Recommended Medical Treatment forHydrofluoric Acid Exposure

This Booklet describes the special First Aid and Medical Treatment measuresnecessary following exposure to or injury from HYDROFLUORIC ACID.

However, it must be emphasized that

PREVENTIONof exposure or injury must be the primary goal.

Preventive measures include:

1. Making everyone who handles or uses HF aware of its properties and dangers.

2. Training everyone who uses HF in proper handling and safety precautions.

3. Utilizing all appropriate engineering controls, and making sure that the controls are maintained and functioning properly.

4. Requiring everyone who handles or uses HF to have available the proper safety and personal protective equipment, to be trained to use the equipment, and to always use the equipment when necessary.

5. Arranging ahead of time to provide first aid or medical treatment measures if necessary.

If you have questions, comments or suggestions, please write to:

Technical Service Manager - Hydrofluoric AcidHoneywellP. O. Box 1053101 Columbia RoadMorristown, New Jersey 07962-1053

Hydrofluoric Acid TreatmentQuick Reference Chart FOLD OUT HERE ➧

May, 2000

NOTE: In addition to the usual medical history, the physician will find it helpful to obtain the following informexposed/affected, first aid measures instituted (what, when, how long). Injuries due to dilute HF solutions or low

SKIN BURNS EYE EXPOSURE

FIRS

CONCENTRATED HF DILUTE HF ALL HF

Water Wash Water Wash Water WashTHEN THEN ORIced Benzalkonium Iced Benzalkonium Saline WashChloride* 0.13% Soaks Chloride* 0.13% SoaksOR ORCalcium Gluconate Calcium Gluconate2.5% Gel 2.5% Gel

CONCENTRATED HF DILUTE HF ALL HF

Debride (if necessary) Debride (if necessary) Topical TetracaineTHEN THEN HydrochlorideContinue Soaks Continue Soaks THENOR OR 1% CalciumCalcium Gluconate Calcium Gluconate Gluconate Irrigation4

5% Injection2,4 2.5% Gel ANDAND OR ConsultObserve for/Treat Calcium Gluconate OphthalmologistSystemic Effects3 5% Injection2,4

(especially if > 25 sq. in.) Systemic Effects3 Unlikely

MEDICAL T

1 This is a brief summary of First Aid and Medical Treatment measures. The text of the brochure “RECOMMENDED MEDICAL TREATMENT FOR HYDROFLUORICACID EXPOSURE” must be consulted for more complete information.

2 5% calcium gluconate injections must be used if the soaks or gel do not significantly relieve pain in 30-40 minutes. Injections may also be used as the primarytreatment, especially for larger and/or deeper burns.

3 Systemic effects include hypocalcemia, hypomagnesemia, hyperkalemia, cardiac arrhythmias, and altered pulmonary hemodynamics. TREATMENT includescardiac monitoring, monitoring serum calcium, magnesium, and electrolytes; administration of IV calcium gluconate, correcting magnesium and electrolyteimbalance, and, in extreme cases, hemodialysis.

4 Calcium gluconate is normally supplied in ampules containing 10% calcium gluconate. Concentrations less than 10% are obtained by diluting with normal saline.* Benzalkonium chloride is a high molecular weight quaternary ammonium compound available as Zephiran® a Registered Trademark of Sanofi Pharmaceuticals, New York, NY 10016 + Registered trademark, Johnson & Johnson - Merck, Fort Washington, PA 19034

TREATMENT OF HYDROFLUQUICK RE

mation: concentration of HF, date and time of exposure, duration of exposure, how exposure occurred, body partsw concentrations of vapors may result in delays in clinical presentation up to 24 hours following exposure.

INHALATION INGESTION

ST AID

CONCENTRATED HF DILUTE HF ALL HF

Do Not Induce VomitingOxygen OxygenAND THEN Milk or Water2.5% Calcium Consider THENGluconate4 by Nebulizer 2.5% Calcium Milk of Magnesia

Gluconate4 by Nebulizer ORMylanta®+

CONCENTRATED HF DILUTE HF ALL HF

Observe Observe Lavage with CalciumAND Chloride or CalciumProphylactic Inhalational Serious Effects Unlikely GluconateSteroids Inhalation of HF Fumes ANDTHEN from Diluted Acid is Treat Systemic Effects3

Treat (if necessary) UncommonBronchoconstriction,Pulmonary Edema,Systemic Effects3

TREATMENT

For additional reference charts or information on properties, storageand handling, or medical treatment for hydrofluoric acid, contact:

HoneywellIndustrial FluorinesP.O. Box l053Morristown, NJ 07962-1053

In the event of an emergency with this product, call the 24-hourHoneywell emergency telephone number: 800-707-4555 or 602-365-4980

All statements, information, and data given herein are believed to be accurate and reliable butare presented without guaranty, warranty, or responsibility of any kind, express or implied.Statements or suggestions concerning possible use of our products are made withoutrepresentation or warranty that any such use is free of patent infringement and are notrecommendations to infringe any patent. The user should not assume that all medical and firstaid measures are indicated or that other measures may not be required.

UORIC ACID (HF) EXPOSUREEFERENCE1

This foldout chart is also available as a laminated15” x 23” wall poster.

TABLE OF CONTENTSPREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Cover Flap

TREATMENT OF HF EXPOSURE: QUICK REFERENCE . . . . . . . .Inside Cover

TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

ACUTE TOXICITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Skin Contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Systemic Toxicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3Eye Contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Inhalation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Ingestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

CHRONIC TOXICITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

FIRST AID TREATMENT FOR HYDROFLUORIC ACID BURNS . . . . . . . . . . . .5Skin Contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Eye Contact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Inhalation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Ingestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

MEDICAL TREATMENT FOR HYDROFLUORIC ACID BURNS . . . . . . . . . . . . .7Burns of the Skin – General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Quaternary Ammonium Compounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Calcium Gluconate Gel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Calcium Gluconate Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Calcium Gluconate Solution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Burns of the Fingers and Nails . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Intra-arterial and Intravenous Calcium Infusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Additional Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Other and Unproven Therapies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Systemic Absorption and Metabolic Effects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Eye Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Inhalation Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Ingestion Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

APPENDIX – FIRST AID AND MEDICAL SUPPLIES . . . . . . . . . . . . . . . . . . . . . 14

INDEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

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INTRODUCTIONBecause the medical treatment of hydrofluoricacid exposure is so specialized and differs fromthe treatment of other inorganic acid expo-sures, not all physicians may be aware of appropriatetreatment measures. It is recommended that HFusers make arrangements ahead of time with localmedical resources to be sure that users are familiarwith first aid measures and that professional personnelare familiar with the toxicity of HF and the treatmentof HF exposure. This would include, at a minimum,thoroughly reviewing this booklet and making surethat treatment facilities and supplies are available.

Hydrofluoric acid (CAS # 7664-39-3) is veryaggressive physiologically because of the fluorideion. Both anhydrous hydrofluoric acid (hydrogenfluoride) and its solutions are clear, colorless liquids.When exposed to air, concentrated solutions andanhydrous hydrofluoric acid produce pungentfumes which are especially dangerous. Unlessheated, dilute concentrations of hydrofluoric acid inwater (e.g., less than 40% HF) do not produce sig-nificant vapor concentrations.

NOTE: Persons unfamiliar with hydrofluoric acidoften mistake it for, or confuse it with, hydrochloricacid. Although hydrofluoric acid (HF) andhydrochloric acid (HCl) have similar soundingnames, the toxicity of these two acids is very different. Todecrease or avoid confusion, we recommend thatHYDROFLUORIC ACID and HYDROGEN FLUORIDEbe referred to as "HF".

HF is primarily an industrial raw material. It is usedin stainless steel manufacturing, iron and steelfoundries, metal finishing, aluminum manufacturing,inorganic and organic chemical manufacturing,petroleum refining, mineral processing, glassmakingand electronic components manufacturing. It is alsoused in certain industrial and consumer cleaningcompounds. However, its use in consumer productsis discouraged because of the hazards describedherein.

Most non-industrial burns are caused by dilute con-centrations of HF (e.g, less than 15% HF). Most ofthe HF used in the electronics industry is less than50%. However, many industrial uses of HF involveconcentrated (50-100%) HF.

WARNING: BURNS WITH CONCENTRATED HF AREUSUALLY VERY SERIOUS, WITH THE POTENTIAL

FOR SIGNIFICANT COMPLICATIONS DUE TO FLU-ORIDE TOXICITY. CONCENTRATED HF, LIQUID ORVAPOR, MAY CAUSE SEVERE BURNS, METABOLICIMBALANCES, PULMONARY EDEMA AND LIFETHREATENING CARDIAC ARRYTHMIAS. EVENMODERATE EXPOSURES TO CONCENTRATED HFMAY RAPIDLY PROGRESS TO FATALITY IF LEFTUNTREATED.

Honeywell is the world's leading supplier of hydro-fluoric acid. The recommended medical proceduresdescribed in this brochure are based on a review ofthe available literature, shared experiences with otherswho have dealt with the health effects of HF, thepersonal knowledge and experiences of Honeywellphysicians, nurses and other professionals in dealingwith the unique hazards of this product, and experi-mental laboratory work sponsored by Honeywell.

Every effort must be made to prevent exposure tohydrofluoric acid. If exposure does occur, the spe-cialized procedures which follow are recommendedto avoid the very serious consequences that mightotherwise occur.

ACUTE TOXICITYSkin ContactHydrofluoric acid (HF) can cause serious, painfulburns of the skin. Specialized first aid and medicaltreatment is required. Burns larger than 25square inches (160 square cm) may result inserious systemic toxicity.

Hydrofluoric acid is a highly corrosive acid whichcan severely burn skin, eyes, and mucous membranes.The vapors from anhydrous hydrofluoric acid or itsconcentrated solutions can also burn these tissues.

Hydrofluoric acid is similar to other acids in that theinitial extent of a burn depends on the concentration,the temperature and the duration of contact with theacid. Hydrofluoric acid differs, however, fromother acids because the fluoride ion readilypenetrates the skin, causing destruction of deeptissue layers. Unlike other acids which arerapidly neutralized, this process may continuefor days if left untreated.

Strong acid concentrations (over 50%), and particularlyanhydrous HF (AHF or 100% HF), cause immediate,severe, burning pain and a whitish discoloration ofthe skin which usually proceeds to blister formation.

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Exposure to HF vapors can also result in similarburns.

In contrast to the immediate effects of concentratedHF, the effects of contact with more dilute hydrofluoricacid or its vapors may be delayed, and this is one ofthe problems with the recognition of some HFburns. Skin contact with acid concentrations in the20% to 50% range may not produce clinical signs orsymptoms for one to eight hours. With concentrationsless than 20%, the latent period may be up to twenty-four hours. HF concentrations as low as 2% maycause symptoms if the skin contact time is longenough. (1)

HF skin burns are usually accompanied by severe,throbbing pain which is thought to be due to irritationof nerve endings by increased levels of potassiumions entering the extracellular space to compensatefor the reduced levels of calcium ions, which havebeen bound to the fluoride. Relief of pain is animportant guide to the success of treatment.

The usual initial signs of an HF burn are redness,edema, and blistering. With more concentratedacids, a blanched white area appears. The fluorideion penetrates the upper layers of the skin. A thickgranular exudate may form under blisters due to liq-uefaction necrosis. In rare (and untreated) cases,there may be penetration to underlying bone withdecalcification. HF burns require immediate andspecialized first aid and medical treatment (2, 3,4, 5, 6, 7) differing from the treatment of other chemicalburns. If untreated or if improperly treated, permanentdamage, disability or death may result. (8) If, however,the burns are promptly and properly recognized andmanaged, the results of treatment are generallyfavorable.

Treatment is directed toward binding the fluorideions to prevent tissue destruction. High molecularweight quaternary ammonium compounds, e.g. ben-zalkonium chloride (Zephiran®), are used as soakingagents. (9, 10, 11) Calcium gluconate as a gel orointment can be applied locally, and calcium gluconatesolution may be injected (subcutaneously, intra-venously, or intra-arterially), inhaled, or used as anirrigant. (3, 12, 13, 14, 15)

Speed is of the essence. Delays in first aid care ormedical treatment or improper medical treatmentwill likely result in greater damage or may, in somecases, result in a fatal outcome.

Systemic Toxicity To produce HF, calcium fluoride is reacted withsulfuric acid:

CaF2 + H2SO4 → 2HF + CaSO4

This production process requires a great deal ofenergy to accomplish. On the other hand, in the body:

2HF + Ca++ → CaF2

This process releases energy, and therefore occursvery readily. The toxic effect of HF on body calciumis certainly more complicated than this. There issome evidence that fluoride may combine with calciumand phosphate, so that five calcium ions are tied upfor each fluoride ion (e.g. Ca5F(PO4)3), rather thantwo. There is also some evidence that there may behigh intracellular levels of calcium in some tissues,rather than low levels, as would intuitively beexpected. (16) However, the reaction of fluoridewith body calcium is one of the major toxic effectsand forms the basis for many treatment recommen-dations.

One of the most serious consequences of severeexposure to HF by any route is the marked loweringof serum calcium (hypocalcemia) and other metabolicchanges, which may result in a fatal outcome if notrecognized and treated. Hypocalcemia should beconsidered a potential risk in all instances ofinhalation or ingestion, and whenever skin burnsexceed 25 square inches, (160 square centimeters).Serum magnesium may also be lowered, and elevationsin serum potassium have been reported to furthercomplicate the metabolic imbalances which willneed to be monitored and corrected. (16, 17, 18)High levels of fluorides have been noted both in theblood and body organs. Hemodialysis has beenreported to be effective therapy for cases of severesystemic intoxication. (19, 20, 21) Treatment forshock may also be required as for other severeinjuries.

Other effects reported from fluoride exposure includecoagulation defects and inhibition of a number ofenzymes, including preglycolytic enzymes, phos-phatases and cholinesterase. The results of thisenzyme inhibition include inhibition of cellular glucosephosphorylation and subsequent glycolysis, inhibitionof respiration, and increased sensitivity of cholinergicmechanisms to acetyl cholinesterase. (22)

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While hypocalcemia has been traditionally consideredthe major systemic effect of severe poisoning with HF,it is apparent that hypomagnesemia, hyperkalemia,the cardiodepressing and vasodilating effects of fluorideand effects on pulmonary hemodynamics and systemiccapacitance vessels, including an increase in pulmonaryvascular resistance, all play a role in systemic toxicity.Although some of these effects have been described,the implications for therapeutic measures have notbeen well defined. (23, 24)

Eye ContactHydrofluoric acid can cause severe eye burns withdestruction or opacification of the cornea. Blindnessmay result from severe or untreated exposures.Immediate first aid and specialized medical care isrequired. (3,13)

InhalationHydrofluoric acid fumes may cause laryngospasm,laryngeal edema, bronchospasm and/or acute pul-monary edema. Acute symptoms may includecoughing, choking, chest tightness, chills, fever andcyanosis. Many reported fatalities from HF exposureshave been due to severe pulmonary edema (coupledwith systemic toxicity) that did not respond to medicaltreatment.

Burns from vapors or liquid contact to the oropha-ryngeal mucosa or upper airway may cause severeswelling to the point of requiring a tracheostomy. Itis recommended that all patients with such exposuresbe hospitalized for observation and/or treatment.

Because of the strong irritant nature of hydrofluoricacid, an individual inhaling HF vapors or fumes willusually experience upper respiratory injury, withmucous membrane irritation and inflammation aswell as cough. All individuals suspected of havinginhaled HF should be observed for pulmonaryeffects. This would include those individuals withsignificant upper respiratory irritation, bronchocon-striction by pulmonary auscultation or spirometry,and any individual with HF exposure to the head,chest or neck areas. It has been reported that pul-monary edema may be delayed for several hoursand even up to two days. If there is no initial upperrespiratory irritation, significant inhalation exposurecan generally be ruled out.

The Permissible Exposure Limit (PEL) set by the U.S.Occupational Safety and Health Administration

(OSHA) is a time weighted average exposure for 8hours of 3 ppm. (25) The American Conference ofGovernmental Industrial Hygienists (ACGIH) recom-mends a ceiling level of 3 ppm or 2.3 mg/m3. (26,27) The National Institute for Occupational Safetyand Health (NIOSH) has established the level that isimmediately dangerous to life and health (IDLH) at30 ppm. (28, 29) The American Industrial HygieneAssociation has published an Emergency ResponsePlanning Guideline setting 50 ppm as the maximumlevel below which nearly all individuals could beexposed for one hour without experiencing ordeveloping life-threatening health effects (ERPG-3),20 ppm as the maximum level below which nearlyall individuals could be exposed for one hour withoutdeveloping irreversible health effects or symptomswhich would impair taking protective action (ERPG-2),and 2 ppm as the maximum level below whichnearly all individuals could be exposed up to onehour without experiencing other than mild, transientadverse health effects (ERPG-1). (30)

IngestionIf hydrofluoric acid is ingested, severe burns to themouth, esophagus and stomach may occur. Severesystemic effects usually also occur. Ingestion ofeven small amounts of dilute HF have resulted indeath. (31)

CHRONIC TOXICITYBecause it is a strong irritant, HF has not beenfound to cause chronic toxicity nor has it been thesubject of long term toxicity studies or testing. OnceHF enters the body, it is expected that the fluoride ionwould be the major concern from a chronic toxicitystandpoint. Chronic toxicity from long term, highexposure to fluoride salts has been reported toresult in tooth mottling in children, bone fluorosisand sometimes osteosclerosis in adults and children.

Skeletal fluorosis is known to be associated withexcessive exposure to fluoride compounds. Casesof skeletal fluorosis have been reported in populationsexposed to naturally occurring drinking water con-taining greater than 10 ppm of fluoride ion and inindividuals exposed to high levels of fluoride con-taining dusts. However, skeletal fluorosis has notbeen reported as a consequence of hydrofluoricacid exposure.

Because of the use of fluoride to prevent dentalcaries, there is ongoing evaluation of fluorides for

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the potential to cause cancer. There is no evidencethat fluoride is genotoxic except in some in vitroassays at cytotoxic concentrations. Epidemiologicalstudies have not demonstrated an associationbetween fluoride in drinking water and an increasein cancer. The International Agency for Research onCancer (IARC) has not classified hydrogen fluorideas to its human carcinogenicity, and neither fluoridesnor HF are listed by IARC, NTP, OSHA, ACGIH,NIOSH, the State of California or other governmentalagencies as causing cancer. (32, 33, 34) In animalstudies, fluoride salts have caused effects in progenyonly at high, maternally toxic levels. Some animalstudies have shown effects on male fertility, e.g.decreased sperm counts. (34) Fluoride exposuresshould be kept below recommended levels toassure no adverse effects to the developing fetalskeletal system or teeth.

Monitoring of urine for fluorides is an acceptedmethod of determining exposure. (35) Urine fluoridelevels above 3 mg/liter at the beginning of a workshift,or above 10 mg/liter at the end of a workshift, mayindicate excessive absorption of fluoride. It shouldbe noted that fluorides are often present in significantamounts in persons not occupationally exposed(because of dietary sources of fluoride such as tea),and that the urine fluoride determination is not specificfor HF. (36, 37)

FIRST AID TREATMENT FORHYDROFLUORIC ACID BURNSIn Case of Contact or SuspectedContact with Hydrofluoric Acid:A. Skin Contact

1. Move victim immediately under safety shower orother water source and flush affected area thor-oughly with large amounts of running water.Speed and thoroughness in washing off the acidis of primary importance.

2. Begin flushing even before removing clothing.Remove all contaminated clothing while continuingto flush with water.

3. Rinse with large amounts of running water. If0.13% benzalkonium chloride (Zephiran®) solutionor 2.5% calcium gluconate gel are available, therinsing may be limited to 5 minutes, with thesoaks or gel applied as soon as the rinsing is

stopped. If benzalkonium chloride (Zephiran®)or calcium gluconate gel is not available, rinsingmust continue until medical treatment is rendered.

4. While the victim is being rinsed with water,someone should alert first aid or medical personneland arrange for subsequent treatment.

5. Immediately after thorough washing, use one ofthe measures below:

a. Begin soaking the affected areas in iced 0.13%benzalkonium chloride (Zephiran®) solution.

Use ice cubes, not shaved ice, in order to preventfrostbite.

If immersion is not practical, towels should besoaked with iced 0.13% benzalkonium chloride(Zephiran®) solution and used as compressesfor the burned area. Compresses should bechanged every two to four minutes.

Do not use benzalkonium chloride (Zephiran®)solution for burns of the eyes. Exercise cautionwhen using benzalkonium chloride (Zephiran®)solution near the eyes as it is an eye irritant.

Benzalkonium chloride (Zephiran®) soaks orcompresses should be continued until pain isrelieved or until more definitive medical treat-ment is provided.

b. Start massaging 2.5% calcium gluconate gelinto the burn site.

Apply gel frequently and massage continuouslyuntil pain and/or redness disappear or untilmore definitive medical care is given.

It is advisable for the individual applying thecalcium gluconate gel to wear surgical glovesto prevent a possible secondary HF burn.

NOTE: Clinical experience has shown thatboth benzalkonium chloride (Zephiran®) andcalcium gluconate gel are effective when usedcorrectly in appropriate situations. In an ani-mal model, benzalkonium chloride (Zephiran®)soaks are superior to calcium gluconate gelunder the experimental conditions used. (38, 39)

6. After treatment of burned areas is begun, the victimshould be examined to ensure there are no otherburn sites which have been overlooked.

7. Arrange to have the victim seen by a physician.(If burns are small and/or caused by weak acid,

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and treatment has been provided by an experiencedindividual, evaluation by a physician may not benecessary.) During transportation to a medicalfacility or while waiting for a physician to see thevictim, continue the benzalkonium chloride(Zephiran®) soaks or compresses or continuemassaging calcium gluconate gel. In many situa-tions, particularly for minor burns covering asmall skin area or for burns caused by dilute HF,continued treatment with soaks or gel may beeffective as the sole type of medical care. Allpersons with extensive burns or burns with sig-nificant blister formation or with the appearanceof whitish or dead skin need to be seen by aphysician. All persons with HF burns which donot respond to either calcium gluconate gel orbenzalkonium chloride (Zephiran®) soaks or com-presses within 30 minutes should be evaluated bya physician.

8. The physician may advise continuation of benza-lkonium chloride (Zephiran®) soaks or calciumgluconate gel.

a. If the physician advises continued treatmentwith benzalkonium chloride (Zephiran®) soaksor compresses, the soaks or compresses areusually required for 2 to 4 hours. Significantrelief of pain should be noted within the first30 minutes. If this does not occur, the victimmust be seen by a physician and more definitivecare instituted. If the pain is substantiallyrelieved within the first 30 minutes, continuethe treatment for a total of two hours. After thattime, discontinue treatment and observe forthe recurrence of pain. If pain recurs, continuesoaks or compresses until relief of pain occurs.Soaking for six hours is sometimes needed.(Note: Because prolonged immersion in theice bath may result in discomfort, relief maybe obtained by removing the part from thebath every ten minutes for a minute or so andthen reimmersing it. After the initial 30-60minutes of treatment, less ice can be used sothe bath is cool rather than cold.)

b. Calcium gluconate gel may be used for severalhours or even repeated over a period of a fewdays. However, if significant relief of paindoes not occur within 30 to 40 minutes, moredefinitive treatment will be required. For smallburns, or burns of the face, ears, and near

mucous membranes, calcium gluconate gelmay be very useful. The gel is appliedfrequently and massaged into the burned area.This is continued until relief is obtained orfurther medical care is available.

9. For serious burns, medical attention must be pro-vided as quickly as possible.

For minor burns, if first aid treatment does notalleviate symptoms or if symptoms persist orrecur, medical attention must be sought.

B. Eye Contact

1. Immediately flush the eyes for at least l5 minuteswith large amounts of gently flowing water. Holdthe eyelids open and away from the eye duringirrigation to allow thorough flushing of the eyes.Do not use the benzalkonium chloride(Zephiran®) solutions described for skintreatment. If the person is wearing contact lenses,the lenses should be removed, if possible.However, flushing with water should not beinterrupted, and the lenses should be removed bya person who is qualified to do so. If sterile 1%calcium gluconate solution is available, washingmay be limited to 5 minutes, after which the1% calcium gluconate solution should be usedrepeatedly to irrigate the eye using a syringe.

2. Take the victim to a doctor, preferably an eyespecialist, as soon as possible. Ice water compressesmay be applied to the eyes while transporting thevictim to the doctor.

3. If a physician is not immediately available, applyone or two drops of 0.5% tetracaine hydrochloride,0.5% proparacaine, or other aqueous, topicalophthalmic anesthetic and continue irrigation.Use no other medications unless instructed to doso by a physician. Rubbing of the eyes is to beavoided.

4. An Eye Irrigator™ may be useful in deliveringflushing or treating solutions, including calciumgluconate solution, to the eye. (See page 15)

C. For Inhalation of Vapors:

1. Immediately move victim to fresh air and getmedical attention.

2. Keep victim warm, quiet and comfortable.

3. If breathing has stopped, start artificial respirationat once. Make sure mouth and throat are free offoreign material.6

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4. Oxygen should be administered as soon as possibleby a trained individual. Continue oxygen whileawaiting medical attention unless instructed oth-erwise by a physician.

5. A nebulized solution of 2.5% calcium gluconatemay be administered with oxygen by inhalation.

6. Do not give stimulants unless instructed to do soby a physician.

7. The victim should be examined by a physician andheld under observation for at least a 24 hour period.

8. Vapor exposures can cause skin and mucousmembrane burns as well as damage to pulmonarytissue. Vapor burns to the skin are treated the sameas liquid HF burns.

D. If Acid is Ingested:

1. Have the victim drink large amounts of water asquickly as possible to dilute the acid. Do notinduce vomiting. Do not give emetics or bakingsoda. Never give anything by mouth to anunconscious person.

2. Give several glasses of milk or several ounces ofmilk of magnesia, Mylanta®, Maalox®, etc or grindup and administer up to 30 Tums™, Caltrate™ orother antacid tablets with water. The calcium ormagnesium in these compounds may act as anantidote.

3. Get immediate medical attention. Ingestion ofHF is a life-threatening emergency.

MEDICAL TREATMENT FORHYDROFLUORIC ACID BURNSBurns of the Skin – GeneralBurns from dilute acid are difficult to distinguishfrom other chemical burns and usually appear asareas of erythema. However, they may progress, ifnot treated, to areas of blistering, necrosis or ulceration.Burns from more concentrated acid have a rathercharacteristic appearance and present as severelyreddened, swollen areas with blanched, whitishregions which rapidly progress to blistering andnecrosis. A thick granular exudate usually appearsunder these blisters which requires debridement andremoval.

Hydrofluoric acid burns cause extreme pain. The painis thought to result from nerve ending irritation dueto increased levels of potassium ions in extracellular

spaces to compensate for the reduced levels of calciumions which have been bound by the fluoride. Reliefof pain is an excellent indication of the successof treatment and, therefore, local anestheticsshould be avoided.

Many different types of therapies have been suggestedfor HF burns. The aim of all treatment is to chemicallysequester the fluoride ion and to prevent extensive,deep-tissue destruction. (38,39)

After treatment of recognized burned areas is begun,the victim should be carefully examined to insurethere are no other burn sites which may have beenoverlooked.

Quaternary Ammonium CompoundsMost HF burns can be satisfactorily treated byimmersion of the burned part in an iced, aqueoussolution of a quaternary ammonium compound.Two solutions have been clinically successful,0.13% benzalkonium chloride (e.g. Zephiran®) or0.2% benzethonium chloride (e.g., Hyamine® 1622).Because of its availability as a non-prescription drug,benzalkonium chloride (Zephiran®) is recommendedin the United States.

The solutions should be cooled with ice cubes.(Shaved or crushed ice may cause excessive cooling,with the danger of frostbite.)

If immersion in the solution is not practical, soakedcompresses of the same iced solution should beapplied to the burned area. The immersion or com-presses should be used for at least two hours.Compresses should be changed or soaked withadditional solution approximately every two to fourminutes.

If blisters are present, they should be opened anddrained and necrotic tissue should be debrided by aphysician or qualified health care practitioner as soonas possible. However, immersion in benzalkoniumchloride (Zephiran®) or use of compresses should notbe delayed if debridement cannot be accomplishedimmediately.

Prolonged immersion in the iced benzalkoniumchloride (Zephiran®) bath may result in discomfortdue to excess chilling; relief may be obtained byremoving the part from the bath every ten to fifteenminutes for a few minutes and then reimmersing it.After the initial 30-60 minutes of treatment, less icecan be used so the bath is cool rather than cold.

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The success of this treatment is indicated by relief ofthe severe pain in the burned area. If there is nosignificant relief of pain within 30 to 40 minutes, theuse of 5% calcium gluconate injections may be neces-sary. If pain recurs when the treatment is stopped atthe end of the first two hours, immersion or compressesshould be resumed until pain is relieved. A total offour to six hours immersion or use of compresses ofbenzalkonium chloride (Zephiran®) is usuallyrequired for the treatment of most burns. No furthertreatment will be required in many instances. The useof iced quaternary ammonium compound solutionsoffers several advantages:

• reduction of local pain

• possible slowing of the rate of tissue destruction

• possible slowing of the passage of the fluorideion into tissues and into the bloodstream

Large burns, serious burns due to concentratedHF, or burns with delayed treatment will probablyrequire the use of calcium gluconate injectionsin addition to or instead of the benzalkoniumchloride (Zephiran®) soaks.

Quaternary ammonium compounds should not beused for burns on the face, ears or other sensitiveareas due to their irritating nature. It is preferable touse calcium gluconate gel or calcium gluconateinjection in these areas.

Calcium Gluconate GelCalcium gluconate gel, consisting of 2.5% USP calciumgluconate in a surgical water soluble lubricant, iswidely used for first aid and/or primary treatment ofHF burns of the skin. The gel is convenient to carryand can be used to initially treat small burns thatmight occur away from medical care. (The gel is notrecommended for burns with concentrated HFexcept as a first aid measure.) The gel is used bymassaging it promptly and repeatedly into theburned area, until pain is relieved. If possible, surgicalgloves should be worn during initial application ofthe gel, so the person providing treatment will notreceive a secondary burn. This treatment can bestarted without waiting for medical direction.

If used as the only method of treatment, liberalquantities of calcium gluconate gel must be massagedinto the burned area continuously for up to severalhours. Relief of pain can be used to assess the efficacy

of this treatment. If good relief of pain is not obtainedafter 30-40 minutes, alternate methods of treatmentsuch as calcium gluconate injections or benzalkoniumchloride (Zephiran®) soaks should be considered.

The gel is especially useful for burns on the face,particularly near the mouth and eyes or on the ears.It may be convenient to use the gel for very smallburns where the victim can easily apply and massagethe gel into the burned area. Use of the gel may bemore convenient for dilute acid burns such as occurwith commercial products like rust removers, alu-minum cleaners or etching solutions.

Calcium Gluconate InjectionsAfter first aid measures have been taken, injection ofa 5% calcium gluconate solution is indicated as theprimary medical treatment for large burns (over 25square inches or 160 square centimeters). For smallerburns, if benzalkonium chloride (Zephiran®) soaksor calcium gluconate gel do not result significantrelief of pain within 30 to 40 minutes, injection ofcalcium gluconate solution is indicated. Injection ofcalcium gluconate solution may also be indicated forburns in which treatment has been delayed.

The physician should inject sterile 5% aqueous calciumgluconate beneath, around and into the burned area.Calcium gluconate is packaged as a 10% solution, andmust be diluted 50-50 (equal parts) with normalsaline. (Note: DO NOT USE calcium chloride, whichis corrosive and may result in additional damage.)

If subcutaneous calcium gluconate injections areused, the amount injected initially is small andshould not exceed 0.5 cc per square centimeter ofaffected skin surface. The injections should not distortthe appearance of the skin. A small-gauge needle(#27 - #30) should be used, and the burned areashould be injected through multiple sites. With suc-cessful treatment, pain relief following injection of5% calcium gluconate solution is very rapid. Thepatient can usually advise when the pain stops, andthis is an indicator of adequate treatment. Multipleinjections in skin that has compromised integrity mayincrease the risk of infection, and the use of antibioticcreams such as Silvadene® (silver sulfadiazine) orGaramycin® (gentamicin sulfate cream) should beconsidered following such treatment. Local anestheticsshould not be used since they mask pain reliefwhich is an important indication of adequacy oftreatment.

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Some physicians prefer using calcium gluconateinjections initially as the primary treatment, insteadof using quaternary ammonium compound soaks orcompresses or using calcium gluconate gel.Injections often are not necessary when there hasbeen early and adequate treatment with soaks or gel.

Calcium Gluconate SolutionIn some instances, a 5% or 10% calcium gluconatesolution may be used in compresses or for irrigation.For example, irrigating with a calcium gluconatesolution may be the best treatment should HF enterthe external ear canal. In this instance, referral toan otolaryngologist may also be needed.

Burns of the Fingers and NailsBurns of the fingers often create special problems intreatment. Finger and toe nails permit penetrationof fluoride ions but prevent soaks or gels frombeing effective. It may be necessary to drill, split oreven remove nails to allow the topical methods oftreatment to be effective. One author has cautionedthat removal of the nail should rarely be necessary inthe case of dilute HF acid (less than 10%) burns. (40)The treating physician must consider the morbidityassociated with removal of the nail versus the needto treat the HF exposure.

If immersion in benzalkonium chloride (Zephiran®)solution is started immediately, it may be possible toavoid removing the nail. Sometimes better penetrationunder the nail can be successfully accomplished bysplitting the nail or by drilling several burr holes inthe nail using a large gauge needle or a nail drill. Ifcalcium gluconate injection is used as treatment, thenail may still need to be split or removed. If nailremoval is necessary, using a short acting regionalor ring-block anesthetic may facilitate this procedureand not interfere with using pain relief as an indicatorof effective treatment. When using calcium gluconateinjections in the digits, care must be taken to injectthe solution cautiously so as to avoid compromisingthe circulation in these areas.

As an alternative to using benzalkonium chloride(Zephiran®) soaks, experience has shown that somefinger or hand burns can be treated by using a glovefilled with calcium gluconate gel. Initially, calciumgluconate gel should be massaged into the burnedarea. Following this, an oversize surgical gloveshould be partially filled with calcium gluconate gel,

and the hand inserted into the glove. The glovedhand may be immersed in ice water, if available,which may aid pain relief. This treatment worksbest for burns where there is no blistering, or afterthe burns have been debrided. As in other caseswhere calcium gluconate gel is used, alternate methodsof treatment should be considered if good relief ofpain is not achieved within 30 - 45 minutes. If painis relieved, the glove should remain in place forthree to for hours.

Intra-arterial and Intravenous CalciumInfusionReports in the literature have described the use ofintra-arterial injection or infusion of dilute calciumgluconate solutions to treat HF burns of the handand digits, usually from prolonged contact withdilute HF, which do not respond to other methods,either due to inadequate or improper treatment, orin cases where treatment has been greatly delayed.The method is described as follows:

"A long catheter was inserted percutaneously intothe radial artery using standard aseptic technique.Intra-arterial catheter placement was confirmedby pressure transducer and oscilloscope. If the burninvolved only the thumb, index, or long fingers,the catheter was advanced only a few centimetersproximally in preparation for digital subtractionarteriography. If the burn involved the ring orsmall fingers, the catheter was advanced proximallyinto the brachial artery because access to theulnar circulation was necessary.

Following satisfactory placement of the arterialcatheter, we performed digital subtraction arteri-ography on all patients in our series to identifythe origin of vascular supply to digits involved.

Once the tip of the arterial catheter was in thedesired location, a dilute preparation of calcium[gluconate] (10 ml of a 10% solution mixed in 40 to50 ml 5% dextrose) was infused with a pumpapparatus into the catheter over four hours. Wegenerally have used calcium gluconate... Eachpatient was observed closely during the infusionperiod for progression of symptoms and potentialcomplications of the procedure, such as alterationsof distal vascular supply.

Following the four-hour infusion, the arterialcatheter was maintained in place in the usual

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manner while the patient underwent an observationperiod. If typical HF pain returned within fourhours, a second calcium infusion was repeateduntil the patient was pain free four hours followingcompletion of the calcium infusion”. (14)

This method, although rather involved, should beconsidered in selected cases, especially where inad-equate or delayed treatment has occurred.

There are now several reports of the successful useof intravenous calcium gluconate to treat HF burnsof the upper extremity. (41, 42, 43) Graudins, et al.describe their method:

An intravenous catheter was placed on the dorsumof the affected hand. The superficial veins wereexsanguinated by elevation. A double-cuffedpneumatic tourniquet was applied above theelbow, inflated to 100 mm Hg above systolicblood pressure, and 10 ml of 10% calcium gluconatediluted with 30 to 40 ml of 0.9% saline solutionwas then infused. Ischemia was maintained for 25minutes; the cuff was sequentially released over 3to 5 minutes.

This method was most successful for burns due todilute acid. If the use of intravenous calcium gluconatewas not successful in relieving pain (which occurredwith burns due to 49% HF, the highest concentrationseen in the series of patients), Graudins et al. turnedto intra-arterial calcium gluconate.

Additional MeasuresWhere blistering and/or necrosis occur, earlydebridement may facilitate healing.

In instances of extensive burns, skin grafting hasoccasionally been required, but the need for thistreatment should be markedly reduced by immediateand aggressive primary treatment.

Follow-up care requires monitoring to prevent sec-ondary infections. The use of antibiotic creams suchas Silvadene® or Garamycin® has proven effective.HF burns may heal slowly, but if properly treatedmost heal with little or no scarring in 14 to 28 days.

Other and Unproven TherapiesThe use of intravenous calcium gluconate is discussedabove. Both Williams, et al. (44) and Cox, et al. (45)have discussed the use of intravenous magnesiumsulfate to treat localized moderate to serious skinburns. Using either a rat or a rabbit model, the

authors administered intravenous magnesium sulfate.Cox used a 0.2 mEq bolus over two minutes, followedby a slower infusion of 0.2 mEq per hour for fourhours, with a total of 1.0 mEq/kg magnesium sulfateadministered. Williams administered 8 mg/kg overfive minutes or 160 mg/kg over 10 minutes. Theseauthors compare this dose to the amount of magne-sium sulfate, infused more slowly, used in the treatmentof eclampsia.

Dunn, et al. (38) have shown effectiveness of locallyapplied calcium acetate solution, 10% in water atroom temperature, in an animal model.

Seyb et al. (47), performed an experiment in rats usinga topically applied solution of 50% aqueous dimethylsulfoxide (DMSO) containing calcium gluconate (20%wt/vol). This treatment gave results comparable toinjecting 10% calcium gluconate or 10% magnesiumsulfate, and was superior to calcium gluconate gel intreating experimental HF burns.

It should be noted that many of these therapies,while promising, have been tested to a limiteddegree, if at all, in humans.

A product developed in France, “Hexafluorine” (46),has been marketed in Europe and the United Statesfor the emergency rinsing of HF skin and eyeexposure. Documentation of effectiveness andexperience with this product are lacking.

Systemic Absorption and MetabolicEffectsSignificant amounts of fluoride ion may be absorbedby skin contact, inhalation, or by ingestion. If systemicabsorption of fluoride occurs, hypocalcemia, hypomag-nesemia and hyperkalemia may also occur. All ofthese parameters need to be monitored and appro-priate therapeutic measures instituted. The patientshould be observed for clinical signs of hypocalcemiafollowing ingestion or inhalation or following extensiveburns greater than 25 square inches. Serum calciumdeterminations must be performed immediately andperiodically to monitor and treat hypocalcemia.Severe lowering of serum calcium levels can occurwithin one to two hours even with HF burns coveringless than 2.5% of body surface area. (8)ContinuousEKG monitoring to observe prolongation of the Q-Tinterval may be useful to detect early changes inserum calcium, although profound hypocalcemiafollowing HF exposure has been reported in the

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absence of EKG changes or in the absence of othersigns of tetany.

The fall in serum calcium may occur precipitouslyfollowing HF exposure. In two reported cases ofexposure to anhydrous HF, the serum calcium fell tolevels around 3 milliequivalents per liter (mEq/L)[normal = 8.8 - 10.3 mEq/L] within one to threehours of exposure. (8)

If necessary, aqueous calcium gluconate may begiven intravenously. Calcium gluconate as a 10%solution must be given slowly since excess calciumcan produce vagal bradycardia, ventricular arrhythmiasand ventricular fibrillation. The IV calcium gluconateshould be repeated until serum calcium levels returnto, and remain at, normal levels. In one fatal case,280 mEq of calcium over four hours was not sufficientto correct the profound hypocalcemia. (8) Withoutadditional measures such as hemodialysis, it maynot be possible to correct extreme hypocalcemia.

Serum magnesium levels should also be monitored andmagnesium loss should be replaced intravenously ifindicated. Yamaura, et al. have reported a case of HFexposure in which prolonged QT interval occurred, inwhich ionized calcium levels were relatively high butthe magnesium level was low. (48) Serum potassiummust also be carefully monitored. Significant elevationsof serum potassium have been noted in cases of fluo-ride toxicity and also in laboratory studies. Hyperkalemiahas also been implicated as a causative factor in car-diovascular collapse. The use of quinidine may behelpful in preventing this serious complication. (20)

Hemodialysis with fluoride free water (and normal tolow potassium and slightly higher calcium concentra-tions), in conjunction with other treatments mentioned,should be considered in all cases of serious burns andmay need to be repeated if indicated. (19, 20, 21)Serum fluoride levels should be monitored. Normalplasma fluoride levels may differ because of variousmethodologies and analytical techniques. The deci-sion to use dialysis should be based on the HFexposure (concentration, body surface area) and theclinical condition of the patient, including the serumlevels of fluoride, calcium and potassium.

Primary excision has been recommended by somepractitioners as a method of reducing systemicabsorption of fluoride. (49) While this could insome instances be life saving, it is a rather drasticmeasure. It is likely that renal dialysis could be

used to effectively treat systemic toxicity and wouldnot result in the disfigurement, disability, or morbiditywhich could be associated with primary excision.

Eye InjuriesHF can cause severe eye burns, which, if not properlytreated, may result in scarring and blindness. Theprognosis is not good if first aid treatment is delayedor inadequate. After first aid treatment (see FIRSTAID section) the following medical treatment maybe provided:

If the individual wears contact lenses, it is usually bestto remove the lenses before additional eye irrigation.

For minor exposures with very dilute HF, the followingtreatment has been successful:

Mix 10 ml of 10% calcium gluconate with 100 ml ofnormal saline to give approximately a 1% calciumgluconate solution. With a syringe, irrigate the eyeintermittently for a period of 15 to 30 minutes oruntil relief of pain occurs.

With more serious HF eye burns, good results havebeen reported with the following procedure:

Mix 50 ml of 10% calcium gluconate with 500 ml ofnormal saline to give approximately a 1% calciumgluconate solution. After administering local anestheticeye drops, use an eye clamp and IV infusion set or atwo pronged nasal oxygen cannula to instill the solu-tion over a period of one to two hours. More pro-longed use of the solution could possibly damage thecornea. Consultation with an ophthalmologist toconsider the use of steroids, antibiotics, cycloplegicsor additional treatment is recommended.

Notes:

Various approaches to the treatment of ocular exposuresto HF have been recommended. Some authoritiesrecommend the use of Lactated Ringer’s solutionrather than normal saline for eye irrigation. (50)

Previous recommendations have included the use ofa Morgan Lens. A Morgan Lens may limit the deliveryof solution to the cornea and sclera, while the methodsdiscussed above allow the solution to contact thelids and surrounding tissues as well. A newerdevice, the Eye Irrigator™, may be useful in deliveringthe irrigating solution to an injured eye. All therapiesmust be based on the individual case and on theexperience and skills of the physician.

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Inhalation InjuriesPatients with inhalation exposures should alsobe observed for signs of systemic absorptionand fluoride toxicity.

Exposure to hydrofluoric acid fumes can causeacute respiratory irritation, bronchospasm, and/orpulmonary edema. Medical personnel should also bealert to the possibility of development of pulmonaryedema when extensive burns of the face, neck orchest have occurred. Intubation should be avoided,if possible.

The victim should be removed from exposure andadministered 100% oxygen immediately. The use of2.5% aqueous calcium gluconate given by nebulizerwith l00% oxygen, or with intermittent positive pres-sure, has been recommended. Theoretically, thisshould reduce toxicity and damage from the fluorideion and should be seriously considered in cases ofinhalation exposure.

Burns of the oral mucosa or upper airway maycause severe swelling and necessitate a tracheostomy.It is, therefore, recommended that all such patientsbe admitted to a hospital for observation.

Because inhalation of HF may be associated withsignificant bronchospasm, inhaled, oral or parenteralbronchodilators should be administered as necessary.Even in the absence of symptoms, the prophylacticadministration of inhalational steroids (e.g.beclomethasone dipropionate) may be indicated. (21)Pulmonary function testing may be helpful in assessingthe degree and progress of pulmonary injury.

Specific measures may be needed to treat pul-monary edema. High doses of parenteral steroidsmay be needed along with the administration ofappropriate diuretics. Caution should be taken not toadminister excessive fluid. Hemoconcentration mayrequire treatment by phlebotomy. The managementof pulmonary edema may result in renal failure dueto reduced fluid volume, and this may be anotherindication for hemodialysis.

If it is necessary to relieve anxiety, use general mea-sures and do not use sedatives which could causecentral nervous system depression or hypoventilation.Although right heart failure is uncommon in chemi-cally-induced pulmonary edema, monitoring ofpulmonary pressure, arterial pressure, and centralvenous pressure may be indicated.

Secondary infections must be treated. It is preferableto start antibiotics at the first signs of infection, suchas fever or tachycardia. Periodic blood cultures maybe advisable. Prophylactic use of antibiotics is notadvised.

Ingestion InjuriesAfter first aid is completed (drinking several glassesof water followed by two glasses of milk or twoounces of milk of magnesia, Mylanta®, or other calciumor magnesium containing antacids), the stomach maybe lavaged with a solution of a calcium containingantacid. The Levin tube must be passed with careto prevent perforation. Treatment for the corrosiveeffects is the same as for ingestion of other strongacids. Systemic toxicity is very likely to occur andmay require aggressive treatment.

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REFERENCES1. Derelanko, M. J., et al.: Acute Dermal Toxicity of DiluteHydrofluoric Acid. J. Toxicol-Cut and Ocular Toxicol 4:73-85,1985.

2. MacKinnon, M. A.: Hydrofluoric Acid Burns. DermatologicClinics 6:67-74, January, 1988.

3. Trevino, M. A.: Treatment of Severe Hydrofluoric AcidExposures. J Occup Med 25:861-3, December, 1983.

4. Edelman, P.: Hydrofluoric Acid Burns. State of the Art RevOccup Med 1:89-103, 1986.

5. Upfal, M. and Doyle, C.: Medical Management of HydrofluoricAcid Exposure. J Occup Med 32: 726-731, August, 1990.

6. Caravati, E. M.: Acute Hydrofluoric Acid Exposure. Am JEmerg Med 6: 143-50, March, 1988.

7. ATSDR: Managing Hazardous Materials Incidents, Volume III.Medical Management Guidelines for Acute Chemical Exposure:Hydrogen Fluoride. 1993.

8. Tepperman, P. B.: Fatality Due to Acute Systemic FluoridePoisoning Following a Hydrofluoric Acid Skin Burn. J OccupMed 22:691-2, October, 1980.

9. Wetherhold, J. M.: Treatment of Hydrofluoric Acid Burns. JOccup Med 7:193-5, May, 1965.

10. MacKinnon, M. A.: Treatment of Hydrofluoric Acid Burns(letter). J Occup Med 28:804, September, 1986.

11. Reinhardt, C. F.: Hydrofluoric Acid Burn Treatment. Am IndHyg Assoc J 27:166-171, l966.

12. Browne, T. D.: The Treatment of Hydrofluoric Acid Burns. JSoc. Occup Med 24:80-9, July, 1974.

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13. Rose, L. and Trevino, M. A.: Further Evaluation ofHydrofluoric Acid Burns of the Eye. J Occup Med 26:483-4, July,1984.

14. Vance, M. V.: Digital Hydrofluoric Acid Burns: Treatment withIntra-arterial Calcium Infusion. Ann Emer Med 15:59-65, August8, 1986.

15. Davanzo, F. et al.: Hydrofluoric Acid Intoxication: A NewTherapy. Med Lav 78:333-6, 1987.

16. Boink, A. B. T. J.: Pathophysiological Mechanisms ofHydrofluoric Acid and Fluoride Intoxication: An ExplorativeStudy in Rats and Pigs. Thesis. University of Utrecht, TheNetherlands. 1993.

17. McIvor, M. E.: Delayed Fatal Hyperkalemia in a Patient withAcute Fluoride Intoxication. Ann Emerg Med 16:1166-7, October, 1987.

18. Cummings, C. and McIvor, M. E.: Fluoride InducedHyperkalemia: The Role of Ca2+ Dependent K+ Channels. Am JEmerg Med 16:1-3, January, 1988.

19. Picazo, H. C.: Fluoride Removal from the Blood byHemodialysis. Presented at CMA HF Safety Seminar, August,1990.

20. McIvor, M. E.: Acute Fluoride Toxicity: Pathophysiology andManagement. Drug Saf 5:79-85, 1990.

21. CTEF (Comité Technique Européan du Fluor, a sector groupof CEFIC): Medical Management of Hydrogen Fluoride Injuries.July, 1998.

22. Hazardous Substances Data Bank (HSDB): Sodium Fluoride.,National Library of Medicine, 1992.

23. Gaugl, J.F. and Woolridge, B.: Cardiopulmonary Response toSodium Fluoride Infusion in the Dog. J Toxicol Environ Health11:765-82, 1983.

24. Strubelt, O., et al.: The Pathophysiological Profile of theAcute Cardiovascular Toxicity of Sodium Fluoride. Toxicology24:313-23, 1982.

25. US Department of Labor (OSHA): CFR 1910.1000, Table Z-2.

26. 1998 Threshold Limit Values (TLVs®) for Chemical Substancesand Physical Agents and Biological Exposure Indices (BEIs®),American Conference of Governmental Industrial Hygienists, Inc.,p 42. Cincinnati, Ohio, 1998.

27. Documentation of the Threshold Limit Values (TLVs®) forChemical Substances and Physical Agents and BiologicalExposure Indices (BEIs®), American Conference of GovernmentalIndustrial Hygienists, Inc., pp 780-1, 6th edition, 1991.

28. NIOSH Pocket Guide to Chemical Hazards. p 168 DHHS(NIOSH) Publication No. 97-140, June 1997.

29. Documentation for Immediately Dangerous to Life or HealthConcentrations (IDLHs). pp 257-8 DHHS (NIOSH). NTISPublication No. PB-94-195047, May 1994.

30. Emergency Response Planning Guideline: HydrogenFluoride. American Ind Hygiene Assn, 1996.

31. Manoguerra, A. S.: Fatal Poisoning from Acute HydrofluoricAcid Ingestion. Am J Emerg Med 4:362-3, 1986.

32. The Regulated Chemicals List of Lists (LOLI), ChemADVISOR®,

Micromedex, Inc., 1998.

33. State of California, Air Resources Board. Toxic AirContaminant Identification List, Compound Summaries.September, 1997.

34. Chemical Substances Bureau, The Netherlands. HydrogenFluoride, Risk Assessment. Draft, 12 August, 1997 (with changes24 November, 1997).

35. Kono, K., et al.: Urinary Fluoride Monitoring of IndustrialHydrofluoric Acid Exposure. Environ Res 42:415-20, April 1987.

36. 1998 Threshold Limit Values (TLVs®) for Chemical Substancesand Physical Agents and Biological Exposure Indices (BEIs®),ibid., p 100.

37. Documentation of the Threshold Limit Values (TLVs®) forChemical Substances and Physical Agents and BiologicalExposure Indices (BEIs®), ibid., pp BEI 83-7.

38. Dunn, B. J., et al.: Hydrofluoric Acid Dermal Burns: AnAssessment of Treatment Efficacy Using an Experimental PigModel. J Occup Med 34:902-9, 1992.

39. Dunn, B. J., et al.: Topical Treatments for Hydrofluoric Acid(HF) Dermal Burns: Further Assessment of Efficacy Using anExperimental Pig Model. J Occup Environ Med 38: 507-14, 1996.

40. Roberts J. R. and Merigian, K. S.: Acute Hydrofluoric AcidExposure (letter). Am J Emerg Med 7:125-6, January, 1988.

41. Henry, J. A. and Hla, K. K. Intravenous Regional CalciumGluconate Perfusion for Hydrofluoric Acid Burns. ClinToxicology 30:203-7, 1992.

42. Graudins, A., et al.: Regional Intravenous Infusion of CalciumGluconate for Hydrofluoric Acid Burns of the Upper Extremity.Ann Emerg Med 30:604-7, 1997.

43. Ryan, J.M. et al.: Regional Intravenous Infusion of CalciumGluconate for Hydrofluoric Acid Burns of the Upper Extremity.Ann Emerg Med 31:526-7, 1998.

44. Williams, J. M. et al. Intravenous Magnesium in the Treatmentof Hydrofluoric Acid Burns in Rats. Ann Emerg Med 23:464-9,1994.

45. Cox, R. D. and Osgood, K. A. Evaluation of IntravenousMagnesium Sulfate for the Treatment of Hydrofluoric Acid Burns.Clin Toxicology 32:123-36, 1994.

46. Hexafluorine Product Literature, DH Marketing, Tarrytown,NY. 1993.

47. Seyb, S. T.: A Study to Determine the Efficacy of Treatmentsfor Hydrofluoric Acid Burns. J Burn Care Rehabil 16:253-7, 1995.

48. Yamaura, K. et al.:Recurrent Ventricular TachyarrythmiasAssociated with QT Prolongation Following Hydrofluoric AcidBurns. Clin Toxicol 35:311-3, 1997.

49. Buckingham, F. M.: Surgery: A Radical Approach to SevereHydrofluoric Acid Burns. J Occup Med 30:873-4, November, 1988.

50. Beiran, I. et al.: The Efficacy of Calcium Gluconate in OcularHydrofluoric Acid Burns. Human & Exper Toxicol 16:223-8, 1997.

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d. Towels (for use as wet compresses).

2. Calcium gluconate gel, 2.5%

Calcium gluconate gel is available commerciallyfrom:

Pharmascience Inc.6111 Royalmount Ave.Montreal, Quebec H4P 2T4CanadaTelephone:

800.207.4477514.340.9735

Fax 514.340.9290www:pharmascience.com

It may also be made by mixing one ampule of10% calcium gluconate solution for each ounce oflubricating jelly (e.g., K-Y® Brand LubricatingJelly) using 40 cc per 4 ounce tube. Althoughthis makes a somewhat "soupy" mixture, it hasthe advantage that the ingredients may be readilyavailable. In addition, the ingredients may bestored separately until needed, and shelf life isless of a concern.

Calcium gluconate gel (2.5% calcium gluconate ina water soluble base) may also be formulated bya pharmacist by dissolving 3.2 grams of calciumgluconate USP in 5 cc of sterile water, and thenmixing with 120 cc (4 oz. tube) of K-Y® Jelly orother water soluble lubricant (2.5 grams per 100cc lubricant). The shelf life is uncertain andreplacement every six months is recommended.

3. Aqueous calcium gluconate, 10% USP, 10 ccampules (4.5 mEq calcium or 93 mg elementalcalcium per 10 cc)

a. To make calcium gluconate gel, or

b. To mix with sterile saline for eye irrigation (5ampules 10% calcium gluconate per 500 ccsterile normal saline for a 1% solution), or

c. To mix with sterile saline for administrationwith oxygen by nebulization (10 cc 10% calci-um gluconate in 30 cc sterile saline for a 2.5%solution), or

d. To be administered by a physician. Wheninjected subcutaneously, 10% calcium glu-conate must be diluted half and half with normalsaline to produce a 5% solution.

APPENDIXFIRST AID AND MEDICAL SUPPLIESThe following supplies should be maintained in adispensary or first aid station near hydrofluoric acidhandling and storage areas:

1. Benzalkonium chloride (Zephiran®) solution*

a. For soaks and compresses, 3 to 4 gallons of0.13% water solution (1:750) of benzalkoniumchloride (Zephiran®). It is recommended thatthe 1:750 (0.13%) solution be purchased. It isavailable as a non-prescription drug in galloncontainers. The solution should be obtainedin advance. It should replaced before theexpiration date on the label. It is recommendedthat it be stored in properly labeled light-resistantcontainers.

Benzalkonium chloride (Zephiran®) is alsoavailable as a 17% solution. If this concentrateis used to make a 0.13% (1:750) solution, thedilution should be performed by a qualifiedindividual, such as a registered pharmacist.The shelf life of the diluted solution is uncer-tain, and it should be replaced annually.

Benzalkonium chloride (Zephiran®) should beavailable as a non-prescription drug throughmost local pharmacies. The local pharmaciesobtain it from pharmaceutical wholesale dis-tributors such as McKesson Pharmaceuticals,Cardinal Health Inc., or the local pharmaceuti-cal wholesaler. It can also be obtained from:

Towne Pharmacy 103 Ridgedale Ave.Cedar Knolls, NJ 07927Tel: 973-538-6787Fax: 973-538-6791

In addition to benzalkonium chloride(Zephiran®), benzethonium chloride (Hyamine1622®) has also been used successfully to treatHF burns. Because of its availability as a non-prescription drug, benzalkonium chloride(Zephiran®) is recommended.

b. Ice cubes (not crushed or shaved ice).

c. Assorted basins (for immersing burned areas inbenzalkonium chloride (Zephiran®) solution).

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Honeywell

4. Sterile 0.9% saline

a. Vials, (e.g. 10 cc, 30 cc, or 50 cc) to dilute 10%calcium gluconate to 5% for injection, or to2.5% for nebulization.

b. 500 cc IV to dilute 10% calcium gluconate to1% for eye irrigation.

5. 0.5% tetracaine hydrochloride solution to counteractblepharospasm and facilitate eye irrigation.

6. Medical oxygen.

7. Nebulizer, to administer 2.5% calcium gluconatewith oxygen.

8. Beta adrenergic bronchodilators and steroids forinhalation.

9. Surgical gloves.

10.Syringes and needles (27-30 gauge).

11.Eye Irrigator™ Ocular Irrigating System

American Health and Safety6250 Nesbitt RoadP. O. Box 46340Madison, WI 53744-6340Tel: 800.522.7554Fax: 800.326.3245

The FIRST AID AND MEDICAL TREATMENTS ANDSUPPLIES recommended in this brochure are basedon information reported in the medical literatureand the personal experience of physicians withHoneywell. It should be noted that there are nomedications in the U.S. for which the specific indicationis the treatment of hydrofluoric acid burns. Thephysician has the dilemma of using prescription drugsin a non-approved manner, or of using substanceswhich are not approved drugs but which have beenproven effective for medical treatment. Given thechoice between recommending effective treatment,or recommending the use of only drugs which areapproved, we have chosen to recommend the effectivetreatment.

Benzalkonium chloride (Zephiran®) is available inthe U.S. as a non-prescription drug. It is a surfaceactive agent sold for use as a disinfectant. It is avail-able in a 1:750 aqueous solution, a 17% concentrate,and a tinted tincture. The concentrated 17% solu-tion must be diluted. The tinted tincture is not rec-ommended to treat HF exposures.

Benzethonium chloride (Hyamine® 1622) has beenused in veterinary medicine as an antiseptic forwounds and infections, but it is not available as adrug. Care should be taken that Hyamine® 1622 isused, not hyamine with other numeric or alphanu-meric modifiers.

CALCIUM GLUCONATE INJECTION, USP (one gramin 10 ml, 10% solution) is labeled for intravenoususe only. Experience has shown that when dilutedto 5% with normal saline, and used as described inthis brochure, it is a safe and effective treatment forHF skin exposure. When diluted to 2.5% and usedas described, it is safe for nebulization and inhala-tion, and when diluted to 1.0% and used asdescribed, it is safe for eye irrigation.

NotesCaltrate® is a Registered Trademark of LederleConsumer Health, Madison, NJ 07940

Garamycin® is a Registered Trademark of ScheringCorporation, Kenilworth, NJ 07033

Hyamine® 1622 is a Registered Trademark of Lonza,Inc., Fairlawn, NJ 07410

K-Y® Brand Lubricating Jelly is a RegisteredTrademark of Johnson & Johnson Products, Inc.,Skillman, NJ 08558

Maalox® is a Registered Trademark of NovartisConsumer Health, Woodbridge, NJ 07095

Mylanta® is a Registered Trademark of Johnson &Johnson - Merck, Fort Washington, PA 19034

Silvadene® is a Registered Trademark of HoechstMarion Roussel, Kansas City, MO 64134

Tums® is a Registered Trademark of SmithKlineBeecham Consumer Healthcare, L.P., Pittsburgh, PA15230

Zephiran® is a Registered Trademark of SanofiPharmaceuticals, New York, NY 10016

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INDEXACGIH 4Acute toxicity 3Benzalkonium chloride

see ZephiranBenzethonium chloride

see HyamineBlisters 7Brochodilators 12Brochospasm 12Calcium acetate 10Calcium gluconate gel

first aid 5, 6medical treatment 8mixing 14ordering 14

Calcium gluconate injections 8, 14, FCalcium gluconate solution

1%, for eyes 6, 11, 142.5%, by nebulizer 6, 145%, subcutaneous 1410% ampules 14compresses, irrigation 9intra-arterial 9intravenous 9, 10, 11

Calcium, serum 10, 11Cancer 5CAS number 2Chronic toxicity 4Concentrated HF 2Consumer products 2Contact lenses 6Debridement 7Dilute HF 2, 3Dimethyl sulfoxide (DMSO) 10DMSO 10EKG monitoring 10Emergency Contact FERPG 4Excision, primary 11Eye, first aid 6Eye Irrigator 6, 15Eye, medical treatment 11Eye toxicity 4Face 8Fingernails 9

anesthesia 9burr holes 9Ca gluconate gel 9Ca gluconate injections 9removal 9

Fingers 9First aid

calcium gluconate gel 5, 6eyes 6

ingestion 7inhalation 6skin contact 5Zephiran Soaks 5, 6

Fluorides in urine 5Fluorosis, skeletal 4Frostbite 7Fumes of HF 3Hemodialysis 3, 11Hexafluorine 10Hyamine 14Hyperkalemia 11Hypocalcemia 3, 11Hypomagnesemia 11IDLH 4Immersion 7Ingestion 4

first aid 7medical treatment 12

Inhalationfirst aid 6medical treatment 11toxicity 4

Intra-arterial infusion Ca solution 9Intravenous infusion Ca solution 10, 11Lactated Ringer's eye 11Large burns 7Magnesium sulfate 11Magnesium, serum 11Medical treatment 7

blisters 7calcium gluconate gel 7, Fcalcium gluconate

5% injections 8, Fconcentrated HF 8, Fdebridement 7dilute HF 7, Feye 11, FIngestion 12, FInhalation 12, Fpain relief 7Quick Reference Fskin burns 7, FZephiran Soaks 7, F

Nails 9Nebulizer 7, 12, 14NIOSH 4OSHA 4Oxygen 12Pain relief 3, 7, 8Permissible Exposure Limit 4Preventative Measures *Primary excision 11Proparacaine 6Pulmonary edema 4, 12

16

Quaternary ammonium compounds 7

Quick reference to treatment FReferences 12Saline solution 15Sensitive areas,,no Zephiran 7Serum calcium determinations 11Serum magnesium 11Skin contact 2

first aid 5medical treatment 7

Skin grafting 10Systemic toxicity 2, 3

absorption and metabolic effects 11

hemodialysis 11treatment 11

Tetany 11Tetracaine HCl 6, 15Toxicity

acute 2chronic 4eye 4inhalation 4skin contact 2systemic 2, 3

Urine fluorides 5Uses of HF 2Zephiran 15

1:750 solution 1417% solution 14about 14dilution 14first aid 5, 6medical treatment 7ordering 14

* Inside Front CoverF Foldout

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Honeywell

Our Vision

Our Commitment

Our Values

We will be one of the world’s premier companies,distinctive and successful in everything we do.

We will become a Total Quality Company by continuouslyimproving all our work processes to satisfy our internaland external customers.

Customers Our first priority is to satisfy customers

Integrity We are committed to the highest level ofethical conduct wherever we operate. We obey alllaws, produce safe products, protect the environment,practice equal employment, and are socially responsible.

People We help our fellow employees improve theirskills, encourage them to take risks, treat them fairly,and recognize their accomplishments, stimulating themto approach their jobs with passion and commitment.

Teamwork We build trust and worldwide teamworkwith open, candid communications up and down andacross our organization. We share technologies and bestpractices, and team with our suppliers and customers.

Speed We focus on speed for competitive advantage.We simplify processes and compress cycle times.

Innovation We accept change as the rule, not theexception, and drive it by encouraging creativity andstriving for technical leadership.

Performance We encourage high expectations,set ambitious goals, and meet our financial and othercommitments. We strive to be the best in the world.

Honeywell Fluorine ProductsProduct Stewardship Policy

Honeywell, in its continuing quest to be one of the world’s premier companies,subscribes to the Chemical Manufacturer’s Association’s “Responsible Care” Program.Product Stewardship is an integral part of that program and enables us to makehealth, safety and environmental protection a key part of all product related activities.

At Honeywell Fluorine Products, Product Stewardship encompasses all aspects ofthe product life cycle including design, manufacture, marketing, distribution, userecycling and disposal of our products. It involves working closely with our world-wide customers, suppliers, employees, distributors, wholesalers, tollers and contrac-tors to meet these goals. Product Stewardship is not a one time effort designed onlyto comply with regulations, but a continuous, long-term process that is appliedthroughout all of our business operations.

Fluorine Products is committed to:

● Giving high priority to health, safety and environmental considerations in our business planning encompassing proper selection of raw materials through Materials Management, Customer Linked Commercialization for all new products,processes and waste materials and our Customer Linked Manufacturing endeavors to improve existing operation processes.

● Guiding customers on the safe use, transportation and disposal of our products.

● Reporting promptly to customers, employees, government officials and the public of any new information on product related issues.

● Providing technical assistance on various uses and applications for our products.

● Sharing pertinent information and experiences with others who produce, handle,use, transport or dispose of our products.

Product Stewardship is a part of everyone’s job. By each employee supporting andimplementing the Product Stewardship practices outlined above, we will moveahead of our competition, be viewed by our customers as a premier partner andcreate growth for Fluorine Products.

Fluorine Products

Industrial Fluorines G525-521 5-00©Honeywell Printed in U.S.A.

HF Products

FOR ADDITIONALINFORMATIONFor additional assistance, including techni-cal information covering all aspects ofhydrofluoric acid, safe handling, use anddisposal write:

HoneywellIndustrial FluorinesP.O. Box l053101 Columbia RoadMorristown, NJ 07962-1053

FAX: 973-455-6141

In the event of an emergency with thisproduct, call the 24-hour Honeywell emer-gency telephone number: 800 707-4555 or602-365-4980

To place an order, obtain prices or productavailablitiy information, call toll free:

● From within the continental United States 800-522-8001

973-455-6300

● From any location in Canada800-553-9749

All statements, information, and data given herein are believedto be accurate and reliable but are presented without guaranty,warranty, or responsibility of any kind, express or implied.Statements or suggestions concerning possible use of ourproducts are made without representation or warranty that anysuch use is free of patent infringement and are not recommen-dations to infringe any patent. The user should not assumethat all medical and first aid measures are indicated or thatother measures may not be required.