Journal of Plastic, Reconstructive & Aesthetic Surgery (2017) 70, 563e567

Review

Is it time for a change in the approach to

chemical burns? The role of Diphoterine

in the management of cutaneous and ocular
chemical injuries
C.J. Lewis*, A. Al-Mousawi, A. Jha, K.P. Allison

Department of Plastic Surgery, James Cook University Hospital, Middlesbrough, UK

Received 22 December 2016; accepted 17 February 2017

KEYWORDS Summary A multitude of household and occupational compounds have the potential to
Chemical burn; induce chemical burns to the eye and skin. Without prompt intervention, irreversible visual
Diphoterine; loss and disfigurement may prevail. Diphoterine
and Hexafluorine
are amphoteric and hyper-
Hexafluorine; tonic chelating solutions used in the management of general chemical and hydrofluoric acid
Review burns, respectively. They rapidly neutralise both acid and alkali agents without heat release
and limit diffusion, making them superior to water irrigation alone. However, although
Diphoterine
and Hexafluorine
uptake is slowly increasing in industrial workplaces, there is
a paucity of education and use in both emergency departments and plastic surgery units world-
wide. Herein, we present a case report of combined ocular and cutaneous acid burn treated
with Diphoterine
, together with a review of the current supporting literature.
Crown Copyright ª 2017 Published by Elsevier Ltd on behalf of British Association of Plastic,
Reconstructive and Aesthetic Surgeons. All rights reserved.

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
Case study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
Pathophysiology of chemical burn injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
Traditional management strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 564
The evidence for Diphoterine
and Hexafluorine
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 565
Recommendations for practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566

* Corresponding author. Department of Plastic Surgery, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 3AB, UK.
E-mail address: christopher.lewis@nuth.nhs.uk (C.J. Lewis).

http://dx.doi.org/10.1016/j.bjps.2017.02.013
1748-6815/Crown Copyright ª 2017 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights
reserved.

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564
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 566
Introduction
Chemical agents include acids, alkalis, oxidising and
reducing agents, alkylating and chelating agents, and sol-
vents. They cause injury by producing a chemical interaction
that can lead to extensive tissue destruction and extreme
pain. Injuries may not be immediately obvious, and there
can be a delay in presentation.1 These injuries account for
only 3% of all burns but lead to approximately 30% of burn
deaths,2 usually secondary to ingestion in children.
Chemical ocular burns account for between 7.7% and
18% of all eye trauma3 Typically, young males working in
industrial environments such as factories, chemical plants
or laboratories are the most common patient group,4e7 with
more than 70% of eye burns occurring at work and sec-
ondary to an alkali.6 In addition to accidental and occupa-
tional exposure, increasing numbers of men and
particularly women both in the UK and overseas are the
victims of violent assault when acid is thrown on their face,
resulting in life-changing cutaneous and ocular injuries.8
The main determinants of the degree of injury are con-
centration of the agent and site and duration of exposure.
Without prompt intervention, irreversible visual loss and
cutaneous disfigurement may prevail.4 Immediate contin-
uous irrigation with water has been the usual first-line
treatment for chemical burns, regardless of the nature of
the chemical involved, with the aim to mechanically rinse
and dilute the agent and limit the injury. Diphoterine
is an
amphoteric and hypertonic chelating solution used in the
management of chemical burns. It rapidly neutralises both
acid and alkali agents without heat release and limits diffu-
sion, making it a superior agent than water for irrigation as an
active treatment for chemical injuries. Although
Diphoterine
uptake is slowly increasing in industrial work-
places,7 there remains a paucity of both education and use in
emergency departments and plastic surgery units world-
wide. Herein, we present a case report of combined ocular
and cutaneous acid burn treated with Diphoterine
, together
with a review of the current supporting literature.
Case study
A 37-year old chemical engineer was sprayed with hot sul-
phuric acid (35% concentration at 85  C) to the face, eyes
and upper body whilst at work. First aid at scene comprised
of decontamination with both a Diphoterine
autonomous
portable shower and Diphoterine
eyewash within minutes
of the injury.
Burn size was evaluated as being 4.5% of the total body
surface area: mixed-depth dermal burns to the face, right
eye, back, left shoulder and posterior neck. There was mild
swelling and blistering of the lips but no evidence of airway
compromise or ingestion of the chemical. Ophthalmic
evaluation demonstrated visual acuity to be 3/3.75.
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C.J. Lewis et al.
Corneal pH was 7, but fluorescein uptake was evident in the
central cornea. Further irrigation with 2 L of normal saline
maintained a pH of 7. Blistered areas were de-roofed, and
liquid paraffin and Polyfax
(Polymyxin B, Bacitracin, Teva,
UK) ointments were regularly applied to the face, ears and
forearm and Hypafix
(BSN Medical, UK) dressing applied
directly to the back and left shoulder burns. He was dis-
charged 5 days following admission with outpatient follow-
up in the ophthalmology and plastic surgery dressing clinics
and psychology referral for further support. Follow-up at 1
week showed the wounds to be healing well with no signs of
infection, erythema or discharge. No further ocular
sequalae were identified.
Pathophysiology of chemical burn injuries
A chemical splash to the skin or eye causes a sudden change
in tissue pH followed by pH-dependent tissue destruction
and denaturation of proteins.4,9e11 However, pH alone is
not the sole determinant of damage; a multitude of factors
are involved including chemical temperature, volume,
impact force, concentration and osmolality.2,4,12
Alkaline agents, such as sodium hydroxide found in drain
cleaner, typically penetrate more deeply than acids, and
through the processes of liquefactive necrosis, hydroxyl
ions cause the saponification of fatty acids in cell mem-
branes and cell lysis.4,11 In the eye, once the corneal
epithelium is breached, alkaline solutions can destroy the
trabecular network leading to secondary glaucoma4 and
penetrate the anterior chamber causing inflammation of
the iris, lens and ciliary body.4 In contrast, acids cause a
coagulative necrosis, i.e. the free hydrogen ions denature
and precipitate proteins, which results in a mechanical
barrier to limit further damage.4
Hydrofluoric acid (HF) burns are rare but dangerous. HF
is a solution of inorganic anhydrous hydrogen fluoride in
water. It is used extensively in a variety of industries, e.g.
glass etching, aerospace industry (where it is used to clean
aluminium), for scouring metal and as a leather tanning
agent. It is also present in household rust removal and
cleaning products.13 HF is transported and stored under
high pressure, with concentrations varying from approxi-
mately 100% for industrial use to 0.5% for domestic use.13
Although a weak acid, HF does not readily dissociate,
allowing it to penetrate through the skin and corneal
epithelium easily.13 Once in the deeper tissues, HF disso-
ciates and free fluoride ions cause liquefactive necrosis and
chelation of intracellular calcium and magnesium,14
resulting in rapid irreversible damage.
Traditional management strategies
First aid for chemical burns of the skin and eyes involves
removing the compound from body contact (e.g. removing
The role of Diphoterine

clothing) followed by copious flowing irrigation to dilute the
chemical.2,15,16 This strategy is taught worldwide and is pro-
moted in a number of life support courses including the
Advanced Trauma Life Support (ATLS) and Emergency
Management of Severe Burns (EMSB) courses. Although
sound in its objectives, this management strategy is not
perfect17,18 as there is no measure for the adequacy of lavage
apart from pH monitoring of the burn site.17 Irrigation may be
performed for up to 2 h2 to return the skin’s pH to between 5.5
and 9 (safe limits). However, this puts the patient at risk of
profound hypothermia, both from evaporative losses from the
burn and the unwarmed lavage fluid.2 Furthermore, as water
is hypotonic, it has been suggested that it may propagate
further penetration of chemicals into tissues.13,18,19
Changes to Management - What options are available
other than water lavage?
1. If newer compounds are not available, irrigation with
isotonic or hypertonic crystalloid solutions and not hy-
potonic water is recommended, the hypothesis being to
draw out the damaging agent rather than causing ab-
sorption of hypotonic water, increasing intracellular
distance and perpetuating the environment for the
injurious chemical.13,18,19
2. Diphoterine
is a commercially available amphoteric and
hypertonic chelating solution used to decontaminate and
irrigate chemical splashes20,21 and is produced by Labo-
ratoire Prevor (Valmondois, France). It is available in
several sizes depending on the volume of chemical splash:
50/500 mL eyewash, 100/200 mL spray canister and 5 L
canister. Initially developed as a readily accessible
eyewash for those based in industrial environment, it has
been shown to be effective in vitro in neutralizing acid and
base splashes to the eyes and skin and is water soluble.20,21
It has low toxicity and does not irritate the skin or eyes.20e25
3. Hexafluorine
(Laboratoire Prevor; Valmondois, France)
is an amphoteric, hypertonic and polyvalent chelating
solution designed specifically for the decontamination of
HF cutaneous and ocular splashes.26 It is available as a
portable and wall-mounted eyewash and 5 L canister. In
addition to the irrigation effect, the hypertonic
Hexafluorine
limits tissue penetration27 and neutral-
ises/chelates the free hydrogen and fluoride ions
responsible for tissue damage. Because of the nature of
HF, dilution with water is not sufficient to prevent burns
and potentially life-threatening hypocalcaemia. Indeed,
in vivo research26 demonstrated that a single
Hexafluorine
application significantly limited burn
evolution when applied to a cutaneous HF injury
compared to both water and calcium gluconate appli-
cation. Serum calcium levels remain stable in vivo
following Hexafluorine
wash and drop after water irri-
gation.26 Ex vivo data has histologically illustrated limi-
tation of HF ingress and tissue damage following
Hexafluorine
wash in both the skin28,29 and cornea.14
The evidence for Diphoterine
and
Hexafluorine

Ex vivo and in vivo murine data supporting the role of
Diphoterine
in the management of chemical injuries is
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565
compelling. Gérard et al.30 identified that early eye irri-
gation with Diphoterine
following ammonia treatment
dramatically neutralized the base effect, with preservation
of cytological architecture and reduced stromal oedema
compared to those in eyes treated with saline alone.
Similarly, Langefeld24 identified that the buffering capacity
of Diphoterine
was greater for acids and bases than for
phosphate buffer or Hartmann’s solution. Schrage31 illus-
trated further encouraging results, finding that
Diphoterine
could reduce anterior chamber pH following
an alkali burn with as little as 5 min of irrigation compared
to that in saline-treated controls. Rihawi32 exposed ex vivo
cornea to sodium hydroxide and once again found that
water and saline were less efficient than Diphoterine
in
returning pH to within an acceptable range. Fosse33 illus-
trated that tetramethylammonium hydroxide, a quaternary
ammonium compound used in etching, required 17 times
more water to normalise pH, after which only one-third of
the cells remained viable compared to the two-thirds after
being treated with Diphoterine
.
In addition to rapidly changing the tissue pH through
chelation, Diphoterine
may also modulate inflammation
and pain25 through effects on neurotransmitters.34 Circu-
lating levels of substance P, which plays regulatory roles in
inflammation and pain modulation, were lower when skin
burns were treated with Diphoterine
than with saline.
Levels of beta-endorphin, which is an endogenous opioid
neuropeptide, are increased following Diphoterine
irriga-
tion of cutaneous chemical burns.34 Taken together, this
suggests that inflammation is abated and pain is improved
following Diphoterine
treatment,25 potentially because of
the limitation of tissue destruction.
Following successful ex vivo and murine in vivo studies,
focus has now turned to the role of neutralizing agents in
clinical practice, and a number of case studies have advo-
cated its use. To confirm animal data, Langefeld24 and
Lynn25 assessed the efficacy of Diphoterine
for eye and
skin irrigation, finding it to have safety comparable to that
of saline. Nehles35 reported the first clinical use of
Diphoterine
in the management of cutaneous and ocular
acid/alkali burns during the 1990s, with further studies
highlighting its potential role in both the management of
ocular and cutaneous burns. Merle36 reported their expe-
rience of Diphoterine
in the management of alkali ocular
burns, finding corneal re-epithelialisation time to be
significantly shorter following amphoteric wash than with
saline. Donoghue20 evaluated the role of Diphoterine
in
cutaneous alkali burns, finding significantly better out-
comes in those treated with the solution than those treated
with water, with a significant reduction in the number of
patients exhibiting blistering and other clinical stigmata of
a chemical burn. Zack-Williams37 reported that in a large
cohort study, delayed application of Diphoterine
signifi-
cantly altered cutaneous wound pH compared to that with
saline irrigation but did not alter the need for surgery or
time to healing. This study, however, lacked a time-
matched injury control group.
Research has also focussed on the role of chelating
washes in the management of chemical warfare agents.
Nitrogen mustards are an abundant warfare agent, pri-
marily designed to affect the eyes.38,39 The use of this gas is
not historic, and it has recently gained notoriety again for
566
its use during the Syrian conflict.40 Goldich41 identified that
immediate ocular irrigation with Diphoterine
was more
effective than saline in reducing corneal, iris and anterior
chamber injury secondary to mustard gas, with corneal
opacity and corneal neovascularization attenuated and iris
atrophy delayed.38 Viala42 assessed the role of amphoteric
wash in the treatment of ortho-chlorobenzylidene malo-
nonitrile (CS) ‘tear gas’, finding rapid relief or negation of
symptoms when applied prior to gas exposure in military
personnel, although this study was limited by the less
number of participants and an absent control group.43
However, Diphoterine
does have limitations and is not
suitable for the cutaneous decontamination of all chem-
icals.44 Furthermore, no studies have assessed its role in
the management of chemical ingestion.
A number of case studies have commented on the role of
HF decontamination using this amphoteric wash in clinical
practice and industry. These demonstrate good results
when applied acutely to cutaneous19,45 and ocular19 burns
but also show success with delayed application to large-
volume HF burns.46
Recommendations for practice
Evidence for the use of both Diphoterine
and
Hexafluorine
in the management of cutaneous and ocular
chemical injury is encouraging. In Europe, it is already
widely used by both paramedics and firefighters for pre-
hospital decontamination.37 However, its use by ambu-
lance crews and in emergency and plastic surgery de-
partments across the UK is scarce.37 We feel that a lack of
education and cost may be responsible for the slow up-
take amongst UK emergency physicians and plastic sur-
geons. Furthermore, a 2012 review of chemical
manufacturing plants in the UK found that only 17%
stocked Diphoterine
, primarily because of unawareness,
cost constraints,37 lack of evidence or absence of quali-
fied staff to administer the solution.7 Since this paper was
published, a number of studies have commented on the
role of amphoteric solutions,25,37,47 including a recent
meta-analysis that highlights improved outcomes with
amphoteric solutions compared to those with water
irrigation.25
The pre-hospital burn consensus guidelines48,49 aimed
to set out a gold-standard streamlined pathway for the
assessment and management of burn injuries by pre-
hospital practitioners. These then formed the basis for
the Joint Royal Colleges Ambulance Liaison Committee
(JRCALC) guidelines in the UK,50 which guides pre-hospital
clinical practice amongst paramedics. On the basis of the
evidence available supporting the role of Diphoterine
and
Hexafluorine
, we propose that these amphoteric solu-
tions would be suitable additions to the first aid manage-
ment of chemical burns laid out in the JRCALC guidelines
by paramedics, as would lavage with room-temperature
isotonic solutions such as Hartmann’s solution or saline if
amphoteric solutions not available. Furthermore, we
believe that these products should be available for use in
UK emergency departments for the treatment of complex
chemical injuries under the guidance of plastic and burn
surgeons.
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C.J. Lewis et al.
Funding
The authors received no funding from an external source.
Conflict of interest
The authors declare no conflict of interest.
References
1. Lewis PM, Ennis O, Kashif A, Dickson WA. Wet cement remains a
poorly recognised cause of full-thickness skin burns. Injury
2004;35:982e5.
2. Herndon D. Total burn care. 4th ed. New York: Elsevier Saun-
ders; 2012.
3. Merle H, Gerard M, Schrage N. Ocular burns. J Fr Ophtalmol
2008;31:723e34.
4. Eslani M, Baradaran-Rafii A, Movahedan A, Djalilian AR. The
ocular surface chemical burns. J Ophthalmol 2014;2014:
196827.
5. Kuckelkorn R, Kottek A, Schrage N, Reim M. Poor prognosis of
severe chemical and thermal eye burns: the need for adequate
emergency care and primary prevention. Int Arch Occup En-
viron Health 1995;67:281e4.
6. Singh P, Tyagi M, Kumar Y, Gupta KK, Sharma PD. Ocular
chemical injuries and their management. Oman J Ophthalmol
2013;6:83e6.
7. Kalson NS, Dheansa B. Low diphoterine provision in UK indus-
trial chemical manufacturing plants highlights the need for
new research. Burns 2013;39:823e4.
8. BBC. How many acid attacks are there? http://www.bbc.co.uk/
news/magazine-23631395. [Accessibility verified November 1,
2016].
9. Paterson CA, Pfister RR. Ocular hypertensive response to alkali
burns in the monkey. Exp Eye Res 1973;17:449e53.
10. Pfister RR. The effects of chemical injury on the ocular sur-
face. Ophthalmology 1983;90:601e9.
11. Wagoner MD. Chemical injuries of the eye: current concepts in
pathophysiology and therapy. Surv Ophthalmol 1997;41:
275e313.
12. Schrage NF, Langefeld S, Zschocke J, et al. Eye burns: an
emergency and continuing problem. Burns 2000;26:689e99.
13. Atley K, Ridyard E. Treatment of hydrofluoric acid exposure to
the eye. Int J Ophthalmol 2015;8:157e61.
14. Spoler F, Frentz M, Forst M, Kurz H, Schrage NF. Analysis of
hydrofluoric acid penetration and decontamination of the eye
by means of time-resolved optical coherence tomography.
Burns 2008;34:549e55.
15. Brent J. Water-based solutions are the best decontaminating
fluids for dermal corrosive exposures: a mini review. Clin
Toxicol (Phila) 2013;51:731e6.
16. Spoler F, Forst M, Kurz H, Frentz M, Schrage NF. Dynamic
analysis of chemical eye burns using high-resolution optical
coherence tomography. J Biomed Opt 2007;12:041203.
17. Chan HP, Zhai H, Hui X, Maibach HI. Skin decontamination:
principles and perspectives. Toxicol Ind Health 2013;29:
955e68.
18. Mathieu L, Burgher F, Fosse C, Blomet J. Water-based solutions
are the best decontaminating fluids for dermal corrosive ex-
posures: a mini revieweletter to the editor. Clin Toxicol (Phila)
2014;52:149.
19. Soderberg K, Kuusinen P, Mathieu L, Hall AH. An improved
method for emergent decontamination of ocular and dermal
hydrofluoric acid splashes. Vet Hum Toxicol 2004;46:216e8.
The role of Diphoterine

20. Donoghue AM. Diphoterine for alkali chemical splashes to the
skin at alumina refineries. Int J Dermatol 2010;49:894e900.
21. Hall AH, Blomet J, Mathieu L. Diphoterine for emergent
eye/skin chemical splash decontamination: a review. Vet Hum
Toxicol 2002;44:228e31.
22. Mathieu L, Burgher F, Hall AH. Diphoterine chemical splash
decontamination solution: skin sensitization study in the
Guinea pig. Cutan Ocul Toxicol 2007;26:181e7.
23. Hall AH, Cavallini M, Mathieu L, Maibach HI. Safety of dermal
diphoterine application: an active decontamination solution
for chemical splash injuries. Cutan Ocul Toxicol 2009;28:
149e56.
24. Langefeld S, Press UP, Frentz M, Kompa S, Schrage N. Use of
lavage fluid containing diphoterine for irrigation of eyes in first
aid emergency treatment. Ophthalmologe 2003;100:727e31.
25. Lynn DD, Zukin LM, Dellavalle R. The safety and efficacy of
diphoterine(R) for ocular and cutaneous burns in humans.
Cutan Ocul Toxicol 2016:1e17.
26. Mathieu L, Nehles J, Blomet J, Hall AH. Efficacy of hexafluorine
for emergent decontamination of hydrofluoric acid eye and
skin splashes. Vet Hum Toxicol 2001;43:263e5.
27. Gerard M, Louis V, Merle H, et al. Experimental study about
intra-ocular penetration of ammonia. J Fr Ophtalmol 1999;22:
1047e53.
28. Burgher F, Mathieu L, Lati E, et al. Part 2. Comparison of
emergency washing solutions in 70% hydrofluoric acid-burned
human skin in an established ex vivo explants model. Cutan
Ocul Toxicol 2011;30:108e15.
29. Burgher F, Mathieu L, Lati E, et al. Experimental 70% hydro-
fluoric acid burns: histological observations in an established
human skin explants ex vivo model. Cutan Ocul Toxicol 2011;
30:100e7.
30. Gerard M, Josset P, Louis V, et al. Is there a delay in bathing
the external eye in the treatment of ammonia eye burns?
Comparison of two ophthalmic solutions: physiological serum
and Diphoterine. J Fr Ophtalmol 2000;23:449e58.
31. Schrage NF, Kompa S, Haller W, Langefeld S. Use of an
amphoteric lavage solution for emergency treatment of eye
burns. First animal type experimental clinical considerations.
Burns 2002;28:782e6.
32. Rihawi S, Frentz M, Schrage NF. Emergency treatment of eye
burns: which rinsing solution should we choose? Graefes Arch
Clin Exp Ophthalmol 2006;244:845e54.
33. Fosse C, Mathieu L, Hall AH, et al. Decontamination of tetra-
methylammonium hydroxide (TMAH) splashes: promising results
with Diphoterine in vitro. Cutan Ocul Toxicol 2010;29:110e5.
34. Cavallini M, Casati A. A prospective, randomized, blind com-
parison between saline, calcium gluconate and diphoterine for
washing skin acid injuries in rats: effects on substance P and
beta-endorphin release. Eur J Anaesthesiol 2004;21:389e92.
35. Nehles J, Hall AH, Blomet J, Mathieu L. Diphoterine for
emergent decontamination of skin/eye chemical splashes: 24
cases. Cutan Ocul Toxicol 2006;25:249e58.
Downloaded for Yohanes Firmansyah (yohanesfirmansyah28@gmail.com) at Universitas Tarumanagara from ClinicalKey.com by Elsevier on May 10, 2018.
For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved.
567
36. Merle H, Donnio A, Ayeboua L, et al. Alkali ocular burns in
Martinique (French West Indies) Evaluation of the use of an
amphoteric solution as the rinsing product. Burns 2005;31:205e11.
37. Zack-Williams SD, Ahmad Z, Moiemen NS. The clinical efficacy
of Diphoterine(R) in the management of cutaneous chemical
burns: a 2-year evaluation study. Ann Burns Fire Disasters
2015;28:9e12.
38. Banin E, Morad Y, Berenshtein E, et al. Injury induced by
chemical warfare agents: characterization and treatment of
ocular tissues exposed to nitrogen mustard. Invest Ophthalmol
Vis Sci 2003;44:2966e72.
39. Morad Y, Banin E, Averbukh E, et al. Treatment of ocular tis-
sues exposed to nitrogen mustard: beneficial effect of zinc
desferrioxamine combined with steroids. Invest Ophthalmol
Vis Sci 2005;46:1640e6.
40. Newsweek. ISIS using chemical weapons against kurds, say
british investigators. http://europe.newsweek.com/isis-using-
chemical-weapons-against-kurds-say-british-investigators-
330549. [Accessibility verified November 1, 2016].
41. Goldich Y, Barkana Y, Zadok D, et al. Use of amphoteric rinsing
solution for treatment of ocular tissues exposed to nitrogen
mustard. Acta Ophthalmol 2013;91:e35e40.
42. Viala B, Blomet J, Mathieu L, Hall AH. Prevention of CS “tear
gas” eye and skin effects and active decontamination with
Diphoterine: preliminary studies in 5 French Gendarmes. J
Emerg Med 2005;29:5e8.
43. Luka A, Stolbach A, Hoffman RS. Response to “Prevention of CS
‘tear gas’ eye and skin effects and active decontamination
with diphoterine: preliminary studies in 5 French Gendarmes”.
J Emerg Med 2007;32:309e10. author reply 10e1.
44. Matar H, Guerreiro A, Piletsky SA, Price SC, Chilcott RP. Pre-
liminary evaluation of military, commercial and novel skin
decontamination products against a chemical warfare agent
simulant (methyl salicylate). Cutan Ocul Toxicol 2016;35:
137e44.
45. Siewe CL, Barbe JM, Mathieu L, Blomet J, Hall A. Hexafluorine
decontamination of 70% hydrofluoric acid (HF) vapor facial
exposure: case report. J Chem Health Saf 2012;19:7e11.
46. Yoshimura CA, Mathieu L, Hall AH, Monteiro MG, de
Almeida DM. Seventy per cent hydrofluoric acid burns: delayed
decontamination with hexafluorine(R) and treatment with
calcium gluconate. J Burn Care Res 2011;32:e149e54.
47. Donoghue AM. Diphoterine(R) for alkali splashes to the skin.
Clin Toxicol (Phila) 2014;52:148.
48. Allison K. The UK pre-hospital management of burn patients:
current practice and the need for a standard approach. Burns
2002;28:135e42.
49. Allison K, Porter K. Consensus on the pre-hospital approach to
burns patient management. Injury 2004;35:734e8.
50. Executives AoAC. UK ambulance services clinical practice
guidelines 2016. 2016 ed. Class Professional Publishing; 2016.