Favorable Article, as Written in:
The American Journal of Surgery
Tar and Asphalt Injuries
Management of Tar and Asphalt Injuries
Robert J. Stratta, MD, Salt Lake City, Utah
Jeffrey R. Saffle, MD, Salt Lake City,
Utah Melva Kravitz, RN, MS, Salt Lake City,
Utah Glenn D. Warden, MD, Salt Lake City, Utah
Burns caused by hot tar or asphalt compose a unique class of thermal injury because these substances are difficult to remove without inflicting additional tissue damage. Moreover, failure to completely remove the solidified tar or asphalt results in suboptimal wound cleansing and Incomplete debridement. which enhances the risk of infection. Previous reports have stressed the importance of early cooling and the use of liquid solvents or petroleum -based ointments to remove tar or asphalt from the affected area [1-41. However, liquid solvents can induce additional local tissue injury and occasionally produce systemic toxic effects from absorption 12]. Antibacterial ointments in a petrolatum base are better tolerated and more effective [I 1 but have relatively slow solvent action which requires continual rubbing and repeated applications that are painful and potentially harmful to the wound 15). Recently, isolated case studies have described the merits of surfaceactive agents, such as polysorbate, for removing tar (2,4,6). Over 21/2 years, we have employed a new surfaceactive, petroleum-based solvent to expedite removal of tar or asphalt from burn wounds without local or systemic side effects. This review of our experience in treating burns caused by molten tar or asphalt. suggests a number of principles of management for approaching this challenging clinical problem. Material and Methods Patient population.
During a 4 1/2 year period extending from July 1978 through December 1982, 42 patients were treated for hot tar or asphalt injuries (Table 1). Twelve patients (28.6 percent) were managed patients whereas the other 30 patients (71.4 percent) required hospitalization at some time. Tar and asphalt injuries represented 2.6 percent of the 1,150 new admissions to the Intermountain Burn Center during the review period. All patients were male with a mean age of 27.7 years.The mean burn size was 7.3 percent of the total body surface area with a mean full-thickness area of injury of 3.9 percent. Burns of critical areas (face, eyes, hands, or feet) were present ill 28 patients (66.7 percent), 19 of whom required ' red immediately ' a te hospitalization. The remaining 23 patients were initially managed as outpatients; however, I I were subsequently, hospitalized for excisional therapy. Circumstances of injury: Industrial -related accldents accounted for all but two of the injuries (95 percent). The inpatients sustained a total of 21 roofing and 9 road accl dents, whereas the outpatient-s sustained 4 roofing and 8 road accidents, (Table 1). The etiologic agent of tissue Ill jury was tar in 30 patients (71.4 percent) and asphalt in patients (28-6 percent). Mechanisms of injury included four explosions, three falls from buildings (fell at leas*, one story), and two truck roll-overs. Four patients percent) suffered associated injuries (two had inhalation injuries, one a Colles' fracture, and one a tibia-fibu!a fracture plus a nasal fracture). Treatment protocols: Initial management at the scene of the accident usually involved the application of cold water to expedite the cooling and solidification process. All patients were initially evaluated and treated in the emergency department. Fluid resuscitation was begun in patients who sustained major thermal injuries.
Only one patient required endotracheal intubation for airway control A surface-active, solvent (De-Solv-it¨) Orange-Sol, Inc., Chandler, AZ) was used to remove the tar or asphalt by direct liberal application and gentle wiping For eye injuries, copious irrigation with the solvent and saline solution enabled extraction of the tar or asphalt without difficulty . Once the wounds were cleansed and debrided, an assessment of the extent and depth of injury was made utilizing the Lund-Browder chart . Standard criteria for admission to the burn center were used, the presence of moderate to severe thermal injuries (partial-thickness injury greater than 10 percent total surface area or a full-thickness injury of greater than...
TABLE I Patient and Injury Characteristics Inpatients outpatients n Total Characteristics n n % n % Number of patients' 30 71.4 12 28.6 42 100 Mean age (yr) 27.2 28.7 27.7 (17-48) (2.5-60) (2,5-60) Mean burn size (% TBSA) 9.3 2.3 7.3 (1.5-73) (0.5-5) (0 Mean size of full- 5.3 < 1 3.9 thickness of burn (% TBSA) (0-57) (0-1) (0 Burns of critical areas 19 63.3 9 75 28 66.7 Inciting agent Tar 22 73.3 8 66.7 30 71.4 Asphalt 8 26.7 4 33.3 12 28.6 Site of accident Roof 21 70 4 33.3 25 59.5 Road 9 30 8 66.7 17 40.5 Numbers in parentheses indicate the range. All patients were male. TBSA = total body surface area. percent total body surface area), moderate to severe burns of critical areas, or presence of associated injury.
Once admitted, conventional burn care was instituted which consisted of fluid resuscitation as necessary, topical silver sulfadiazine cream (Silvadenc¨, Marion Labs, Kansas City , MO) applied to large burns, or Bacitracin¨ ointment (Fougera, Melville, NY) for smaller burns, and early excision and autografting of deep partial partial-thickness and fullthickness wounds. Conjunctival and corneal burns were treated with an antibiotic ophthalmic ointment (Neosporin), Burroughs Wellcome, Research Triangle Park, NC) plus eye patching for 24 to 48 hours- Outpatients were instructed in twice daily dressing changes utilizing a topical antibacterial ointment (Bacitracin) and were reexamined in a follow-up clinic. Vigorous physical therapy and an aggressive early back-to-work philosophy were encouraged in all the patients. Results Fluid resuscitation from burn shock was required in all seven patients (16.7 percent) with burns exceeding 17 percent total body surface area. Six patients responded appropriately to resuscitation. Prolonged burn shock (40 hours) occurred in a 29 year old white man who sustained a 73 percent total body surface area asphalt burn (57 percent fullthickness injury) In a truck roll-over accident. This patient subsequently died 22 days after incurring the burn from burn wound sepsis. He represented the only mortality in the patient group (2.4 percent).
Of the remaining 41 patients, 26 (63.4 percent) underwent surgical excislonal therapy (Table 11). Three of these patients required two excision and autografting procedures to achieve burn wound closure, and another three required late reconstructive procedures (scar contracture releases). The mean length of hospitalization was 11.3 days with excisional therapy performed at a mean time postburn of I week. The mean number of days lost from work for the total inpatient group was 46.4 days. However, for the inpatients without associated injuries, the mean Volume 146, December 1983 time lost from work was 36.7 days. Eighty percent of I I requiring I I I the patients requiring hospital hospitalization were back to work within 6 weeks of injury. Complications occurred it) six patients (14.3 percent) and included three donor site infections, two burn wound infections (one cellulitis and one sepsis), and one pulmonary embolus (Table 11). No complications occurred in the outpatient group. Since July 1980, 21 patients were treated with De-Solv-it without apparent adverse reaction. This agent was found to be nontoxic and nonirritating -and removed .tar much faster than a agents previously described. Comments Tar and asphalt are used as protective coatings in paving, roofing, and other industrial applications. They are derived from ]ong-chaln petroleum and coal long TABLE 11 Tar and Asphalt Burns Data Surgical procedures Excision and grafting Excision and primary closure Multiple excision and grafting Late reconstructions Total no. of surgical patients Hospitalization Mean hospital stay (days) Time interval from injury to excision and gratling (days) Mean no. of days lost from work .
All inpatients Inpatients without associated injuries Multiple hospitalizations Complications Mortality Numbers in parentheses indicate the range. Results n 58-5 4.9 7.1 7.1 26 63.4 7-1 (1-15) 46.4 (7-180) 36.7 (7-90) 7 16.7 6 14.3 1 2.4 767 I I hydrocarbons with thermoplastic properties which permit liquification at temperatures above 93 C. Roofing tars and asphalts are often heated to temperatures of 232'C to achieve desirable viscosities, whereas substantially lower temperatures (about (140'C) are required to achieve a manageable form for paving roads [8,9). Therefore, roofing accidents are usually associated with deeper burn injuries. When these substances splatter, they rapidly cool to between 93 and 104'C before landing. However, when skin becomes the contact point, the tar or asphalt usually retains sufficient heat to produce a significant burn by prolonged heat transfer to the skin. Although tar and asphalt are sterile, the skin is not. With cooling, these substances solidify, become enmeshed in hair, and function as an occlusive barrier which enables subsequent bacterial proliferation. Once solidified, tar or asphalt can be extremely difficult to remove. Initial management of tar or asphalt burns at the scene of the accident involves the application of cold water to expedite the cooling and solidification process [10,11]. Prolonged cooling may result in hypothermia and should therefore be applied judiciously. Immersion in cold water is probably useful only for patients with minor burns who present immediately after tile accident (within 10 minutes), and is therefore rarelv indicated by tile time the patient arrives at a medical facility. Treatment regimens have included allowing the tar or asphalt to peel off with the underlying burn eschar, but this approach may be associated with a prohibltive risk of infection arid potential conversion of partial -thickness injuries to full-thickness injuries. Manual or mechanical debridement is painful, relatively ineffective, arid results in removal of viable skill and hair follicles, thus extending tile depth and area of dermal injury. Therefore, attempted manual debridement should be avoided at the scene, with defiriltive removal and care of the burn reserved for medical personnel. For removing tar, numerous organic solvents have been employed in the past with variable results, in - cluding mineral oil, kerosene, gasoline, alcohol, acetone, ether, and aldehydes [1-31. However, these substances are relatively ineffective and can induce further tissue damage and occasionally produce systemic toxicity through absorption.
The...propensity of tar and asphalt burns to become infected suggested the use of topical antibacterials in the care of these wounds, and this enabled the subsequent fortuitous discovery of the 768 solvent action of ointments with a petroleum or petrolatum base [11. Ashbell et al 111, in 1967, first reported tile use of Neosporin¨ ointment, which is actually polymyxin B, zinc bacitracin, and ncomycin sulfate in a petrolaturn base, in the treatment of severe facial tar burns- All tar was dissolved within 12 hours, and no infection supervened. Demling et al 121, in 1980, reported tile use of a surfaceactive agent, polyoxy ethylene sorbitan (Polysorbatcuml;, Sigma, St. Louis, MO) by itself or in combination with antibacterial cream (Neomycinuml; sulfate, Burroughs Welcome) as a safe and effective means of tar removal. Neosporin cream contains polysorbate as an emulsifying agent, whereas Neosporin ointment contains petroleum.
Polysorbate lowers surface tension and promotes micelle formation, cleaving tile bond between tile cell surface and the adherent material and thus enabling tile emulsified tar or asphalt to be washed off ( 121 Tween 80,10 (Sigma) is another readily available polysorbate preparation which is nontoxic and preferable to Neosporin n cream because It is More water soluble, easily washable, and can emulsify tar in a shorter time period. Mathews and Sharpnack (6) also in 1980, successfully treated bilateral corneal and conjunctival tar burns with polysorbate-containing Neomycin sulfate and concluded that it was a safe and effective modality for removing tar from ,...The oil compounds possess adequate solvent power ~,77 but are, remarkably free of toxicity with no demon strable eye or mucous membrane irritability I no 11, halation toxicity, arid mild skill irritability: 1131. The surface-active moiety facilities I wetting of the si;, face and emulsification of the tar or asphalt whereas lanolin functions as a lubricant to prevent skin drying- The nontoxic, nonirritating, odorless and solvent properties this substance are particularly well suited for the safe and expeditious removal of tar and asphalt from skin arid mucous membranes. We encountered no adverse reactions with tills agent when treating 21 patients over tile last 2 1/2 year-, Tar and asphalt burns constitute a serious industry hazard and a challenging clinical problem Fortunately, they are relatively rare (in our experience 2.6 percent of new ad missions over a 4 1/2 year period The vast majority of 1 injured red persons are men who \York in the roofing and paving industries Roofing accidents are associated with higher morbidity when compared with road accidents, as seen in our study by the higher rate of roofing accidents (70 percent) in the inpatient group versus the outpatient group (33.3 percent). Associated injuries are The American Journal of Surgery Tar and Asphalt Injuries infrequent (9.5 percent) and mortality is rare (2.4 percent).
Molten tar or asphalt causes deep burns and an increased risk of Infection if not removed early. Removal of the tar should be performed early by medical personnel utilizing a solvent that Is relatively painless, effective, rapid acting, and safe. Once the inciting agent is removed, the burn wound is treated as any other burn. Early excisional therapy and vigorous physical therapy can minimize disability and return the patient to the work force within a short period of time Summary Tar and asphalt burns are unique injuries because the chemical is difficult to remove without Inflicting further tissue injury. Since 1978, 42 patients have been treated for hot tar or asphalt injuries, 30 of whom required hospitalization. Inpatients were all male with a mean age of 27.2 years and a mean burn size of 9.3 percent total body surface area (mean full-thickness injury 5.3 percent total body Surface area). Burns of critical areas were present in 63.3 percent of the inpatients.
A surface-active solvent was used I to remove the tar or asphalt solvent proved nonirritating and removed tar much faster than other agents.
Early excisional therapy was Performed in 63.4 percent of the patients SO percent of whom returned to work withIn 6 weeks of injury. Principles id, management, include rapid cooling of tar or ,isphah to solidify tile inciting agent and dissipate heat removal with a new, non toxic solvent, earl), excision and grafting of appro priate injuries and an early back-to-work philosophy References I Ashbell TS, Crawford HH, Adamson JE. Horton GE. Tar and grease removal from Plast Reconstr Surgery 196 7,40.330 - 1 2 Demling RH, Buerstatte WR, Perea A Management of hot tar burns J Trauma 1980.20 242 3 Halfacre S. Apesos J. Rodeheaver GT, Edlich RF. Hot tar skin burns. Corr Concepts in Trauma Care 198 1:18-9. 4 Bose B, Tredget T. Treatment of hot tar burns, Can Med Assoc J 1982;127:21-2 5 Schiller WR, Shuck, JM Treating tar burns Emergency Med 1980:12.18 6 Mathews RC. Sharpnack P. Removal of tar from eyes. J Trauma 1980.20:910. 7 Lund C, Browder NC The estimation of areas of burns- Surgery Gynecol Obsiet 1944.79 352-8. 8 Puzinauskas VP, Corbett LW Differences between petroleum asphalt, coal-tar pitch, and road tar. Research Report 78-1 College Park, Maryland: The Asphalt Institute. 9. Othmer DF, McKetta JJ, Mark HF. Encyclopedia of chemical technology. 2nd ed New York:Wiley 1964:284 10 Feller 1, Jones CA, Richards K. Emergent care of the burn victim. Ann Arbor: National Institute of Burn Medicine, 1977. 1 1. Pruitt BA, Edlich RF.
Treatment of bitumen burns. JAMA 1982 ; 247 1565. 12. Florence AT. Surface chemical and micellar properties of drugs Volume 146, December 1983 I in solution. In: Overbeck JTG, Prins W, Lettlemoyer AL. eds. Advances in colloid interface science. Volume 2. Amster dam: Elsevier. 1968:115-46. 13. Gosselin RE. Hodge HC, Smith RP, Gleason MN. Clinical toxicology of commercial products. 4th ed. Ballimore: Williams and Wilkins. 1976:106. 169. 208. Discussion William R. Schiller (Albuquerque, NM): In my experience most of these accidents are the result of slipping while carrying tar and falling into it. The injuries are generated predominantly by the roofing industry 'in our community, and greater safety efforts would likely prevent a significant number of them. About three quarters of the patient have injuries that do not involve large body surface areas and the remaining patients tall into a severe injury group with an average burn size of 21 percent total body surface area. These patients have about double the hospitalization time of the group as a whole. I have been using the enzymatic debridement technique for some of the smaller hand burns to clean up the superficial eschar, and I believe that some of the hands heal faster than might be expected. Could the authors comment on their experiences with this technique" MacDonald Wood (Phoenix, AZ): We see a number of tar and asphalt injuries each year at the burn center at Maricopa Medical Center. We are using petroleum -based Neosporin ointment on these tar and asphalt eschars, and have found the dissolution of these substances occur within a 12 to 24 hour period.
We appreciate knowing about the new solvent De-Solv-it...Of interest is the cost of the materials. Neosporin ointment runs about 6 to 7 dollars per ounce, and a 4 ounce container...will be 4 dollars.
We have another type of asphalt injury in Arizona. Black. asphalt absorbs a tremendous amount of heat. The Arizona Highway Patrol and Jim Berens, one of the members of this association I did a stud), measuring the temperature of concrete and asphalt in Flagstaff, which is about a mile high, and also in the Phoenix area. As you know, protein will coagulate at 115'C. With ambient temperatures of 100 to 110'C, the concrete temperature will be close to 150 degrees, and black asphalt will run up to 170 to 180 degrees. Because of this, the highway patrol is trained in removing patients from automobile accidents and making sure that there is a double or triple thickness of blankets between the patient and the highway. If a person stays in contact with 170 or 180 degree asphalt after at) accident, a third degree burn can occur. Robert J. Stratta (closing): I would like to reiterate Dr. Schiller's point that the vast majority of these patients do have small burn injuries. Only 7 of the 42 patients in our series required fluid resuscitation All these patients had 17 percent or greater total body surface injuries. With regard to his question concerning enzymatic debridement of hand burns, our burn unit does not have any experience using Travase¨ ointment. We have an aggressive approach in terms of treating our deep partial -thickness and fullthickness injuries to critical areas, because we believe that we can get these patients out of the hospital sooner and back to a functional status.
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