Medical Management Guidelines for Hydrogen Fluoride
(HF)
CAS# 7664-39-3
UN# 1052 (anhydrous), 1790 (solution)
PDF Versionpdf icon[84.6 KB]
Synonyms include hydrogen fluoride,
fluoric acid, hydrofluoride, hydrofluoric acid, and fluorine monohydride.
- Victims exposed only to hydrogen fluoride vapor do not pose substantial risks of secondary contamination; however, victims whose clothing or skin is contaminated with hydrogen fluoride liquid or solution can secondarily contaminate response personnel by direct contact or through off-gassing vapor.
- Hydrofluoric acid is a serious systemic poison. It is highly corrosive. Its severe and sometimes delayed health effects are due to deep tissue penetration by the fluoride ion. The surface area of the burn is not predictive of its effects.
- Most hydrogen fluoride exposures occur by inhalation of the gas and dermal contact with hydrofluoric acid.
General Information
Description
Hydrogen fluoride is a colorless,
fuming liquid or gas with a strong, irritating odor. It is
usually shipped in steel cylinders as a compressed gas.
Hydrogen fluoride readily dissolves in water to form
colorless hydrofluoric acid solutions; dilute solutions are
visibly indistinguishable from water. It is present in a
variety of over-the-counter products at concentrations of 6%
to 12%.
Although hydrofluoric acid is weak
compared with most other mineral acids, it can produce
serious health effects by any route of exposure. These
effects are due to the fluoride ion's aggressive,
destructive penetration of tissues.
Routes of Exposure
Inhalation
Inhalation hazards result not only from
exposure to hydrogen fluoride gas, but also from fumes
arising from concentrated hydrogen fluoride liquid. Hydrogen
fluoride gas is lighter than air. Even fairly low airborne
concentrations of hydrogen fluoride produce rapid onset of
eye, nose, and throat irritation. Hydrogen fluoride has a
strong irritating odor that is discernable at concentrations
of about 0.04 ppm, which is considerably less than the OSHA
PEL of 3 ppm. Therefore, odor generally provides adequate
warning of hazardous concentrations.
Children exposed to the same levels of
hydrogen fluoride as adults may receive larger doses because
they have greater lung surface area:body weight ratios and
increased minute volumes:weight ratios. Children may also be
more vulnerable to corrosive agents than adults because of
the relatively smaller diameter of their airways.
Skin/Eye Contact
Most hydrogen fluoride exposures occur
by cutaneous contact with the aqueous solution. The fluoride
ion, which penetrates tissues deeply, can cause both local
cellular destruction and systemic toxicity and is readily
absorbed through both intact and damaged skin. Hydrogen
fluoride is irritating to the skin, eyes, and mucous
membranes.
Children are more vulnerable to
toxicants absorbed through the skin because of their
relatively larger surface area:body weight ratio.
Ingestion
Ingestion of even a small amount of
hydrofluoric acid is likely to produce systemic effects and
may be fatal.
Sources/Uses
Hydrogen fluoride is primarily an
industrial raw material. It is produced commercially by
action of sulfuric acid on the mineral fluorspar. Hydrogen
fluoride is used in separating uranium isotopes, as a
cracking catalyst in oil refineries, and for etching glass
and enamel, removing rust, and cleaning brass and crystal.
It also is used in manufacturing silicon semiconductor chips
and as a laboratory reagent. Some consumer products that may
contain hydrogen fluoride include automotive cleaning
products (e.g., for aluminum and chrome), rust inhibitors,
rust removers (e.g., for ceramic tubs, sinks, and fabrics),
and water-spot removers.
Standards and Guidelines
OSHA PEL (permissible exposure limit) =
3 ppm (averaged over an 8 hour work shift)
NIOSH IDLH (immediately dangerous to
life or health) = 30 ppm
AIHA ERPG-2 (emergency response
planning guideline) (maximum airborne concentration below
which it is believed that nearly all individuals could be
exposed for up to 1 hour without experiencing or developing
irreversible or other serious health effects or symptoms
which could impair an individual's ability to take
protective action) = 20 ppm
Physical Properties
Description: Colorless gas or
fuming liquid; weak solutions have the appearance of water.
Warning properties:
Disagreeable, pungent odor at 0.04 ppm; irritation of eyes
and throat at 3 ppm.
Molecular weight: 20.0 daltons
Boiling point (760 mm Hg): 68°
(20°C)
Freezing point: -118° (-83°)
Specific gravity: 1 for liquid
at 67°F (20°C) (water = 1)
Vapor pressure (68°F): 783 mm Hg
Gas density: 0.7 (air = 1)
Water solubility: Miscible with
water with release of heat
Flammability: Nonflammable
Incompatibilities
Hydrogen fluoride reacts with metals
and water or steam. It will attack glass and concrete.
Health Effects
- Hydrogen fluoride is irritating to the skin, eyes, and
mucous membranes, and inhalation may cause respiratory
irritation or hemorrhage. Systemic effects can occur from
all routes of exposure and may include nausea, vomiting,
gastric pain, or cardiac arrhythmia. Symptoms may be delayed
for several days, especially in the case of exposure to
dilute solutions of hydrogen fluoride (less than 20%).
- Hydrofluoric acid is corrosive and also causes
destruction of deep tissues when fluoride ions penetrate the
skin. Absorption of substantial amounts of hydrogen fluoride
by any route may be fatal.
- The systemic effects of hydrogen fluoride are due to
increased fluoride concentrations in the body which can
change the levels of calcium, magnesium, and potassium in
the blood.
- Hypocalcemia can cause tetany, decreased myocardial
contractility, and possible cardiovascular collapse while
hyperkalemia has been suggested to cause ventricular
fibrillation leading to death.
Acute Exposure
The toxic effects of hydrogen fluoride
are due primarily to the fluoride ion, which is able to
penetrate tissues and bind intracellular calcium and
magnesium. This results in cell destruction and local bone
demineralization. Systemic deficiency of calcium and
magnesium and excess of potassium can occur. Hypocalcemia
can cause tetany, decreased myocardial contractility, and
possible cardiovascular collapse, while hyperkalemia has
been suggested to cause ventricular fibrillation leading to
death. The adverse action of the fluoride ion may progress
for several days before symptoms appear.
Children do not always respond to
chemicals in the same way that adults do. Different
protocols for managing their care may be needed.
Respiratory
Inhaled hydrogen fluoride mist or vapor
initially affects the nose, throat, and eyes. Mild clinical
effects include mucous-membrane irritation and inflammation,
cough, and narrowing of the bronchi. Severe clinical effects
include almost immediate narrowing and swelling of the
throat, causing upper airway obstruction. Lung injury may
evolve rapidly or may be delayed in onset for 12 to 36
hours. Accumulation of fluid in the lungs, constriction of
the bronchi, and partial or complete lung collapse can
occur. Pulmonary effects can result even from splashes on
the skin.
Children may be more vulnerable to corrosive agents than
adults because of the relatively smaller diameter of their
airways.
Children may be more vulnerable to gas
exposure because of relatively increased minute ventilation
per kg and failure to evacuate an area promptly when
exposed.
Dermal
Depending on the concentration and
duration of exposure, skin contact may produce pain, redness
of the skin, and deep, slow-healing burns.
Acid concentrations of more than 50%
(including anhydrous hydrogen fluoride) cause immediate
severe, throbbing pain and a whitish discoloration of the
skin, which usually forms blisters. Hydrogen fluoride
solutions from 20% to 50% may produce pain and swelling,
which may be delayed up to 8 hours. Hydrogen fluoride
solutions of less than 20% cause almost no immediate pain on
contact but may cause delayed serious injury 12 to 24 hours
later.
Because of their relatively larger
surface area:body weight ratio, children are more vulnerable
to toxicants absorbed through the skin.
Ocular
Mild effects of hydrogen fluoride
exposure include rapid onset of eye irritation. More severe
effects, which may result from even minor hydrofluoric acid
splashes, include sloughing of the surface of the eye,
swelling of various structures of the eye, and cell death
due to lack of blood supply. Potentially permanent clouding
of the eye surface may develop immediately or after several
days.
Gastrointestinal
Ingestion of hydrofluoric acid may
cause corrosive injury to the mouth, throat, and esophagus.
Inflammation of the stomach with bleeding occurs commonly.
Nausea, vomiting, diarrhea, and abdominal pain may occur.
Systemic effects are likely. An acid-base imbalance can
occur after acute ingestion. Pulmonary aspiration may lead
to respiratory complications.
Electrolyte
Exposure by any route may result in
systemic effects, namely, low levels of calcium and
magnesium and high levels of potassium in the blood. Low
blood pressure, irregular heartbeat, involuntary muscle
contractions, seizures, and death may ensue.
Potential Sequelae
Survivors of severe inhalation injury
may suffer residual chronic lung disease. Healing of skin
burns caused by concentrated hydrogen fluoride may be
prolonged, and extensive scarring may result. Fingertip
injuries are troublesome with persistent pain, bone loss,
and nail-bed injury. After eye exposure, prolonged or
permanent visual defects, blindness, or total eye
destruction may occur. Hydrogen fluoride ingestion may
damage the esophagus and stomach progressively for weeks.
Persistent narrowing of the esophagus may result.
Chronic Exposure
Repeated ingestion of more than 6 mg of
fluoride per day may result in mottling of the teeth in
developing children, accumulation of fluoride in the bone,
and hardening of the bone in adults and children. Long-term
hydrogen fluoride exposure has been reported to damage the
kidneys and liver.
Chronic exposure may be more serious
for children because of their potential longer latency
period.
Carcinogenicity
Hydrogen fluoride has not been
classified for carcinogenic effects.
Reproductive and Developmental Effects
Hydrogen fluoride is not included in
Reproductive and Developmental Toxicants, a 1991
report published by the U.S. General Accounting Office (GAO)
that lists 30 chemicals of concern because of widely
acknowledged reproductive and developmental consequences.
Fluoride crosses the placenta, and at low doses is thought
to be essential for normal fetal development in humans. It
is rarely excreted in breast milk. There have been rare
cases of mottling of deciduous teeth in infants born to
mothers who had high daily intakes of fluoride during
pregnancy; skeletal abnormalities are considered unlikely.
No reproductive effects due to hydrogen fluoride are known.
Prehospital Management
- Victims exposed only to hydrogen fluoride gas or vapor
do not pose substantial risks of secondary contamination to
rescuers. However, victims whose clothing or skin is
contaminated with hydrogen fluoride liquid, solution, or
condensed vapor can secondarily contaminate response
personnel by direct contact or through off-gassing vapor.
- Hydrogen fluoride is irritating to the skin, eyes, and
mucous membranes. It is a corrosive chemical that can cause
immediate or delayed onset of deep, penetrating injury.
Systemic effects can occur from all routes of exposure and
include pulmonary edema, nausea, vomiting, gastric pain, and
cardiac arrhythmia. Absorption of fluoride ions can cause
hypocalcemia, hypomagnesemia, and hyperkalemia, which can
result in cardiac arrest.
- Rapid decontamination is critical. Calcium-containing
gels, solutions, and medications are used to neutralize the
effects of hydrogen fluoride. Patients may require support
of respiratory and cardiovascular functions.
Hot Zone
Rescuers should be trained and
appropriately attired before entering the Hot Zone. If the
proper equipment is not available, or if rescuers have not
been trained to use it, assistance should be obtained from a
local or regional HAZMAT team or other properly equipped
response organization.
Rescuer Protection
Hydrogen fluoride is corrosive to the
respiratory tract and skin and is a serious systemic poison.
Respiratory Protection:
Positive-pressure, self-contained breathing apparatus (SCBA)
is recommended in response situations that involve exposure
to potentially unsafe levels of hydrogen fluoride.
Skin Protection:
Chemical-protective clothing is recommended because skin
exposure to either vapor or liquid may cause severe burns
and systemic toxicity.
ABC Reminders
Quickly access for a patent airway,
ensure adequate respiration and pulse. If trauma is
suspected, maintain cervical immobilization manually and
apply a cervical collar and a backboard when feasible.
Victim Removal
If victims can walk, lead them out of
the Hot Zone to the Decontamination Zone. Victims who are
unable to walk may be removed on backboards or gurneys; if
these are not available, carefully carry or drag victims to
safety.
Consider appropriate management of
chemically contaminated children, such as measures to reduce
separation anxiety if a child is separated from a parent or
other adult.
Decontamination Zone
Victims exposed only to hydrogen
fluoride gas or vapor who have no skin or eye irritation do
not need decontamination. They may be transferred
immediately to the Support Zone. Other patients will require
decontamination as described below.
Rescuer Protection
If exposure levels are determined to be
safe, decontamination may be conducted by personnel wearing
a lower level of protection than that worn in the Hot Zone
(described above).
ABC Reminders
Quickly access for a patent airway,
ensure adequate respiration and pulse. Stabilize the
cervical spine with a collar and a backboard if trauma is
suspected. Administer supplemental oxygen as required.
Assist ventilation with a bag-valve-mask device if
necessary.
Basic Decontamination
Rapid decontamination is critical.
Victims who are able may assist with their own
decontamination. Quickly remove and double-bag contaminated
clothing while flushing exposed skin and hair with plain
water or saline for at least 30 minutes. Cover exposed skin
with a calcium-containing slurry or gel (2.5 g calcium
gluconate in 100 mL of water-soluble lubricant, such as K-Y
Jelly, or 1 ampule of 10% calcium gluconate per ounce of K-Y
Jelly).
Use caution to avoid hypothermia when
decontaminating children or the elderly. Use blankets or
warmers when appropriate.
Irrigate exposed or irritated eyes with
plain water or saline for at least 20 minutes. Remove
contact lenses if easily removable without additional trauma
to the eye. Continue irrigation during other decontamination
procedures. Use of ophthalmic anesthetic eyedrops will
increase patient comfort and efficiency of irrigation.
In case of hydrofluoric acid ingestion,
do not induce emesis. Do not administer activated
charcoal. Victims who are conscious and able to swallow
should be given 4 to 8 ounces of water or milk. If
available, also give 2 to 4 ounces of an antacid containing
magnesium (e.g., Maalox, milk of magnesia) or calcium (e.g.,
Tums).
Consider appropriate management of
chemically contaminated children, such as measures to reduce
separation anxiety if a child is separated from a parent or
other adult. If possible, seek assistance from a child
separation expert.
Transfer to Support Zone
As soon as basic decontamination is
complete, move the victim to the Support Zone.
Support Zone
Be certain that victims have been
decontaminated properly (see Decontamination Zone
above). Victims who have undergone decontamination or have
been exposed only to vapor generally pose no serious risks
of secondary contamination. In such cases, Support Zone
personnel require no specialized protective gear.
ABC Reminders
Quickly access for a patent airway. If
trauma is suspected, maintain cervical immobilization
manually and apply a cervical collar and a backboard when
feasible. Ensure adequate respiration and pulse. Administer
supplemental oxygen as required and establish intravenous
access if necessary. Place on a cardiac monitor. Monitor ECG
for prolonged Q-T interval or QRS duration.
Additional Decontamination
Continue flushing exposed skin for 15
minutes. Do not inject or use calcium chloride for
treating skin burns. It will cause extreme pain and may
further injure tissues.
Treat the burned areas with calcium
gluconate gel (2.5 g in 100 mL water-soluble lubricant, such
as K-Y Jelly, or 1 ampule of 10% calcium gluconate per ounce
of K-Y Jelly). Initially, the health care provider should
wear rubber or latex gloves to prevent secondary
contamination. Continue this procedure until pain is
relieved or more definitive care is rendered.
If the eyes are still irritated,
continue irrigating with water or saline. Remove contact
lenses if present and easily removable without additional
trauma. Continue irrigating the eyes with saline during
transport. Use of ophthalmic anesthetic eyedrops will
increase patient comfort and efficiency of irrigation.
In cases of ingestion, do not induce
emesis. Do not administer activated charcoal. Victims
who are conscious and able to swallow should be given 4 to 8
ounces of water or milk. If available, also give 2 to 4
ounces of an antacid containing magnesium (e.g., Maalox,
milk of magnesia) or calcium (e.g., Tums).
Advanced Treatment
In cases of respiratory compromise
secure airway and respiration via endotracheal intubation.
If not possible, perform cricothyroidotomy if equipped and
trained to do so.
Treat patients who have bronchospasm
with aerosolized bronchodilators. The use of bronchial
sensitizing agents in situations of multiple chemical
exposures may pose additional risks. Consider the health of
the myocardium before choosing which type of bronchodilator
should be administered. Cardiac sensitizing agents may be
appropriate; however, the use of cardiac sensitizing agents
after exposure to certain chemicals may pose enhanced risk
of cardiac arrhythmias (especially in the elderly). Hydrogen
cyanide poisoning is not known to pose additional risk
during the use of bronchial or cardiac sensitizing agents.
Consider racemic epinephrine aerosol
for children who develop stridor. Dose 0.25-0.75 mL of 2.25%
racemic epinephrine solution in 2.5 cc water, repeat every
20 minutes as needed, cautioning for myocardial variability.
Patients who are comatose, hypotensive,
or are having seizures or cardiac arrhythmias should be
treated according to advanced life support (ALS) protocols.
Hypocalcemia (manifested by tetany and
dysrhythmias) is probable after ingestion of even small
amounts of hydrogen fluoride. With medical consultation,
treat hypocalcemia with intravenous injections of a 10%
solution of calcium gluconate.
For inhalation victims, 2.5% calcium
gluconate (2.5 g of calcium gluconate in 100 mL of water or
25 mL of 10% calcium gluconate diluted to 100 mL with water)
administered by nebulizer with oxygen has been recommended,
but the success of this therapy has not been demonstrated.
Transport to Medical Facility
Only decontaminated patients or
patients not requiring decontamination should be transported
to a medical facility. "Body bags" are not recommended.
Report to the base station and the
receiving medical facility the condition of the patient,
treatment given, and estimated time of arrival at the
medical facility.
If hydrofluoric acid has been ingested,
prepare the ambulance in case the victim vomits toxic
material. Have ready several towels and open plastic bags to
quickly clean up and isolate vomitus.
Multi-Casualty Triage
Consult with the base station physician
or regional poison control center for advice regarding
triage of multiple victims.
Persons who have had only minor or
brief exposure to hydrogen fluoride gas or vapor and are
initially asymptomatic are not likely to develop
complications. After their names, addresses, and telephone
numbers are recorded, patients may be released from the
scene with follow-up instructions (see Patient
Information Sheet below).
Inhalation Exposure
Immediately transport to a medical
facility those patients who have inhaled hydrogen fluoride
and have upper respiratory irritation or other acute
symptoms.
Skin/Eye Contact
All persons who have eye exposure or
serious skin exposure (i.e., fingertip exposure or skin
exposure greater than the total surface area of the palm) or
any evidence of burns (e.g., erythema, pain, or blisters)
should be transported to a hospital as soon as possible.
Continue skin and eye irrigation or treatment during
transport. Patients who have had even mild skin or eye
contact with hydrogen fluoride should be brought to the
attention of a physician as soon as possible because they
may have delayed pain and systemic complications.
Ingestion Exposure
In cases of ingestion, patients should
be transported to a hospital without delay. Watch patients
carefully because systemic effects are likely to occur.
Emergency Department Management
- Patients exposed only to hydrogen fluoride gas or vapor
do not pose substantial risks of secondary contamination to
personnel outside the Hot Zone. However, patients whose
clothing or skin is contaminated with hydrogen fluoride
liquid or solution can secondarily contaminate personnel by
direct contact or through off-gassing vapor.
- Hydrogen fluoride is a corrosive chemical that can cause
deep, penetrating injury. Absorption of fluoride ions can
result in hypocalcemia and cardiac arrest. Hypocalcemia
should be considered a risk in all instances of inhalation
or ingestion and whenever skin burns exceed 25 square inches
(an area about the size of the palm).
- Because of hydrogen fluoride's rapid skin penetration
and the serious toxicity of the fluoride ion, rapid
decontamination is critical. Calcium-containing gels,
solutions, and medications can be used to neutralize the
fluoride ion. The intense pain of hydrogen fluoride burns
should not be suppressed with local anesthetics because the
degree of pain is an indicator of treatment efficacy.
Treatment may also include support of respiratory and
cardiovascular functions.
Decontamination Area
Previously decontaminated patients and
patients exposed only to hydrogen fluoride gas or vapor who
have no skin or eye irritation may be transferred
immediately to the Critical Care Area. Other patients will
require decontamination as described below.
Because coming in contact with hydrogen
fluoride-soaked clothing or skin can cause burns, ED
personnel should don chemical resistant jumpsuits (e.g., of
Tyvek or Saranex) or butyl rubber aprons, multiple layers of
latex gloves, and eye protection.
Be aware that use of protective
equipment by the provider may cause fear in children,
resulting in decreased compliance with further management
efforts.
Because of their relatively larger
surface area:body weight ratio, children are more vulnerable
to toxicants absorbed through the skin. Also, emergency room
personnel should examine children's mouths because of the
frequency of hand-to-mouth activity among children.
ABC Reminders
Evaluate and support airway, breathing,
and circulation. In cases of respiratory compromise secure
airway and respiration via endotracheal intubation. If not
possible, surgically create an airway.
Treat patients who have bronchospasm
with aerosolized bronchodilators. The use of bronchial
sensitizing agents in situations of multiple chemical
exposures may pose additional risks. Consider the health of
the myocardium before choosing which type of bronchodilator
should be administered. Cardiac sensitizing agents may be
appropriate; however, the use of cardiac sensitizing agents
after exposure to certain chemicals may pose enhanced risk
of cardiac arrhythmias (especially in the elderly). Hydrogen
cyanide poisoning is not known to pose additional risk
during the use of bronchial or cardiac sensitizing agents.
Consider racemic epinephrine aerosol
for children who develop stridor. Dose 0.25-0.75 mL of 2.25%
racemic epinephrine solution in 2.5 cc water, repeat every
20 minutes as needed, cautioning for myocardial variability.
Patients who are comatose,
hypotensive, or are having seizures or cardiac arrhythmias
should be treated in the conventional manner.
Basic Decontamination
Rapid skin decontamination is
critical. Patients who are able may assist with their
own decontamination. If the patient's clothing is wet with
hydrogen fluoride, remove and double-bag the clothing while
flushing the skin with water (preferably under a shower).
Flush exposed skin for at least 20 minutes. Use caution to
avoid hypothermia when decontaminating children or the
elderly. Use blankets or warmers when appropriate.
Flush exposed eyes with plain water or
saline for at least 20 minutes. Remove contact lenses if
present and easily removable without additional trauma to
the eye. Continue irrigation while transporting the patient
to the Critical Care Area. An ophthalmic anesthetic, such as
0.5% tetracaine, may be necessary to alleviate
blepharospasm, and lid retractors may be required to allow
adequate irrigation under the eyelids.
In cases of ingestion, do not induce
emesis. Do not administer activated charcoal. If it has
not been given previously and the patient is alert and able
to swallow, administer 4 to 8 ounces of water. (More
information is provided in Ingestion Exposure under
Critical Care Area below.)
Critical Care Area
Be certain that appropriate
decontamination has been carried out (see Decontamination
Area above).
ABC Reminders
Evaluate and support airway, breathing,
and circulation as in ABC Reminders above. Children
may be more vulnerable to corrosive agents than adults
because of the relatively smaller diameter of their airways.
Establish intravenous access in seriously ill patients if
this has not already been done.
Patients who are comatose, hypotensive,
or are having seizures or cardiac arrhythmias should be
treated in the conventional manner.
Monitor heart, renal, and liver
functions. Hypocalcemia may cause prolonged Q-T interval and
cardiac rhythm abnormalities.
Inhalation Exposure
Calcium gluconate (2.5 grams of calcium
gluconate in 100 mL of water or 25 mL of 10% calcium
gluconate diluted to 100 mL with water) may be administered
with oxygen by nebulizer to victims who have severe
respiratory distress.
Pulmonary edema or edema of the upper
airway may occur. Observe the patient for at least 24 hours
and monitor with repeated chest examinations, blood gas
determinations, and other appropriate tests. Follow up as
clinically indicated.
Skin Contact
A burn specialist or plastic surgeon
should be consulted early in the treatment of fluoride burns.
Because of their relatively larger
surface area:body weight ratio, children are more vulnerable
to toxicants absorbed through the skin.
If blisters have formed, they should be
opened and drained and debrided of necrotic tissue before
treatment; early debridement may facilitate healing.
Do not inject calcium chloride to
treat skin burns. It will cause extreme pain and may
further injure tissues.
Treat the burned area with calcium
gluconate gel (2.5 grams in 100 mL water-soluble lubricant,
such as K-Y Jelly) until the pain is relieved. If used as
definitive treatment, the gel should be applied 4 to 6 times
daily for 3 to 4 days. Initially, health care providers
should wear rubber gloves to protect their fingers from
secondary contamination. If some relief of pain is not
obtained within 30 to 60 minutes, consider calcium gluconate
injections.
Subungual (under the nail) burns often
do not respond to immersion treatment. The treatments for
hand burns require expert assistance; consult a poison
center, medical toxicologist, or hand surgeon. Care must be
used because multiple injections into the fingers can lead
to pressure necrosis. It will be necessary to split or
remove the nail.
Large burns or deeply penetrating burns
(i.e., from delayed treatment or exposure to hydrogen
fluoride concentrations greater than 50%) may require
injections of sterile aqueous calcium gluconate into and
around the burned area. The recommended dose is to inject up
to 0.5 mL of 10% calcium gluconate solution per cm2 of
affected skin surface using a small-gauge needle (#30). No
local infiltration of anesthetic should be used, but in the
case of severe burns, regional or general anesthesia may be
considered. Injection may not be feasible in the case of
burns to the fingers; in such cases, intra-arterial infusion
should be considered.
Intra-arterial calcium gluconate has
been found to be effective for the treatment of burned
digits and upper extremities. The radial artery has been
preferentially used, with the brachial artery used if there
is incomplete anastomotic flow between the radial and ulnar
circulations. The initial dosage is 10 mL of 10% calcium
gluconate diluted with 40 mL D5W given intra-arterially over
4 hours. If pain is unrelieved, 20% concentrations have been
used. After the first dose, the infusion can be stopped, but
the line should be maintained so that further doses can be
infused if pain recurs. Once the patient has been pain-free
for 4 hours, the catheter can be removed. Although
anesthesia can be used, it is not recommended since it
invalidates the pain relief which is a titration endpoint
for effective treatment.
Eye Contact
Immediate consultation with an
ophthalmologist is indicated.
Do not use oils, salves, or
ointments for injured eyes. Do not use the gel form of
calcium gluconate in eyes, as described for skin treatment.
Irrigate exposed eyes with 1 to 2 L of
plain water or saline. Administering drops of a 1% aqueous
solution of calcium gluconate (50 mL of 10% solution in 450
mL of sterile saline) has also been suggested as a possible
therapy. After irrigation, the pH of the eye should be
checked and a complete ophthalmic examination should be
carried out.
A topical anesthetic can minimize the
tendency for eyelid closure and facilitate irrigation. One
or two drops of proparacaine or tetracaine will usually
provide rapid-onset ocular anesthesia for 20 minutes to an
hour. If exposure was minor, perform visual acuity testing.
Examine the eyes for corneal damage and treat appropriately.
Ingestion Exposure
Do not give emetics and do not
administer activated charcoal. If the patient is conscious
and alert, and treatment has not been administered
previously, immediately give 4 to 12 ounces of water to
dilute the acid. Orally administer a one-time dose of
several ounces of Mylanta, Maalox, or milk of magnesia; the
magnesium in these products may act chemically to bind the
fluoride in the stomach. Do not give sodium bicarbonate to
neutralize acid because it can cause burns.
Consider endoscopy to evaluate the
extent of gastrointestinal-tract injury. Extreme throat
swelling may require endotracheal intubation or
cricothyroidotomy. Gastric lavage is useful in certain
circumstances to remove caustic material and prepare for
endoscopic examination. Consider gastric lavage with a small
nasogastric tube if: (1) a large dose has been ingested; (2)
the patient's condition is evaluated within 30 minutes; (3)
the patient has oral lesions or persistent esophageal
discomfort; and (4) the lavage can be administered within 1
hour of ingestion. Care must be taken when placing the
gastric tube because blind gastric-tube placement may
further injure the chemically damaged esophagus or stomach.
Because children do not ingest large
amounts of corrosive materials, and because of the risk of
perforation from NG intubation, lavage is discouraged in
children unless performed under endoscopic guidance.
Toxic vomitus or gastric washings
should be isolated (e.g., by attaching the lavage tube to
isolated wall suction or another closed container).
Systemic Toxicity
Treat hypocalcemia using intravenous
10% calcium gluconate infusions with doses of 0.1 to 0.2
mL/kg up to 10 mL. Infusions can be repeated until serum
calcium, ECG, or symptoms improve. Calcium levels should be
checked hourly. Treat hypomagnesemia with 2 to 4 mL of 50%
of magnesium sulfate intravenously over 40 minutes.
Laboratory Tests
Routine laboratory studies for all
exposed patients include CBC, glucose, and electrolyte
determinations. Patients exposed to hydrogen fluoride should
also have serum calcium, potassium, and magnesium levels
monitored. Chest radiography and pulse oximetry (or ABG
measurements) may be useful for patients exposed through
inhalation.
Disposition and Follow-up
Patients in whom treatment fails to
diminish pain and those who have respiratory distress,
ingestion exposure, fingertip or eye burns, or substantial
skin burns should be admitted to an intensive care unit and
watched carefully for 24 hours. (Substantial skin burns are
those covering an area greater than the palm of a hand, and
causing skin change, or producing pain within 1 hour of
exposure.) ECG monitoring may help determine treatment need
and effectiveness.
Patient Release
Patients who have eye exposure who have
no signs of irritation after treatment do not require
hospitalization.
Patients in the ED who have burns
covering less than an area equivalent to the palm of the
hand and who have normal serum calcium levels who have
responded to treatment can be discharged for outpatient
follow-up after remaining stable for at least 6 hours. They
should be advised to seek medical care promptly if pain
recurs (see the Hydrogen Fluoride-Patient Information
Sheet).
Follow-up
Obtain the name of the patient's
primary care physician so that the hospital can send a copy
of the ED visit to the patient's doctor.
Survivors of a serious exposure should
be evaluated for damage to the lungs and heart. Patients who
have serious systemic hydrogen fluoride poisoning may be at
risk for respiratory sequelae and should be monitored for
several weeks to months. Healing of skin burns may be
prolonged and eye exposure can lead to permanent damage.
Ingestion may produce progressive damage to the stomach and
esophagus for weeks after exposure and may result in
persistent narrowing of the esophagus.
Patients who have corneal injuries
should be reexamined within 24 hours.
Reporting
If a work-related incident has
occurred, you may be legally required to file a report;
contact your state or local health department.
Other persons may still be at risk in
the setting where this incident occurred. If the incident
occurred in the workplace, discussing it with company
personnel may prevent future incidents. If a public health
risk exists, notify your state or local health department or
other responsible public agency. When appropriate, inform
patients that they may request an evaluation of their
workplace from OSHA or NIOSH. See Appendices III and IV for
a list of agencies that may be of assistance.
Patient Information Sheet
This handout provides information and
follow-up instructions for persons who have been exposed to hydrogen fluoride.
Print instructions only.pdf icon[PDF - 44.6 KB]
What is hydrogen fluoride?
Hydrogen fluoride is a colorless, highly irritating gas with a pungent odor. It dissolves easily in water to form hydrofluoric acid. Consumer products that contain hydrogen fluoride include rust removers, water-spot removers, and chrome cleaners.
What immediate health effects can be caused by exposure to hydrogen fluoride?
Most poisonings occur when hydrogen
fluoride gets on the skin or in the eyes. Concentrated
hydrogen fluoride solutions can cause severe, deep, and
disfiguring burns. Absorption of the chemical into the body can cause the heart to beat irregularly, leading to death. Exposure to dilute solutions (less than 20% concentration) may cause few or no symptoms at first, but may cause severe pain later. Drinking hydrofluoric acid can cause severe burns to the throat and stomach and even death. Injury can also occur from breathing hydrogen fluoride gas or the vapor from concentrated hydrogen fluoride solutions. Breathing high concentrations of hydrogen fluoride vapor can cause rapid death from throat swelling or from chemical burns to the lungs.
Can hydrogen fluoride poisoning be treated?
Patients who have experienced serious
symptoms, such as severe or persistent coughing or skin or
eye burns, may need to be hospitalized. Calcium- or
magnesium-containing medicines may be used to treat the
skin, and doctors may inject calcium-containing medicines
into burned areas or into the blood. If hydrofluoric acid is
swallowed, a solution containing calcium or magnesium may be
given.
Are any future health effects likely to occur?
A single small exposure from which a
person recovers quickly is not likely to cause delayed or
long-term effects. After a severe exposure, you may not
notice any symptoms for up to 36 hours. Scarring may result
from skin contact with hydrogen fluoride.
What tests can be done if a person has been exposed to hydrogen fluoride?
The doctor may order blood tests, urine
tests, chest x-ray, and heart monitoring to see whether
damage has been done to the heart, lungs, or other organs.
Testing is not needed in every case. If hydrogen fluoride
contacts the eyes, the doctor may put a special dye into the
eyes and examine them with a magnifying device.
Where can more information about hydrogen fluoride be found?
More information about hydrogen
fluoride or hydrofluoric acid can be obtained from your
regional poison control center; your state, county, or local
health department; the Agency for Toxic Substances and
Disease Registry (ATSDR); your doctor; or a clinic in your
area that specializes in occupational and environmental
health. If the exposure happened at work, you may wish to
discuss it with your employer, the Occupational Safety and
Health Administration (OSHA) or the National Institute for
Occupational Safety and Health (NIOSH). Ask the person who
gave you this form for help in locating these telephone
numbers.
Follow-up Instructions
Keep this page and take it with you to
your next appointment. Follow only the instructions
checked below.
Print instructions only.pdf icon[PDF - 44.6 KB]
[ ] Call your doctor or the Emergency
Department if you develop any unusual signs or symptoms
within the next 24 hours, especially:
- difficulty breathing, shortness of breath or wheezing
- hoarseness, high-pitched voice, or difficulty speaking
- chest pain or tightness
- any skin changes, discharge, or increased pain where
skin is burned
- stomach pain, vomiting, or diarrhea
- increased pain or a discharge from exposed eyes
[ ] No follow-up appointment is
necessary unless you develop any of the symptoms listed
above.
[ ] Call for an appointment with
Dr.____ in the practice of ________.
When you call for your appointment,
please say that you were treated in the Emergency Department
at _________ Hospital by________and were advised to be seen
again in ____days.
[ ] Return to the Emergency
Department/Clinic on ____ (date) at _____ AM/PM for a
follow-up examination.
[ ] Do not perform vigorous physical
activities for 1 to 2 days.
[ ] You may resume everyday activities
including driving and operating machinery.
[ ] Do not return to work for
_____days.
[ ] You may return to work on a limited
basis. See instructions below.
[ ] Avoid exposure to cigarette smoke
for 72 hours; smoke may worsen the condition of your lungs.
[ ] Avoid drinking alcoholic beverages
for at least 24 hours; alcohol may worsen injury to your
stomach or have other effects.
[ ] Avoid taking the following
medications: ________________
[ ] You may continue taking the
following medication(s) that your doctor(s) prescribed for
you: _______________________________
[ ] Other instructions:
____________________________________
_____________________________________________________
- Provide the Emergency Department with the name and the
number of your primary care physician so that the ED can
send him or her a record of your emergency department visit.
- You or your physician can get more information on the
chemical by contacting: ____________ or _____________, or by
checking out the following Internet Web sites:
___________;__________.
Signature of patient _______________ Date ____________
Signature of physician _____________ Date ____________
Where can I get more information?
If you have questions or concerns, please contact your community or state health or environmental quality department or:
For more information, contact:
Agency for Toxic Substances and Disease Registry
Division of Toxicology and Human Health Sciences
4770 Buford Highway
Chamblee, GA 30341-3717
Phone: 1-800-CDC-INFO 888-232-6348 (TTY)
Email: Contact CDC-INFO
ATSDR can also tell you the location of occupational and environmental health clinics. These clinics specialize in recognizing, evaluating, and treating illnesses resulting from exposure to hazardous substances.