CHEMICAL B U R N S OF THE SKIN A F T E R C O N T A C T WITH P E T R O L

By G. A. HUNTER, M.B., F.R.C.S.

Accident Service, Radcliffe Infirmary, Oxford

IN view of the widespread use of petrol in industry and transport , it is surprising that the skin changes after contact with petrol, without ignition of the petrol, are not more widely known amongst the public or recorded in the medical literature. For this reason four patients are reported who sustained chemical burns of the skin after contact with petrol. Two of these patients developed renal failure, one requiring h~emodialysis. They were seen in the Accident Service of the Radcliffe Inf i rmary in the last two years.

CASE REPORTS

Case r . - -A girl of I9 was admitted after a road traffic accident in which she sustained a supracondylar fracture of the right femur, a mild head injury and multiple abrasions. There were io per cent. partial skin loss burns of her back, right arm and right leg. The burns were treated by exposure and healed I I days after admission. When seen eight months later she complained of persistent discoloration at the site of the burns. There was extensive light brown pigmentation over these areas, which caused a minor cosmetic disability two years after her accident.

Case 2.--A 24-year-old woman was admitted after a road traffic accident in which she sustained a fracture of the pelvis, facial lacerations, a fracture of the right radius, multiple abrasions and burns of her back and both arms. The areas were initially noticed to be erythematous but blisters soon developed and after two weeks the cuticle hardened and peeled off revealing lightly pink stained skin. Delayed internal fixation of the right radius was performed when these areas had healed. One year later, however, staining of the skin was still visible but was thought to be fading slowly.

Case 3.--A 3-year-old girl was admitted after a road traffic accident in which she sus- tained a compound depressed fracture of the skull and 15 per cent. partial skin loss burns of both surfaces of the trunk. She was resuscitated with blood and plasma and the burns cleaned and exposed. Eight hours after admission the fracture of the skull was elevated. Over the next few days it became apparent that the initial assessment was inaccurate because what was originally thought to be merely erythema on admission was found to be 4 ° per cent. partial skin loss burns with blistering. Her blood urea rose to IOO rag. per IOO ml. after five days but had returned to normal 12 days after admission. The burns crusted over, and two weeks after admission the cuticle peeled off to leave persistent pink staining of the skin. This staining was still present six months after the accident.

Case 4.--An i8-year-old boy was trapped underneath a Land-Rover for two hours. When help .came and the vehicle was removed the patient noticed a strong smell of petrol in the vlcm~ty. He was seen 45 minutes later when the petrol-soaked clothing was removed, and it was found that he had sustained 40 per cent. partial skin loss burns of the trunk, right thigh and both buttocks. There was incomplete paralysis and loss of sensation below the right mid- thigh level, corresponding with the site of the crushing force. The right fourth toe was cyanotic but peripheral pulses were easily palpable. He received intravenous colloid in the form of plasma, dextran and Rheomacrodex. The burns were cleaned and treated by exposure. In the first 24 hours, the urine output was 70o ml. and contained h~emoglobin and myoglobin. The blood urea was 30 rag. per ioo ml. On the second day the urine output had fallen to

4 A 337

338

260 -

240 t

220 I

200

180 I

• F m

-~ 160

g 140

120 c~

=' I00

80

0 - - 60

B R I T I S H JOURNAL OF PLASTIC SURGERY

TABLE TO SHOW DALLY URINE FLOW AND BLOOD UREA - CASE 4.

D I ALYS I S URINE FLOW n | ! I ~ ~ ~ , ,

! !

! I

I ~ A I \ I ", i ' X / \ " ~ , ~ ,

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2 4 6 8 10 12 1'4 Days a f t e r

i

16 18 a d m i s s i o n

FIG. z

io k J4 ~; 18 ~o

Showing the daily urine flow and blood urea estimations in Case 4.

' 8, 000

7, 000

6, 000 2. c o

5,00o ~

4, ooo

3,000 - .

3 t ~

2, OOO

I, 000

FIGS. 2, 3 and 4 Showing the burns of Case 4 at days 5, 16 and 24 after admission.

CHEMICAL BURNS OF SKIN AFTER CONTACT WITH PETROL 339

I6o ml. and the blood urea had risen to IIO rag. per ioo ml. The urinary urea concentration was ioo mg. per Ioo ml. and the urinary sodium concentration was n 6 mEq. per litre. A diagnosis of acute tubular necrosis was confirmed, and the advice of Dr J. G. G. Ledingham was sought.

A mannitol infusion (200 ml. of 2o per cent. mannitol) failed to produce a diuresis, and an arteriovenous cannula was therefore inserted into the right arm (Mr J. C. Smith).

Five periods of hmmodialysis were carried out over the next lO days (Fig. I), and a diuresis was established 12 days after admission. Five weeks after admission his creatinine clearance was 98 ml.

The burns showed the usual changes of erythema and blistering and after three weeks the cuticle began to peel off (Figs. 2, 3 and 4) revealing healed pink skin. The patient developed a phimosis as a result of the burns and required a circumcision.

His right leg remained swollen for a few days and the neurological deficit of his right leg improved whilst in hospital ; two months after admission, he had full power in all muscle groups with no loss of sensation in the right leg.

Skin Changes due to Contact with P e t r o l . - - T h e s e were reported by Page (I918) and have been commented on in the Ministry of Supply Memoranda (I952), by Aidin (I958) and by Ainsworth (I96O). Recent enquiries at three burns centres in England revealed that this condition is rare in civilian practice (Jackson, one case ; Evans, io cases ; Clarkson, two cases).

The lesions produced have been compared to the raw areas seen on the body of a macerated stillborn foetus (Aidin, I958 ; Ainsworth, I96o).

All writers stress the erythema and blistering, and Ainsworth described the super- ficial epidermis as being loose and easily removed. Partial skin loss would appear to be the rule, and healing is usually uneventful. Persistent skin discolouration was seen in the above four patients, and is probably due to dyestuffs in the petrol (Broughton, I967). The fat solvent action of petrol would appear to be the principal cause of these changes in the skin (Barry, I967).

All petrol nowadays contains lead alkyls (tetraethyl and tetramethyl lead) in a concentration of one part of lead alkyl to 1,3oo parts of petrol. Aidin (i958) states that there is some evidence that the skin lesions due to petrol may be caused by the lead alkyls. This evidence was based upon the work of Kehoe (I925) who reported that if tetraethyl lead concentrate was left in contact with the skin of rabbits for half an hour, desquamation occurred after a day or two. Kehoe (I967) now says that this statement is incorrect, and was the result of carrying out observations with tetraethyl lead containing traces oftriethyl lead oxide or carbonate.

Lead alkyls are present in such small concentrations in petrol that they are of no importance in a consideration of their role in the local or systemic toxicity of petrol (Broughton, I967).

The Cause o f Renal Fai lure in these P a t i e n t s . - - I n Case 3 the probable cause of renal failure with a blood urea of Ioo mg. per Ioo ml. was an inaccurate assessment of the severity of the initial burn with resultant inadequate replacement therapy. Only after three days did the erythematous areas blister and reveal 40 per cent. partial skin loss burns. According to Cameron and Miller-Jones (I967) only one burned child out of 22 survived with a blood urea above Ioo mg. per Ioo ml. Considering these figures, it is surprising that this patient survived.

In Case 4 the renal failure may have been due to several causes : I. Dehydration from 3 ° per cent. Burns.--This is unlikely for two reasons : renal

failure in this size of burn is uncommon (Evans, I963), and according to clinical and pathological data, the patient was well rehydrated in the first 36 hours.

34 ° BRITISH JOURNAL OF PLASTIC SURGERY

Crush Injury (Bywaters, i942).--This would appear to be the most likely cause of the renal failure in this patient, because his right leg was crushed for two hours, and his case history is exactly similar to that of the cases reported by Bywaters.

3. The Use of Rheomacrodex.--Rheomacrodex has been incriminated, perhaps unjustifiably, as a cause of acute renal failure in at least 27 reported cases (Niall and Doyle, I966 ; Hulme and Lawson, I966). By the nature of their illness most of these patients were liable to develop renal failure, and Matheson (I966) feels that present evidence is inadequate to blame low molecular weight dextrans as a cause of renal failure.

This patient received 1,83o ml. of Rheomacrodex in the first 24 hours as colloid replacement, but it is impossible to say what part its administration played in the axiology of renal failure.

4. Poisoning from Inhalation and Skin Absorption of Petrol.~The role of petrol is probably of no significance. The chief reaction to petrol poisoning is depression of the central nervous system and death is usually due to respiratory arrest (Wang and Irons, I96I). In cases of petrol poisoning, there is said to be autopsy evidence of damage to the vascular endothelium with kidney ha:morrhages (Ministry of Supply Memoranda, I952). Aidin (I958) reports that the kidneys were microscopically normal in his case report but Ainsworth (I96o) reported oedema of the kidneys and damage to the proximal tubules and glomeruli in a case of poisoning by petrol vapour. No cases have been reported suffering from renal failure as a result of skin absorption or inhalation of petrol vapour.

The toxicity of the lead alkyls is related to the lead content. Lead has a selective action upon the central nervous system, and the possibility of lead poisoning and in particular renal damage from the use of leaded petrol where the concentration does not exceed I : 1,3oo has been uniformly discounted (Cassels and Dodds, I946).

TREATMENT

i. Remove any contaminated clothing as soon as possible. 2. Cleanse the skin with soap and water as soon as possible. In the absence of soap

and water the affected skin should be dried with absorbent material (Broughton, i967). 3. There is no known local or systemic antidote (Broughton, I967). 4. Beware of ignition accidents. 5. Treat the associated loss of fluid and look for other injuries, e.g. fractures, head

injuries, etc. Unless one is aware that the erythematous areas may not be apparent immediately after the accident, and that they may only blister after a day or two, an inaccurate assessment might be made of the extent of the burn with resultant inadequate therapy.

6. The burn should be treated by exposure. It would appear that skin grafting is usually unnecessary in this particular type of burn.

7- The patient should be reassured about the subsequent pink staining of the skin, which fades over the ensuing months.

SUMMARY

Four patients are reported with partial skin loss burns of the skin due to contact with petrol.

The axiology and nature of these skin changes are discussed. Two of these patients developed renal failure. Inhalation or skin absorption of

petrol or the lead alkyls appears to be of no significance in the axiology of this condition. Treatment of these chemical burns is discussed.

CHEMICAL BURNS OF SKIN AFTER CONTACT WITH PETROL 341

I wouM like to thank Mr ft. C. Scott, Director of the Accident Service, for permission to publish this paper, Dr ft. G. G. Ledingham for his help in the treatment of this patient, and the Department of Medical Illustration of the Radcliffe Infirmary.

REFERENCES

AIDIN, R. (I958). Br. reed. ft., 2, 369- AINSWORTH, R. W. (I96O). Br. reed. ft., I, 1547. BARRY, P. S. I. (I967). The Associated Octel Company. Personal communication. BROUGHTON, W. E. (1967). Shell Petroleum Company. Personal communication. BYWATERS, E. G. L. (I942). Br. reed. ft., 2, 643. CAMERON, J. S., and MILLER-JoNEs, C. M. H. (1967). Br. ft. Surg., 54, I32. CASSELS, D. A. K., and DODDS, E. C. (1946). Br. reed. ft., 2, 681. CLARKSON, P. (1967). Personal communication. EVANS, A. J. (1963). In " Recent Advances in the Surgery of Trauma ", ed. D. N.

Matthews. London : Churchill. EVANS, A. J. (I967). Personal communication. HULME, B., and LAWSON, L. J. (1966). Br. reed. ff.o 2, 1455o JACKSON, D. MAcG. (I967). Personal communication. KEHOE, R. A. (1925). J. Am. reed. Ass., 85, lO8. KEHOE, R. A. (1967) Personal communication. MACHLE, W. (I941). ft. Am. reed. Ass., 117, 1965. MATHESON, N. A. (1966). Br. med. J . , 2, 1198. Ministry of Supply Technical and Medical Memoranda, No. 25 (i952). NIALL, J. F., and DOYLE, J. C. (1966). Lancet, I, 817. PAGE, G. B. (1918). Practitioners IOO, 451. WANG, C. C., and IRONS, G. V. (1961). Archs envir. Hlth., 2, 715.