hydroxide

Is Water Effective?

Is Water Effective?
Nitric acid

Is Water Effective?

Is Water Effective?
Sulfuric acid

Is Water Effective?

Is Water Effective?
While reports of injuries can be obtained,
reports of successful decontamination
are more difficult to document.
• Anecdotal
• Incomplete
• Unreported

Is Water Effective?

Is Water Effective?
1998 – 2001 Hazardous Substances Emergency Events
Surveillance (HSEES) Cumulative Report
28,767 events
8126 persons
7759 person were decontaminated
• 5116 decon’d at the scene
• 2643 decon’d at medical location
• Some decon’d at both
132 deaths

Is Water Effective?

Chemicals
Based on the selected incidents
DISTRIBUTION BY CHEMICAL TYPE

OTHER
18% ACIDS
30%

CAUSTICS
19%

SOLVENTS GASES
14% 19%

Is Water Effective?

Injury Type
(Full data set)
INJURY TYPE

400
300 To t al Injuries
No ne
200 At Scene
At M ed ical
100 Bo t h
0
T RAUMA EYE IRRIT AT ION BURNS SKIN
IRRIT AT ION

Is Water Effective?

Decontamination Results
(based on 102 cases)

25
20
15 NOT ADM ITTED
ADM ITTED
10 FATALITY
5 ADVERSE HEALTH IM PACT
0 FIRST AID ON SCENE
)

TE
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(1

(3

(4
N

CI
E

L

TH
O

EN

A

O
EC

IC

BO

N
SC
D

ED
T
O

M
A
N

T
A

Is Water Effective?

Is Water Effective?

Morbidity of Decon'd Patients
Full Data

Admitted
Treated/Released

Is Water Effective?

Is Water Effective?
OBSERVATIONS
• Most persons suffer inhalation and eye
irritation.
• Most persons do not require decontamination
or medical follow-up.
• Effectiveness of decontamination is not
predictable from these data.

Is Water Effective?

Is Water Effective?
LIMITATIONS of DATA
• No concentration information
• No time of exposure information
• All decontamination assumed to be with water
or saline
• No detailed outcome information
• Data reporting biases
• Reporting frequency and details varies by State
• General reporting not mandatory
Is Water Effective?

Is Water Effective?
LITERATURE REVIEW
• Primary research via ACS’ STN
• Additional data from Eileen Segal (HF) and
Alan Hall
• Work performed in 2004 - 2005

Is Water Effective?

Is Water Effective?
Non-HF Cases
• 15 reports
• 1967 – 2000
• Reports (including reviews) discussed
outcomes, insufficient information on decon
procedures

Is Water Effective?

Is Water Effective?
*Mozingo, 1988,retrospective review, 87 cases
15 agents, white phosphorous most common
(49%), military hospital
13.8% mortality rate;
• greater than 100% complication rate - 105
complications in 87 patients!
Appropriate first aid described for all agents -
no data on care actually rendered.
No inferences can be made from the results of
this study on the impact of pre-hospital care.

Is Water Effective?

Is Water Effective?
*Sykes, 1986, retrospective review, 51 cases, 38 requiring
hospital admission.
• Patients divided into 2 groups,
• 20 adequate (Group A)
• 16 inadequate (Group B) emergency treatment.
• 13 agents, alkalis most common, midwestern burn center (agricultural
area)
• 13% mortality rate overall
• Mortality rate 9.5% in Group A,
• 21% in Group B.
• Skin grafting needed in 19% of Group A
• 36% of Group B;
• A clear demonstration of the benefits of appropriate first aid. Emphasis
of this study is on the primary importance of emergency treatment,
generally water lavage.

Is Water Effective?

Is Water Effective?
*Pardoe, 1976, report of 3 cases, literature review
Phenol, urban university hospital burn center
2 patients had 60% and one 80% BSA burns.
• All 3 needed intensive treatment of multiple organ system dysfunction
& 2 had skin grafts;
• all were discharged in under a month, with eventual full recovery
except for patchy skin pigment changes.
A heavy-flow deluge system activated 10-20 seconds after the
accident.
Boots and clothing were removed only after an interval;
• one patient had full-thickness burns of the ankles due to retained
contaminated water.
Extensive discussion of the mechanisms of phenol burns,
systemic toxicity and treatment, particularly early
decontamination.

Is Water Effective?

Is Water Effective?
Horch, 1994, case report, literature review
phenol,urban burn center (Germany)
Complete recovery after 20.5%BSA burns
Early, repeated PEG & water decontamination
thought to have prevented systemic toxicity.
Good discussion on specific topical
decontamination agents for phenol.

Is Water Effective?

Is Water Effective?
*Latenser, 2000, “case controlled” report of 2 cases
exposed in single industrial spill
Anhydrous Ammonia, urban trauma center.
Patient A hospitalized overnight for corneal abrasions,
face & neck redness.
Patient B hospitalized 13 days, needed intubation,
ventilator, debridement, STSG.
Both men had similar exposures, by history.
• Patient A showered & changed clothing immediately.
• Patient B did neither, came to hospital 90 minutes after spill.
Good anecdotal evidence for critical importance of early
decontamination.

Is Water Effective?

Is Water Effective?
Husain, 1989, report of 7 cases. Only one case, by far
the most severe, fully documented
Concentrated sulfuric acid, university hospital (Saudi
Arabia)
The patient, a 4-yr-old male with 60% BSA 3rd degree
burns, had 10 procedures during 166 days in hospital;
required 2 readmissions and more surgery for hand &
shoulder contractures.
No first aid given, not even removal of contaminated
clothing.
Discussion of recommended pre-hospital treatment -
removal of clothing, copious water lavage.

Is Water Effective?

Is Water Effective?
Wang, 1985, report of a case
Hot Chromic acid, university hospital burn unit
Patient had 40% BSA burns, died 6 days post-
injury from multiple organ system failure due
to chromium toxicity.
Immediate copious water lavage at the scene
did not prevent absorption of lethal dose of
chromium.
Discussion of toxic effects of chromium,
medical & surgical treatment methods.

Is Water Effective?

Is Water Effective?
HF Cases
• 34 reports
• 1939 – 1999
• Reports (including reviews) discussed
outcomes, insufficient information on decon
procedures
• Significant discussions on using Calcium
gluconate or alternatives to water

Is Water Effective?

Is Water Effective?
Browne, 1974, retrospective review of 53 cases
43 splashes, 10 vapour burns, no details on severity or
distribution, chemical plant medical facility (England).
38 of 43 splashes, all 10 vapour burns treated
successfully by Ca gluconate gel alone.
• (28 burns initially self-treated by workers.)
Plant protocol calls for shorter water lavage time, early
and prolonged inunction with the gel, till pain gone.
Gives details of successful use of Ca gluconate gel in
industrial setting.

Is Water Effective?

Is Water Effective?
Dibbell, 1970, retrospective review of 45 cases, 3 cases
presented
All were hand injuries in industrial and househould users
• no details on severity, university hospital plastic surgery
service.
13 pts treated with immediate Ca gluconate injection had no
tissue loss & no complications.
• 3 injected >24 hrs after burns required debridement.
29 treated by other means had high incidence of tissue loss.
3 representative cases presented show effectiveness of
adequate initial treatment, dangers of inadequate treatment.
Supports Ca gluconate injection treatment.

Is Water Effective?

Is Water Effective?
Jones, 1939, retrospective review of 12 cases
Mostly small splash burns of upper extremities, face &
neck with concentrated HF, chemical plant medical facility
(England).
Except for the first pt in this series, all 2nd degree burns
due to HF were injected with Ca gluconate & had
immediate pain relief & good recovery.
Impact of pre-hospital care is not directly addressed.
This is the earliest well-documented report of a series of
patients treated by a rationally conceived method.
Classic description of 2nd degree HF burns.

Is Water Effective?

Is Water Effective?

Standards Status

Is Water Effective?

Is Water Effective?
29 CFR 1910.151(c)
• Where the eyes or body of any person may
be exposed to injurious corrosive materials,
suitable facilities for quick drenching or
flushing of the eyes and body shall be
provided within the work area for immediate
emergency use.

Is Water Effective?

Is Water Effective?
ANSI Z358.1
• Flushing Fluid: Potable water, preserved water,
preserved buffered saline solution or other medically
acceptable solution manufactured in accordance with
applicable government regulations.
• Personal wash: A supplementary device that
supports plumbed and/or self-contained units, by
delivering immediate flusing fluid to the eyes or body.
• Personal Wash Units shall have the capacity to
deliver immediate flushing fluid without being injurious
to the user. Personal wash units do not meet the
criteria of plumbed or self-contained eyewash
equipment.

Is Water Effective?

Is Water Effective?

Is Water Effective?

Is Water Effective?
Alternatives
• Diphoterine and Hexafluorine
• D-Tam, Skin Swypes, etc.
• Ca salts

Is Water Effective?

Is Water Effective?
Moving forward with alternatives to
water:
• Education of industrial/institutional users
• Determine the applicability of the ANSI
language “other medically acceptable solution
manufactured in accordance with applicable
government regulations”
• Examine applicability of State OSHA rules

Is Water Effective?

Is Water Effective?
Solid Research is Needed
• Good documentation on pre-hospital care
• Good documentation on outcomes
• Ability to correlate pre-hospital care with
outcomes

Is Water Effective?

Is Water Effective?
Is water effective?
• YES, if used promptly on dilute agents
• NO, when the agent is very aggressive due to
concentration, temperature or reactivity
• MAYBE, under moderate circumstances
Is there a better alternative?

Is Water Effective?

Is Water Effective?

Support was generously
provided by Prevor
Laboratories

Is Water Effective?

Langerman

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