Endgames Case Review

Ongoing effects of burns

BMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i1104 (Published 15 March 2016) Cite this as: BMJ 2016;352:i1104
  1. Karan Jolly, core surgical trainee year 21,
  2. James Andrew Douglas, surgical teaching fellow2,
  3. Nathan Hamnett, burns and plastic surgery registrar1,
  4. Ibrahim Natalwala, core surgical trainee year 21,
  5. William J C van Niekerk, consultant plastic, reconstructive, and burn surgeon1
  1. 1Queen Elizabeth Hospital Birmingham, Birmingham B15 2TH, UK
  2. 2Royal Wolverhampton Hospital, Wolverhampton, UK
  1. Correspondence to: K Jolly kjolly{at}nhs.net

A 29 year old man presented with isolated injury to both lower limbs after accidental spillage of caustic soda 20 hours earlier at the metal cleaning factory where he worked. Despite removing soaked protective clothing at the time of exposure, a lack of irrigation of the area resulted in progressive development of skin changes (figs 1 and 2) and associated pain to the affected limbs. This prompted him to attend his local emergency department.

Fig 1 Patient’s right leg

Fig 2 Patient’s left leg


  1. What type of injury is this?

  2. What is the size and depth of the burn?

  3. What are the different types of burns?

  4. How would you manage this patient?


1. What type of injury is this?

Short answer

Bilateral lower limb alkali chemical burns caused by exposure to caustic soda. The injury is circumferential and of heterogeneous depth.


This injury is consistent with chemical burns caused by caustic soda (sodium hydroxide), which can occur in industrial and domestic settings. Other chemicals that cause such burns include:

  • Wet cement (calcium hydroxide and calcium silicates)

  • Bleach (sodium hypochlorite and calcium hypochlorite)

  • Oven cleaners (sodium hydroxide and potassium hydroxide)

  • Fertilisers (ammonium nitrate, monocalcium phosphate, and monoammonium phosphate)

  • Drain cleaners (alkali cleaners may contain sodium hydroxide or sodium hypochlorite, acidic cleaners usually contain sulphuric acid)

  • Sulphuric acid and hydrochloric acid

  • Hydrofluoric acid

  • White phosphorus (tetraphosphorus, P4)—mostly encountered in battle zones, industrial accidents, and firework injuries.

Although exposure mainly causes cutaneous and ocular burns, some chemicals can have systemic effects if absorbed or inhaled. Chemical burns account for about 13% of all burns related mortality and 3.3% of all burns in the United Kingdom.1

An important feature of chemical burns is the tendency for the burning process to persist despite macroscopic source removal and resuscitation. Chemicals continue to denature proteins and damage tissues for as long as traces of …

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