Acute chemical skin injuries in the United States: a review

Figures & data

Table 1. AAPCC NPDS data 2006–2015* Total Human Poison Exposure vs. Total Dermal Poison Exposure and %; Fatal Dermal Poison Exposures.

Year	Total Human Poison Exposures	Total Dermal Poison Exposures	% Dermal Poison Exposures	Fatal Dermal Poison Exposures
2006	2,403,537	188,848	7.50	21
2007	2,482,041	191,298	7.30	14
2008	2,491,049	188,930	7.22	22
2009	2,479,355	179,832	6.90	12
2010	2,384,825	172,318	7.23	18
2011	2,334,004	162,638	6.97	16
2012	2,275,141	159,513	7.01	17
2013	2,188,013	152,028	6.95	11
2014	2,165,142	151,796	7.01	8
2015	2,168,371	150,866	6.96	8
Totals	23,371,444	1,698.067	7.27	147

*(Bronstein et al. 2007, 2008, 2009, 2010, 2011, 2012; Mowry et al. 2013, 2014, 2015, 2016).

Table 2. Ages, numbers, and rates of fatally-injured workers. Adapted from BLS (2017a).

Age (years)	Number of fatal injuries	Fatal injury rates*
<16	12	N/A
16–17	12	N/A
18–19	50	2.1
20–24	329	2.7
25–34	758	2.3
35–44	864	2.7
45–54	1,130	3.5
55–64	1,031	4.3
65 and over	650	9.4

* Rates per 100,000 full-time worker equivalents.

Table 3. ABA data, top 10 chemical skin injury complications (ABA, 2013).

Complication	Number	% of total complications	% of patients with this complication
Cellulitis	131	16.1	2.6
Pneumonia	64	7.8	1.3
Wound infection	56	6.9	1.1
Urinary tract infection	53	6.5	1.1
Respiratory failure	52	6.4	1.0
Septicemia	42	5.1	0.8
Renal failure	26	3.2	0.5
Other blood/Systemic infection	24	2.9	0.5
Dysrhythmias	22	2.7	0.4
Other hematological complications	20	2.5	0.4

Table 4. ABA data top 10 performed procedures among chemical skin injury patients (ABA, 2013).

Procedure	Number	Percentage of total procedures (%)
Excisional debridement	2137	18.8
Other skin graft to other sites	1510	13.3
Application of other Wound dressing	798	7.0
- Skin homografting	677	6.0
- Skin heterografting	399	3.5
Venous catheterization	387	3.4
Dermal regeneration grafting	287	2.5
Fiberoptic bronchoscopy	189	1.7
Packed red blood cell transfusion	181	1.6

Table 5. Data from the 50 US States Health Departments where data were available.

State	Time period covered	Number of cases	Available descriptive information
Alaska	2012–2013	7 (with 1 fatality)	• Non-fatal injury hospitalization in infants: Burns (not further categorized) = 10.7% • Ammonia release, Sitka, AK, 06/24/2002: 7 victims (10–82 years old; median 38 years old); 3/7 with chemical skin injuries + respiratory tract effects; 1 fatality • 2012: 32 Releases of extremely hazardous substances; those that could have resulted in chemical skin injuries:   ^ Anhydrous ammonia: 23 releases (72%); 21,382 pounds   ^ Sulfuric acid: 3 releases (9%); 608 pounds   ^ Hydrofluoric acid: 1 release (3%); 40 pounds   ^ Hydrochloric acid: 1 release (3%); 4 pounds
Arizona	2008 2013	187 (Children) 63 (EMS burn cases)	• Unintentional burn and scald injuries in children aged 0–17 years   ^ 2242 total (with 4 deaths)   ^ Caustic or corrosive substances =187 cases (8%)  • EMS June Quarterly Report: AZ-PIERS, Q3 & Q4, 2012   ^ Total patients: 12,833   ^ Burns (not further classified): 63 (0.49%)
Arkansas	2000–2007 2000–2009	549 1042	• Deaths from unintentional fires/burns (burns not further characterized)   ^ 549 total cases?  • Hospitalizations from unintentional fires/burns (burns not further characterized)   ^ 1042 total cases   ^ 2007: 303 cases   ^ 2008: 305 cases   ^ 2009: 434 cases
California	2011	168	• Unintentional burn, fire/flame deaths (burns not further characterized)   ^ Total: 168 cases
Colorado	1995–2012 2001–2007	3434/ 3157 276	• Hospitalizations for fire/burns – scalds/caustic substances/hot objects (not further characterized)   ^ Crude rate = 3.9 per 100,000 population  • Hospitalizations for work-related burns (not further characterized)   ^ 2001: 44/crude rate 2.0   ^ 2002: 39/crude rate 1.7   ^ 2003: 34/crude rate 1.5   ^ 2004: 28/crude rate 1.2   ^ 2005: 54/crude rate 2.2   ^ 2006: 42/crude rate 1.7   ^ 2007: 35/crude rate 1.4   ^ Average: 39.4/crude rate 1.7  • See also below for additional 2003 data
Connecticut	1990–1998 2003–2008	148 297	• Total burns =777   ^ Chemical burns: 19% (148 cases)  • Total workplace burn injuries: 1649  • Chemical burns =18% (297 cases)
Delaware	1979–1998 1996–2005 2001 2004 2005–2009 2009	69 30 Not reported 63 Not reported 36	• Leading causes of childhood injury deaths: fire/burn (not further characterized   ^ 69 cases (6.8%)  • Leading causes of childhood injury deaths: fire/burn (not further characterized   ^ 30 cases (6.5%)  • Childhood injury report – leading causes of injury deaths: fire/burn (not further characterized   ^ 10.4%  • Trauma system registry – fire/burn/explosion/electrical (not further characterized)   ^ 63 cases (1.4%)  • Unintentional injury, suicide, and homicide mortality: fire/burn unintentional injury (not further characterized)   ^ 2.8%  • Hospital discharges: burn (not further characterized)   ^ 36 cases (0.4%)   ^ Mean length of stay: 5.6 days
Georgia	2006–2009	684	• Occupational health surveillance report: hospitalizations for work-related burns (not further characterized)   ^ 2006: 185 cases   ^ 2007: 186 cases   ^ 2008: 165 cases   ^ 2009: 149 cases   ^ Total: 684 cases
Iowa	2006 2011	Not reported 113	• Hazardous Substances Emergency Events Surveillance (Released chemicals that could have caused chemical skin injuries)   ^ Acids    ▪ Fixed facility: 26 events (10%)    ▪ Transportation: 6 events (8%)    ▪ Total: 35 events: (8%)   ^ Ammonia    ▪ Fixed facility: 108 events (39%)    ▪ Transportation: 17 events (22%)    ▪ Total: 125 events (35%)   ^ Bases    ▪ Fixed facility: 11 events (4%)    ▪ Transportation: 2 events (3%)    ▪ Total: 13 events (4%)   ^ Chemical burns    ▪ Fixed facility: 27 injuries (14.5%)    ▪ Transportation: 0 injuries    ▪ Total: 27 injuries (13.7%)   ^ Skin irritation    ▪ Fixed facility: 26 cases (14.0%)    ▪ Transportation: 3 cases (27.3%)    ▪ Total: 29 cases (14.7 %)  • Trauma service statistics summary report: burn/thermal injury (not further classified)   ^ Survivors: 111 cases   ^ Deaths: 2 cases   ^ Total cases: 113  • See below for 1999 Burn Center Data
Kansas	1995–2003 2005–2009	4,184 326	• Health statistics report: burn hospitalizations (not further characterized)   ^ Total: 4184 cases   ^ Hospitalization rates were greatest for young children and the elderly  • Unintentional injury hospital discharges: fire/burn (not further characterized)   ^ <1 y.o.: 43 cases (10%)   ^ 1–4 y.o.: 184 cases (12%)   ^ 0–14 y.o.: 326 cases (8%)  • Report on unintentional injuries in children: age-specific top 5 causes of unintentional injury emergency department visits   ^ Fire/burn (not further characterized): < 1 y.o.: 116 cases (6%)
Kentucky	1998–2000	69	• Epidemiological notes & reports: Occupational Burn Surveillance   ^ Total occupational burn cases: 430   ^ Hospitalized (of total): 32 cases (7%)   ^ Fatalities (of total): 3 cases (1 %)   ^ Chemical skin injuries: 16% (69 cases)   ^ Acid skin injuries: 17 cases (4%)
Louisiana	1998–2007 2002 2001–2007	463 732 events Not Reported	• Work-related hospitalizations: review of hospital inpatient discharge data   ^ Total burns (not further characterized): 463   ^ Deaths from burns (not further characterized): 9 cases (16.1%)  • Hazardous Substances Emergency Events Surveillance: HSEES-related injuries, fatalities, and evacuations   ^ 732 total events: 630 (88.3%) at fixed facilities; 124 (16%) during transportation   ^ 20 events with victims (65%) had only 1 victim; 95% of events had either 1 or 2 victims   ^ At fixed facilities, the most common adverse effects were chemical burns (38.9%)   ^ Acids    ▪ Total releases: 47 (39%)    ▪ Releases with victims: 4 (20%)   ^ Ammonia    ▪ Total releases: 33(2.7%)    ▪ Releases with victims: 2 (10%)   ^ Bases    ▪ Total releases: 22 (1.8%)    ▪ Releases with victims: 2 (10%)  • Hazardous Substances Emergency Events Surveillance (HSEES) system: summary report – injuries to responders during HSEES events   ^ Fixed facility: 0 cases   ^ Transportation: Chemical burns – 1 case (12.5%)   ^ Total chemical burns: 1 (2.4%)   ^ 15 events where responders were injured (with the potential for chemical skin injuries)    ▪ Ammonia: 1 event, 3 cases    ▪ Acid NOS*: 1 event, 4 cases    ▪ Phenol: 1 event, 1 case
Michigan	2006–2011 2011 2012	661 127 events 197 events	• Unintentional fatal injuries; burn, fire/flame (not further characterized)   ^ 2006: 96 cases   ^ 2007: 122 cases   ^ 2008: 119 cases   ^ 2009: 130 cases   ^ 2010: 95 cases   ^ 2011: 99 cases   ^ Total: 661 cases  • HSEES (Hazardous Substance Emergency Event Surveillance)   ^ 127 events   ^ 44 events resulted in an injury in 68 victims   ^ 10 fatalities   ^ Most frequently reported injuries were burns and trauma   ^ Fixed facilities: 115 events (90.6%)   ^ Transportation: 12 events (9%)   ^ Substances involved with the potential to cause chemical skin injuries:    ▪ Ammonia: 10 events    ▪ Hydrochloric acid: 2 events   ^ Events with 1 victim:    ▪ Fixed facility: 29 (65.9%)    ▪ Transportation: 2 (4.5%)    ▪ Total: 31 (70.4%)   ^ Events with 2 victims:    ▪ Fixed facility: 6 (13.6%)    ▪ Transportation: 2 (4.5%)    ▪ Total: 8 (18.2%)   ^ Events with 3 victims:    ▪ Fixed facility: 2 (4.5%)    ▪ Transportation: 0 (0%)    ▪ Total: 2 (4.5%)   ^ Events with >/= 4 victims:    ▪ Fixed facilities: 3 (6.8%)    ▪ Transportation: 0 (0%)    ▪ Total: 3 (6.8%)   ^ Total events/victims:    ▪ Fixed facility: 40 events; 62 victims    ▪ Transportation: 4 events; 6 victims    ▪ Total: 44 events; 68 victims   ^ Victims by population group:   ^ General population: 44.65%   ^ Employees: 27.3%   ^ Firefighters: 2.3%   ^ 10 victims died (none from chemical skin injuries)   ^ Burns (not further characterized) accounted for 26 injuries (43.3%)   ^ Chemical substances involved with the potential to cause chemical skin injuries:    ▪ Ammonia: 10 events (7.9%)    ▪ Hydrochloric acid: 2 events (1.6%)    ▪ Nitric acid: 1 event (0.8%)    ▪ Sulfuric acid: 1 event (0.8%)  • HSEES (Hazardous Substance Emergency Event Surveillance)   ^ 197 events   ^ Most frequently reported injuries were burns and trauma   ^ 164 events occurred in fixed facilities (83.2%)   ^ Substances releases in more than 1 event with the potential to cause chemical skin injuries:    ▪ Ammonia: 7 releases    ▪ Sodium hydroxide: 3 releases    ▪ Sulfuric acid: 2 releases   ^ Released substances with the potential to cause chemical skin injuries:    ▪ Ammonia: 7 releases (3.6%)    ▪ Sodium hydroxide: 3 releases (1.5%)    ▪ Sulfuric acid: 2 releases (0.5%)    ▪ Hydrochloric acid: 1 release (0.5%)    ▪ Potassium hydroxide: 1 release (0.5%)   ^ Events with 1 victim:    ▪ Fixed facility: 38 events (58.4%); 38 victims    ▪ Transportation: 5 events (7%); 5 victims    ▪ Total: 43 events (66.2%); 43 victims   ^ Events with 2 victims:    ▪ Fixed facility: 8 events (12.3%); 16 victims    ▪ Transportation: 2 events (3.1%); 4 victims    ▪ Total: 6 events (9.2%); 20 victims   ^ Events with 3 victims:    ▪ Fixed facility: 4 events (6.2%); 12 victims    ▪ Transportation: 0 events (0%); 0 victims    ▪ Total: 4 events (6.2%); 12 victims   ^ Events with >/= 4 victims:    ▪ Fixed facility: 8 events (12.3%); 45 victims    ▪ Transportation: 0 events (0%); 0 victims   ^ Total: 65 events; 120 total victims   ^ Victims by population group:    ▪ General population: 83.69%    ▪ Employees: 28.23%    ▪ Firefighters: 6.5%    ▪ Police: 3.3%   ^ 10 (8.3%) fatalities (none due to chemical skin injuries)   ^ Most common injuries were Burns (not further characterized) (47 victims; 43.5%) and trauma (27 victims; 25.0%)
Minnesota	1995–2005 2000–2010	136 560	• Environmental health information; an overview of accidental anhydrous ammonia releases   ^ Accidentally released: 459 times (∼14.4% of all HSEES releases)   ^ 25% of these events resulted in evacuations, injuries, or both (chemical burns not specifically listed)   ^ 136 persons injured during 47 releases (16.8% of all HSEES events)   ^ 391 (85%) of releases occurred at fixed facilities  • Work-related burn injuries (not further characterized)/rates (rate per 100,000 employed persons >/= 16 years of age)   ^ 2000: 76; 2.5   ^ 2001: 65; 2.4   ^ 2002: 75; 2.7   ^ 2003: 61; 2.2   ^ 2004: 61; 2.2   ^ 2005: 61; 2.2   ^ 2006: 51; 1.8   ^ 2007: 35; 1.3   ^ 2008: 38; 1.4   ^ 2009: 22; 0.8   ^ 2010: 24; 0.9   ^ Total: 560   ^ ∼ 92% were males
Missouri	2003–2009	439	• Annual number of work-related burn (not further characterized) Hospitalizations for persons age 16 and older   ^ 2003: 74   ^ 2004: 58   ^ 2005: 71   ^ 2006: 84   ^ 2007: 57   ^ 2008: 45   ^ 2009: 50   ^ Total: 439
Nebraska	2008–2009	42	• 2012 occupational health indicators report – hospitalizations for work-related burns (not further characterized); employed persons age 16 and older   ^ 2008: 34   ^ 2009: 8   ^ Total: 42
Nevada	2009 2010 2001	4 6 12	• Annual hospitals report; sentinel events   ^ Burns (not further characterized): 4  • Annual sentinel events summary report   ^ Burns (not further characterized): 6 (1.4%) Annual sentinel events summary report   ^ Burns (not further characterized): 12 (1/1%)
New Hampshire	2000–2007	5874 (ED† discharges) 98 (Inpatient hospital – IH‡ – Discharges)	• Annual number of employees hospitalized for burns (not further characterized)  • 2000   ^ ED: 942   ^ IH: 8  • 2001   ^ ED: 882   ^ IH: 9  • 2002   ^ ED: 863   ^ IH: 16  • 2003   ^ ED: 673   ^ IH: 16  • 2004   ^ ED: 710   ^ IH: 8  • 2005   ^ ED: 595   ^ IH: 9  • 2006   ^ ED: 619   ^ IH: 20  • 2007   ^ ED: 590   ^ IH: 12  • Total   ^ ED: 5,874   ^ IH: 98
New Jersey	2004	5; 7	• Work-related fatalities   ^ 5 (50%) of incidents due to harmful substances or environments were associated with caustic, noxious, or allergenic substances   ^ Burns (not further characterized): 7 (5%) of 129 fatal injuries
New York	1992–1997 1992–2000	6 3%	• Injuries following reported hydrochloric acid events; HSEES   ^ Chemical burns    ▪ Employees: 3    ▪ General public: 2    ▪ Responder: 1    ▪ Total: 6  • Census of fatal occupational injuries; percent distribution of fatal occupational injuries by nature   ^ Burns (not further characterized): 3%
North Carolina	2006 2007 2007 2007 2008	964 996 9433 141 112	• Number and rates per 100,000 population, hospitalizations, unintended injuries   ^ Fire/burn (not further characterized): 964 Cases; Hospitalization rate: 10.9  • Number and rates per 100,000 population, hospitalizations, unintended injuries   ^ Fire/burn (not further characterized): 996 cases; Hospitalization rate: 11.0  • Number and rates per 100,000 population, ED visits, total   ^ Fire/burn (not further characterized): 9,433 cases; ed visit rate: 104.1  • Unintentional injury-related deaths and death rates per 100,000 population   ^ Fire/burn (not further characterized): 141 cases; death rate: 1.6  • Unintentional injury-related deaths and death rates per 100,000 population   ^ Fire/burn (not further characterized): 112 cases; death rate: 1.2
North Dakota	2008 2009–2010 2011	57 120 69	• Trauma data report   ^ Burn (not further characterized): 57 cases; % mortality: 1.754  • Trauma data report   ^ 2009: burn (not further characterized): 51 cases   ^ 2010: burn (not further characterized): 69 cases   ^ Total: burn (not further characterized): 120 cases  • Trauma data report   ^ Burn (not further characterized): 69 cases
Ohio	2013 2002–2005 2004 2006	22 44 27 37	• Child fatality review, 2011 deaths   ^ Fire/burn (not further characterized): 22 cases  • MCH fact sheet, school-aged children, adolescents and young adults, injuries   ^ Age 5–24 years; death by intent; fire/burn (not further characterized): 44 cases  • Child fatality review   ^ Fire/burn (not further characterized): 27 cases (2%)  • Child fatality review   ^ Fire/burn (not further characterized): 37 cases (8%)
Oklahoma	1988–2004 1999–2008 2003–2008	197 49 340	• Summary of reportable injuries; burn and smoke inhalation injuries   ^ Chemical skin injuries: 197 cases (2%)   ^ Fatalities: 3 cases   ^ Case fatality rate: 2%  • Chemical burns; occupational safety and health surveillance program   ^ 463 persons were hospitalized in burn centers and 125 died as a result of work-related burns   ^ Chemical skin injuries: 49 cases (8% of Total Burn Injuries)   ^ 1 fatality from chemical skin injury   ^ Chemical skin injuries were severe and resulted in high numbers of lost work days   ^ 75% of chemical skin injuries involved <10% TBSA; but 2 victims had >20% TBSA and 17% had >/=10 days of hospitalization  • Occupational health indicators; hospitalizations for work-related burns (not further characterized)   ^ 2003: 42 cases; hospitalization rate per 100,000 population: 2.6   ^ 2004: 51 cases; hospitalization rate per 100,000 population: 3.1   ^ 2005: 60 cases; hospitalization rate per 100,000 population: 3.6   ^ 2006: 57 cases; hospitalization rate per 100,000 population: 3.4   ^ 2007: 63 cases; hospitalization rate per 100,000 population: 3.8   ^ 2008: 67 cases; hospitalization rate per 100,000 population: 4.0   ^ Total: 340 cases
Oregon	2005–2007	–	• Top 10 acute chemical releases captured by the Hazardous Substances Emergency Event Surveillance (HSEES) program   ^ Frequency of releases (substances with the potential to cause chemical skin injuries)    ▪ Ammonia: 45 releases (6.3%)    ▪ Sodium hydroxide: 45 releases (6.3%)    ▪ Sulfuric acid: 24 releases (3.4%)    ▪ Hydrochloric acid: 19 releases (2.7%)   ^ Percent of Victims Reporting Symptoms in the Top 10 Chemical Incidents    ▪ Burns: 1%
Utah	1956–2001 1998 2009	– 62 –	• Unintentional injury deaths by cause of injury   ^ Fire and burns (not further characterized): 3%  • Work-Related Burns Surveillance   ^ Total work-related burns: 270   ^ Chemical source: 23% (62 Cases)  • Hazardous Substances Emergency Event Surveillance (HSEES)   ^ Total events: 252   ^ 62 events (24.6%) resulted in 108 symptomatic victims with 8 fatalities   ^ Released substances with the potential to cause chemical skin injuries:    ▪ Sodium hydroxide: 32 events (6.3%)    ▪ Corrosive liquid basic inorganic NOS: 15 events (4.1%)    ▪ Hydrochloric acid: 9 events (2.5%)  • Burn injuries (not further characterized)    ▪ Total: 8 (4.6%)    ▪ Fixed facility: 7 (4.7%)    ▪ Transportation: 1 (4.0%)
Vermont	1990–2000	–	• Unintentional injury deaths   ^ Fire/burn (not further characterized): 5%
Virginia	1994–1997	95, 582	• Childhood injury: A report on injury-related deaths and hospitalization among children and adolescents ages 0––19   ^ Fire and burn (not further characterized) deaths: 95 cases (7%)   ^ Fire and burn (not further characterized) hospitalizations: 582

* NOS: Not Otherwise Specified.

† ED: Emergency Department/Emergency Department Discharges.

‡ IH: Inpatient Hospital Discharges.

Table 6. First aid rate, serious injury rates in Alcoa locations where Diphotnerine^® is or is not available for emergent decontamination (Data Courtesy of the International Alcoa Aluminum Company and the United Steelworkers Union).

Location	First aid rate	Serious injury rate
Western Australia*	1.95	0.32
Jamaica*	0.16	0.00
Latin America*	0.18	0.02
Europe*	0.25	0.04
Point Comfort, Texas, USA†	5.04	0.70

* Locations where Diphoterine^® solution was available for skin decontamination.

† Location where Diphoterine^® solution was not available for skin decontamination.

Table 7. Data adapted from Donoghue (2010).

Clinical severity	Water first	Diphoterine^® solution first
None	9 (21.4%)	73 (52.9%)
Erythema	23 (54.8%)	54 (39.1%)
Blisters	8 (19%)	10 (7.2%)
More severe	2 (4.8%)	1 (0.7%)
Totals	42 (100%)	138 (100%)

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