Conflict of Interest Declaration
The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None
The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: None
Task Force Synthesis Citation
Kule A, Pek JH, Charlton NP, Nguyen P, Djarv T - on behalf of the International Liaison Committee on Resuscitation First Aid Task Force. First Aid Interventions for a Caustic Agent Attack in Adults and Children Task Force Synthesis of a Scoping Review [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force. Available from: http://ilcor.org
Methodological Preamble and Link to Published Scoping Review
The continuous evidence evaluation process initiated a scoping review conducted by the ILCOR First Aid Task Force Scoping Review team. Evidence for adult and pediatric literature was sought by the First Aid Task Force group to scope the first aid literature on the treatment of caustic attacks. Both randomized and non-randomized data was considered. With the expert guidance of a medical librarian, a systematic search of the literature was conducted on September 13, 2025. Six-hundred-eleven articles were identified and following dual screening by the reviewers, 21 were included in the full text review. Eight articles met final inclusion criteria, including two prospective studies, two case series, three case reports and one animal study. No randomized trials were identified.
Scoping Review
Webmaster to insert the Scoping Review citation and link to PubMed using this format when/if it is available.
PICOST
The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)
Population: Any adult or child in the out of hospital setting subjected to a caustic agent attack to the skin or eye
Intervention: Any intervention immediately available to the trained or untrained first aid provider (e.g. irrigation, cold compression, washing with soap, baking soda) and duration
Comparators: Any other treatment and duration, or no treatment
Outcomes: Any clinical outcomes including pain relief, reduction in pain score, need for analgesia, extent of burn or tissue damage, intervention needed for burn or tissue damage, survival, adverse reaction from use of treatment (e.g. pain, erythema, allergy), and including harm to first aid providers
Study Designs: Any studies including animal studies, conference proceedings, abstracts, case reports and case series (all languages as long as there is an English abstract)
Timeframe: Published all years.
Literature search updated to 13 Sep, 2025.
Search Strategies
PubMed
# |
Concept |
Keywords |
MeSH |
1 |
Acid Attack |
“acid attack”[tiab:~3] OR “acid attacks”[tiab:~3] OR “acid throw”[tiab:~3] OR “acid throwing”[tiab:~3] OR “acid assault”[tiab:~3] OR “vitriol attack”[tiab:~3] OR “vitriol attacks”[tiab:~3] OR “vitriol throw”[tiab:~3] OR “vitriol throwing”[tiab:~3] OR vitriolage[tiab] OR vitriolism[tiab] OR “chemical assault”[tiab:~3] OR “assault corrosive”[tiab:~3] OR “violence corrosive”[tiab:~3] OR “throw corrosive”[tiab:~3] OR “corrosive attack”[tiab:~3] OR “corrosive attacks”[tiab:~3] |
|
2 |
First Aid Setting |
“emergenc*”[tiab] OR prehospital[tiab] OR “pre-hospital”[tiab] OR paramedic*[tiab] OR “rescue personnel”[tiab] OR “emergency respon*”[tiab] OR EMS[tiab] OR “emergency medical technician*”[tiab] OR EMT[tiab] OR “first respon*”[tiab] OR bystander*[tiab] OR “first-line”[tiab] OR “lay rescue*”[tiab] OR “lay person*”[tiab] OR layperson*[tiab] OR “lay population”[tiab] OR emergen*[tiab] OR immediat*[tiab] |
“Emergency Service, Hospital”[MeSH] OR “Emergency Medical Services”[MeSH] OR “First Aid”[MeSH] |
3 |
Acid Substances and Burns |
Alkali*[tiab] OR “sodium hydroxide”[tiab] OR “potassium hydroxide”[tiab] OR caustic*[tiab] OR acid[tiab] OR chemical*[tiab] OR burn*[tiab] OR “corrosive substance*”[tiab] |
Alkalies[MeSH] OR Acids[MeSH] OR Caustics[MeSH] OR “Burns, Chemical”[MeSH] OR “Burns, Inhalation”[MeSH] OR “Eye Burns”[MeSH] |
4 |
Treatment |
treat*[tiab] OR therap*[tiab] OR care[tiab] OR “first aid”[tiab] OR “initial assist*”[tiab] OR “first respon*”[tiab] OR “first assist*”[tiab] |
Therapy[sh] |
Limits |
NOT ("Animals"[Mesh] NOT ("Animals"[Mesh] AND "Humans"[Mesh])) AND english[la] NOT (comment[pt] OR editorial[pt] OR news[pt]) |
Medline via PubMed
https://pubmed.ncbi.nlm.nih.gov/ > Advanced search:
n=436 for all years on 9/13/25; n=55
Strategy 1: 1 AND (2 OR 3) (first aid/therapy specific to acid attacks) n=341 on 9/13/25
("acid attack"[tiab:~3] OR "acid attacks"[tiab:~3] OR "acid throw"[tiab:~3] OR "acid throwing"[tiab:~3] OR "acid assault"[tiab:~3] OR "vitriol attack"[tiab:~3] OR "vitriol attacks"[tiab:~3] OR "vitriol throw"[tiab:~3] OR "vitriol throwing"[tiab:~3] OR vitriolage[tiab] OR vitriolism[tiab] OR "chemical assault"[tiab:~3] OR "assault corrosive"[tiab:~3] OR "violence corrosive"[tiab:~3] OR "throw corrosive"[tiab:~3] OR "corrosive attack"[tiab:~3] OR "corrosive attacks"[tiab:~3]) AND ("emergenc*"[tiab] OR prehospital[tiab] OR "pre-hospital"[tiab] OR paramedic*[tiab] OR "rescue personnel"[tiab] OR "emergency respon*"[tiab] OR EMS[tiab] OR "emergency medical technician*"[tiab] OR EMT[tiab] OR "first respon*"[tiab] OR bystander*[tiab] OR "first-line"[tiab] OR "lay rescue*"[tiab] OR "lay person*"[tiab] OR layperson*[tiab] OR "lay population"[tiab] OR emergen*[tiab] OR immediat*[tiab] OR "Emergency Service, Hospital"[MeSH] OR "Emergency Medical Services"[MeSH] OR "First Aid"[MeSH] OR treat*[tiab] OR therap*[tiab] OR care[tiab] OR "first aid"[tiab] OR "initial assist*"[tiab] OR "first respon*"[tiab] OR "first assist*"[tiab] OR Therapy[sh]) NOT ("Animals"[Mesh] NOT ("Animals"[Mesh] AND "Humans"[Mesh])) AND english[la] NOT (comment[pt] OR editorial[pt] OR news[pt])
Strategy 2: 3 AND 4 AND (assault OR attack OR vitriol OR Violence[MeSH]) (therapy/treatment for acid substances used in attacks) n=114 on 9/13/25
(alkali*[tiab] OR "sodium hydroxide"[tiab] OR "potassium hydroxide"[tiab] OR "sulfuric acid*"[tiab] OR "nitric acid"[tiab] OR "hydrochloric acid"[tiab] OR "hydrofluoric acid"[tiab] OR "acid attack*"[tiab] OR caustic*[tiab] OR "chemical burn*"[tiab] OR "corrosive substance*"[tiab] OR Caustics[MeSH] OR "Burns, Chemical"[MeSH] OR "Burns, Inhalation"[MeSH] OR "Eye Burns"[MeSH]) AND (treat*[tiab] OR therap*[tiab] OR care[tiab] OR "first aid"[tiab] OR assist*[tiab] OR "first respon*"[tiab] OR Therapy[sh]) AND (vitriol*[tiab] OR violen*[tiab] OR terroris*[tiab] OR Violence[MeSH]) NOT ("Animals"[Mesh] NOT ("Animals"[Mesh] AND "Humans"[Mesh])) AND english[la] NOT (comment[pt] OR editorial[pt] OR news[pt])
Embase via Embase.com (Elsevier)
https://www.embase.com > Advanced search (no Embase mapping options selected): all years n=403 for all years on 9/13/25; n=55
Strategy 1: 1 AND (2 OR 3) (first aid/therapy specific to acid attacks) n=280 on 9/13/25
((('acid' NEAR/4 'attack'):ti,ab,kw) OR (('acid' NEAR/4 'attacks'):ti,ab,kw) OR (('acid' NEAR/4 'throw'):ti,ab,kw) OR (('acid' NEAR/4 'throwing'):ti,ab,kw) OR (('acid' NEAR/4 'assault'):ti,ab,kw) OR (('vitriol' NEAR/4 'attack'):ti,ab,kw) OR (('vitriol' NEAR/4 'attacks'):ti,ab,kw) OR (('vitriol' NEAR/4 'throw'):ti,ab,kw) OR (('vitriol' NEAR/4 'throwing'):ti,ab,kw) OR 'vitriolage':ti,ab,kw OR 'vitriolism':ti,ab,kw OR (('chemical' NEAR/4 'assault'):ti,ab,kw) OR (('assault' NEAR/4 'corrosive'):ti,ab,kw) OR (('violence' NEAR/4 'corrosive'):ti,ab,kw) OR (('throw' NEAR/4 'corrosive'):ti,ab,kw) OR (('corrosive' NEAR/4 'attack'):ti,ab,kw) OR (('corrosive' NEAR/4 'attacks'):ti,ab,kw) OR 'acid attack (violence)'/exp) AND ('emergenc*':ti,ab,kw OR 'prehospital':ti,ab,kw OR 'pre-hospital':ti,ab,kw OR 'paramedic*':ti,ab,kw OR 'rescue personnel':ti,ab,kw OR 'emergency respon*':ti,ab,kw OR 'ems':ti,ab,kw OR 'emergency medical technician*':ti,ab,kw OR 'emt':ti,ab,kw OR 'bystander*':ti,ab,kw OR 'first-line':ti,ab,kw OR 'lay rescue*':ti,ab,kw OR 'lay person*':ti,ab,kw OR 'layperson*':ti,ab,kw OR 'lay population':ti,ab,kw OR 'emergen*':ti,ab,kw OR 'immediat*':ti,ab,kw OR 'first responder (person)'/exp OR 'emergency care'/exp OR 'first aid'/de OR 'emergency treatment'/de OR 'rescue personnel'/de OR 'emergency health service'/exp/mj OR 'treat*':ti,ab,kw OR 'therap*':ti,ab,kw OR 'care':ti,ab,kw OR 'first aid':ti,ab,kw OR 'initial assist*':ti,ab,kw OR 'first respon*':ti,ab,kw OR 'first assist*':ti,ab,kw) AND [english]/lim NOT ([animals]/lim NOT [humans]/lim) NOT ('conference abstract'/it OR 'editorial'/it OR 'clinical trial'/it OR 'comment'/it OR 'letter'/it)
Strategy 2: 3 AND 4 AND (assault OR attack OR vitriol OR Violence) (therapy/treatment for acid substances used in attacks) n=141 on 9/13/25
('alkali*':ti,ab,kw OR 'sodium hydroxide':ti,ab,kw OR 'potassium hydroxide':ti,ab,kw OR 'sulfuric acid*':ti,ab,kw OR 'nitric acid':ti,ab,kw OR 'hydrochloric acid':ti,ab,kw OR 'hydrofluoric acid':ti,ab,kw OR 'acid attack*':ti,ab,kw OR 'caustic*':ti,ab,kw OR 'chemical burn*':ti,ab,kw OR 'corrosive substance*':ti,ab,kw OR 'acid attack (violence)'/exp OR 'caustic agent'/exp/mj OR 'chemical burn'/exp/mj OR 'lung burn'/exp/mj OR 'eye burn'/exp/mj) AND ('treat*':ti,ab,kw OR 'therap*':ti,ab,kw OR 'care':ti,ab,kw OR 'first aid':ti,ab,kw OR 'first aid'/de OR 'assist*':ti,ab,kw OR 'first respon*':ti,ab,kw) AND ('vitriol*':ti,ab,kw OR 'violen*':ti,ab,kw OR 'terroris*':ti,ab,kw OR 'terrorism'/exp/mj OR 'violence'/exp/mj) AND [english]/lim NOT ([animals]/lim NOT [humans]/lim) NOT ('conference abstract'/it OR 'editorial'/it OR 'clinical trial'/it OR 'comment'/it OR 'letter'/it)
CINAHL with Full Text via EBSCOHost
Advanced Search: Search Mode=Proximity, no Expanders selected, Filters =Academic Journals, English
n=60 for all years on 9/13/25
(XB (acid N3 attack) OR (acid N3 attacks) OR (acid N3 throw) OR (acid N3 throwing) OR (acid N3 assault) OR (vitriol N3 attack) OR (vitriol N3 attacks) OR (vitriol N3 throw) OR (vitriol N3 throwing) OR vitriolage OR vitriolism OR (chemical N3 assault) OR (assault N3 corrosive) OR (violence N3 corrosive) OR (throw N3 corrosive) OR (corrosive N3 attack) OR (corrosive N3 attacks)) AND XB (emergenc* OR prehospital OR pre-hospital OR paramedic* OR “rescue personnel” OR “emergency respon*” OR ems OR “emergency medical technician*” OR emt OR bystander* OR first-line OR “lay rescue*” OR “lay person*” OR layperson* OR “lay population” OR emergen* OR immediat* OR treat* OR therap* OR care OR “first aid” OR “initial assist*” OR “first respon*” OR “first assist*” OR (MH "Emergency Responders+") OR (MH "Prehospital Care") OR (MH "Red Cross") OR (MH "American Red Cross") OR (MH "Emergency Treatment") OR (MH "First Aid") OR (MH “Emergency Medical Services”))) OR (XB (“alkali*” OR “sodium hydroxide” OR “potassium hydroxide” OR “sulfuric acid*” OR “nitric acid” OR “hydrochloric acid” OR “hydrofluoric acid” OR “acid attack*” OR “caustic*” OR “chemical burn*” OR “corrosive substance*”) AND XB (treat* OR therap* OR care OR “first aid” OR “initial assist*” OR “first respon*” OR “first assist*”) AND (XB (vitriol* OR violen* OR terroris*) OR (MH Violence) OR (MH Terrorism))
APA PsycInfo via EBSCOHost
Advanced Search, Search Mode=Proximity, no Expanders selected, Filters =Academic Journals, English
n=32 for all years on 9/13/25
(XB (acid N3 attack) OR (acid N3 attacks) OR (acid N3 throw) OR (acid N3 throwing) OR (acid N3 assault) OR (vitriol N3 attack) OR (vitriol N3 attacks) OR (vitriol N3 throw) OR (vitriol N3 throwing) OR vitriolage OR vitriolism OR (chemical N3 assault) OR (assault N3 corrosive) OR (violence N3 corrosive) OR (throw N3 corrosive) OR (corrosive N3 attack) OR (corrosive N3 attacks)) AND XB (emergenc* OR prehospital OR pre-hospital OR paramedic* OR “rescue personnel” OR “emergency respon*” OR ems OR “emergency medical technician*” OR emt OR bystander* OR first-line OR “lay rescue*” OR “lay person*” OR layperson* OR “lay population” OR emergen* OR immediat* OR treat* OR therap* OR care OR “first aid” OR “initial assist*” OR “first respon*” OR “first assist*”)) OR (XB (“alkali*” OR “potassium hydroxide” OR “sulfuric acid*” OR “nitric acid” OR “sodium hydroxide” OR “hydrochloric acid” OR “hydrofluoric acid” OR “acid attack*” OR “caustic*” OR “chemical burn*” OR “corrosive substance*”) AND XB (treat* OR therap* OR care OR “first aid” OR “initial assist*” OR “first respon*” OR “first assist*”) AND (XB (vitriol* OR violen* OR terroris*) OR DE "Violence" OR DE "Terrorism"))
Cochrane Library via Wiley, Search Manager
n=3 on 9/13/25
Strategy 1 n=3
((acid NEAR/4 attack):ti,ab,kw OR (acid NEAR/4 attacks):ti,ab,kw OR (acid NEAR/4 throw):ti,ab,kw OR (acid NEAR/4 throwing):ti,ab,kw OR (acid NEAR/4 assault):ti,ab,kw OR (vitriol NEAR/4 attack):ti,ab,kw OR (vitriol NEAR/4 attacks):ti,ab,kw OR (vitriol NEAR/4 throw):ti,ab,kw OR (vitriol NEAR/4 throwing):ti,ab,kw OR vitriolage:ti,ab,kw OR vitriolism:ti,ab,kw OR (chemical NEAR/4 assault):ti,ab,kw OR (assault NEAR/4 corrosive):ti,ab,kw OR (violence NEAR/4 corrosive):ti,ab,kw OR (throw NEAR/4 corrosive):ti,ab,kw OR (corrosive NEAR/4 attack):ti,ab,kw OR (corrosive NEAR/4 attacks):ti,ab,kw) AND (emergenc*:ti,ab,kw OR prehospital:ti,ab,kw OR pre-hospital:ti,ab,kw OR paramedic*:ti,ab,kw OR rescue personnel:ti,ab,kw OR emergency respon*:ti,ab,kw OR ems:ti,ab,kw OR emergency medical technician*:ti,ab,kw OR emt:ti,ab,kw OR bystander*:ti,ab,kw OR first-line:ti,ab,kw OR lay rescue*:ti,ab,kw OR lay person*:ti,ab,kw OR layperson*:ti,ab,kw OR lay population:ti,ab,kw OR emergen*:ti,ab,kw OR immediat*:ti,ab,kw OR [mh "Emergency Service, Hospital"] OR [mh "Emergency Medical Services"] OR [mh "First Aid"] OR treat*:ti,ab,kw OR therap*:ti,ab,kw OR care:ti,ab,kw OR first aid:ti,ab,kw OR initial assist*:ti,ab,kw OR first respon*:ti,ab,kw OR first assist*:ti,ab,kw)
Strategy 2 n=0
(alkali*:ti,ab,kw OR "sodium hydroxide":ti,ab,kw OR "potassium hydroxide":ti,ab,kw OR "sulfuric acid":ti,ab,kw OR "nitric acid":ti,ab,kw OR "hydrochloric acid":ti,ab,kw OR "hydrofluoric acid":ti,ab,kw OR "acid attack":ti,ab,kw OR caustic:ti,ab,kw OR "chemical burn":ti,ab,kw OR "corrosive substance":ti,ab,kw OR [mh Caustics] OR [mh "Burns, Chemical"] OR [mh "Burns, Inhalation"] OR [mh "Eye Burns"]) AND (treat*:ti,ab,kw OR therap*:ti,ab,kw OR care:ti,ab,kw OR "first aid":ti,ab,kw OR assist*:ti,ab,kw OR first respon*:ti,ab,kw)
AND (vitriol*:ti,ab,kw OR violen*:ti,ab,kw OR terroris*:ti,ab,kw OR [mh terrorism] OR [mh violence])
Inclusion and Exclusion criteria
Inclusion Criteria: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies), case reports, case series, and animal studies that were conducted with agents common to caustic attacks. All sex and age groups were included if they suffered intentional skin and/or eye exposure injury. All years of publication and all languages as long as there is an English abstract. Published peer-reviewed, conference proceedings and abstracts were eligible for inclusion.
Exclusion criteria: Inhalation and ingestion caustic exposure, accidental injury.
Data tables
Nonrandomized Trials, Observational Studies
Study Acronym; Author; Year Published |
Study Type/Design; Study Size (N) |
Patient Population |
Primary Endpoint and Results (include P value; OR or RR; & 95% CI) |
Summary/Conclusion Comment(s) |
Merle 2005 205 |
Prospective cohort; n=66 patients (104 eyes) |
66 patients (104 eyes) with alkali ocular burns - 30 (45.5%) due to assault |
Eye irrigation was conducted with either 500 mL of physiologic solution (48 eyes) or 500 mL of Diphoterine® (56 eyes). Grade 1 and 2 burns had shorter time to reepithelization when rinsed with Diphoterine® (1.9 +/- 1 days) versus physiological solution (11.1 +/- 1.4) days, and (5.6 +/- 4.9) days and (10 +/- 9.2) days respectively. |
The time elapsed to reepithelialization was shorter with Diphoterine® for grade 1 and 2 burns. There were not enough cases of grade 3 and 4 burns to make a conclusion regarding the efficacy of treatment for these burns. The study demonstrated that the longer the delay between the accident and the rinse, the more serious the burn, suggesting that the establishment of a standardized protocol in advising the susceptible workforce to seek treatment in emergencies of chemical ocular burn will contribute to reduce this delay. |
Das 2015 484 |
Prospective cohort; n=93 patients had water applied as first aid therapy |
126 patients with acid injury presenting from July 2004 to Dec 2012, 95 patients were attacked, 31 patients had accidental injury. Alkali burns, late presentations and infected wounds were excluded. 93 patients had water applied as first aid therapy. |
On presentation, all 126 patients were washed with normal saline, hydrocolloid dressing applied for 48-72 hrs, then burns reassessed. All full and deep partial thickness burns underwent excision and grafting. 93 out of 126 studies had water applied as first aid. 63 out of the 93 cases were superficial or of superficial partial thickness and did not require any surgical intervention. 11 of 93 (11.4%) treated with first aid water application developed hypertrophic scarring as opposed to 16 of 33( 48.5%) that did not have first aid water application, RR 0.2440 (95% CI 0.1265 -0.4706). 83 out of 126 cases developed scarring. Out of 40 cases requiring excision and skin grafting, full thickness graft was applied in two cases and direct suturing of the wound was performed in four cases. In the remainder of cases split skin grafting was performed. |
If water irrigation is prompt and protracted, the burn depth is likely to be significantly reduced and unlikely to be full thickness. Authors suggest a protocol of removing clothes, then performing large volume irrigation for 30min-2hours. Eyes, if injured, should be irrigated for 0.5-1hrs. Hydrocolloid dressing helps burn depth determination after removal. |
Kessel 2015 e230 |
Case series; n=13 patients (19 eyes) |
13 patients (19 eyes). All male; mean age 32 ± 9 years. All were victims of assault using sprayed ammonium hydroxide. |
Initial treatment included irrigation with saline at emergency clinics. A combination of topical antibiotics, steroids, pupil dilation, sodium ascorbate (topical/systemic), doxycycline (systemic) were used depending on the severity of the injury. Outcomes were compared across Roper-Hall injury grades (1–4) and adherence to treatment. Severity at presentation: 3 eyes grade 1–2; 10 eyes grade 3; 3 eyes grade 4. Vision outcomes: Of 7 eyes with ≤0.1 Snellen (20/200), 5 were eviscerated, 1 phthisic with light perception only, 1 recovered to 0.2 (40/200). Eye loss: 5 eyes enucleated, 1 phthisic (total 6/19 eyes, 31.6%). Prognostic factors for severity of injury were poor initial visual acuity and full corneal epithelial defect. |
Irrigation was an initial treatment. However, no comment is made by the authors on the efficacy of this treatment and treatment was commenced in the emergency clinics. The authors noted that following collaboration between ophthalmologists, social workers and police, ammonium hydroxide assault was curtailed. |
Kadivar 1991 171 |
Case series; n=>5000 soldiers |
The population affected by the Majnoon Island attack - battlefield victims, civilians and healthcare personnel. Interventions include: Self-protective measures for healthcare providers; separation of victims from contaminants by clothing removal, fresh air, decontamination of the skin by water alone; ophthalmic anti-inflammatories, mydriatics. |
All battlefield victims were transported to a field hospital there they were decontaminated (mechanism of decontamination not listed) Skin symptoms included itching and erythema, papules, vesicles, and blisters. Burns covered 20% to 70% of the total skin surface. Eye symptoms included lacrimation, conjunctivitis, corneal abrasion and temporary loss of vision. Airway irritation symptoms included coughing, shortness of breath and occasional hemoptysis, wheezing and ARDS. |
This paper is a discussion on the effects of chemical warfare on victims and treatments for unknown multiple toxin exposures in the Majnoon Island attack. There is a description of treatment recommendations for chemical exposure in general, including washing of all exposed areas for decontamination and water being the best all-purpose decontaminating agent. The authors state that the eyes should be irrigated copiously with water or physiologic saline solution. |
Satbir 2025 11 |
Case report; n=1 |
21-year-old female assaulted with battery acid solution containing a high concentration of sulfuric acid during an altercation. |
In the prehospital setting, she removed her clothing and rinsed off the acid with tap water. Upon arrival at the emergency department, eschar formation over face, chest, bilateral upper limbs, bilateral thighs (9% TBSA). Underwent early tangential excision, hydrosurgery, and skin allograft application over the chin, anterior chest, bilateral upper limbs, and bilateral thighs 3 days later. Underwent further debridement over face via hydrosurgical techniques and skin allograft application. Once allografts were rejected 2 weeks later, another wound debridement and thick split-thickness skin graft was applied over her face, neck and bilateral thighs. |
The authors conclude that immediate and thorough irrigation is important in chemical burns, to reduce contamination and contact time of the chemical and help lessen tissue damage. |
D'Alessandro 2020 e123 |
Case report; n=1 |
27-year-old male assaulted with sulphuric acid poured over his head causing extensive burns and eye injury. |
No apparent first aid irrigation was received. On arrival to ED, he received soap and water decontamination, and irrigation of corneas with Morgan’s lenses. Further decontamination and corneal irrigation were performed on the Burns Unit. He had multiple surgeries, 102 day stay, 20/50 vision in left eye, light perception in right eye. |
The report concludes that prognosis is dependent on time to treatment and lack of standardized studies pertaining to sulphuric acid burns. |
Leung 2015 223 |
Case report; n=1 |
One 16-year-old female victim of an acid (unknown type) assault |
No apparent first aid irrigation was received. Treatment included irrigation upon arrival at the local hospital, transfer to burn center with continued irrigation. She had examination under anesthesia with skin shaving thin layer removal, saline soaks q2h × 48 h, and definitive split-thickness skin grafting on days 3–5. On one year follow-up wounds had healed with minimal hypertrophic scarring on the trunks, limbs and face. There were two linear areas of hypertrophic scar on the face that were attributed to the inability to do tangential shaving in that area. |
Irrigation of the burns were commenced at the local hospital and continued at the burn center. Early tangential shaving was postulated to reduce residual acid load and preserves viable tissue, decreasing hypertrophic scarring and reconstructive need. |
Matar 2024 1968 |
Animal study |
Full thickness skin obtained post-mortem from four female pigs are exposure to sulphuric acid and decontaminated by using weighted 3-ply absorbent paper applied for a total of 10sec (dry decontamination), 90sec showering with water at 21 degrees Celsius, 7.2ml/min (wet decontamination), dry followed by wet decontamination, a layer of 100% cotton t-shirt material applied for a total of 10sec (clothing layer decontamination). |
Wet, dry and wet, and clothing layer decontamination resulted in significant improvement in receptor chamber pH when performed 10sec post exposure. However, decontamination from 30sec onwards negated this effect. There was no statistically significant difference in the extent of skin surface damage between decontaminated groups. Wet, and dry and wet were consistently the most effective treatment for reducing sulphur content. |
The study suggests that decontamination procedures which include aqueous irrigation may be slightly more effective than those based on dry decontamination. The sooner water irrigation was performed the less severe the resulting chemical burn. The study found practically no window of opportunity for acid decontamination as damage is virtually instantaneous. Dry decontamination which involves rubbing or wiping the skin appears to be contraindicated for acid exposures. |
Task Force Insights
1. Why this topic was reviewed.
The global incidence of caustic agent attacks, also referred to as chemical assaults, is rising, with an estimated 10,000 cases annually worldwide (“Acid Survivors Trust International,” 2025). These assaults are rarely fatal but are typically intended to cause permanent scarring, disfigurement, and long-term disability, and they are frequently associated with profound psychological trauma and socioeconomic hardship (Burd 2010 29; Grundlingh 2017 358; Mannon 2007 159). Data from the United Kingdom highlight the public health significance of these injuries: in an 8-year review of 185 patients, chemical burns represented only about 10% of all burn cases yet were responsible for a disproportionately high share of burn-related mortality. Over a 25-year period, industrial chemical injuries declined, while domestic chemical burns increased, comprising 42% of exposures in the more recent cohort (Hardwicke 2012 383). Commonly implicated agents include nitric and sulfuric acids, sodium hydroxide, and in some regions, hydrofluoric acid, which is easily accessible through household and industrial cleaning products (Atley 2015 157; Mannan 2006 235; Milton 2010 924). Although several countries have introduced or proposed regulatory measures, significant gaps remain in the evidence guiding optimal first aid management for these victims. For this reason, and because no prior systematic evaluation existed, the ILCOR First Aid Task Force selected this topic for formal review.
2. Narrative summary of evidence identified
In this review, a total of eight observational studies were identified: two prospective cohorts, two case series, three case reports and one animal study.
The caustic agent was identified as an alkali in two studies (Merle 2005 205; Kessel 2015 e230), an acid in four studies (Matar 2024 1968, Satbir 2025 11, D'Alessandro 2020 e123, Das 2015 484), and unknown in two studies (Leung 2015 223; Kadivar 1991 171). Two studies had victims with skin and eye involvement (Kadivar 1991 171; D'Alessandro 2020 e123), three had victims with only skin involvement (Satbir 2025 11, Das 2015 484; Leung 2015 223), two had victims with only eye involvement (Merle 2005 205; Kessel 2015 e230) and the animal study involved pig skin (Matar 2024 1968). The agents used for decontamination included water (Matar 2024 1968, Satbir 2025 11, Das 2015 484), water and soap (D'Alessandro 2020 e123), physiological solution or normal saline (Merle 2005 205, Das 2015 484, Kessel 2015 e230) and Diphoterine® (Merle 2005 205). Two studies did not mention how decontamination was performed (Leung 2015 223 and Kadivar 1991 171). Decontamination was performed as first aid in the pre-hospital setting in two studies (Satbir 2025 11, Das 2015 484), and in the emergency department or hospital in five studies (Satbir 2025 11, D'Alessandro 2020 e123, Leung 2015 223, Kadivar 1991 171 and Kessel 2015 e230).
Outcomes reported included improvement in pig skin pH and reduction in sulphur content post exposure, extent of pig skin surface damage for the animal study (Matar 2024 1968; Scarring (Das 2015 484 and Leung 2015 223), need for surgical intervention (Satbir 2025 11, D'Alessandro 2020 e123, Das 2015 484 and Leung 2015 223) and grafting (Satbir 2025 11, Das 2015 484 and Leung 2015 223) for skin exposure; Eye evisceration (Kessel 2015 e230), time to re-epithelization (Merle 2005 205) and vision (D'Alessandro 2020 e123 and Kessel 2015 e230) for eye exposure.
One prospective cohort study (Merle 2005) evaluated Diphoterine®, a commercially available amphoteric irrigation solution for the skin and eyes, versus physiologic saline for ocular alkali burns (Merle 2005 205). Among grade 1–2 injuries, time to corneal re-epithelialization was substantially shorter with Diphoterine® irrigation. Data on severe (grade 3–4) burns were insufficient for meaningful conclusions. The study also demonstrated that delays to irrigation correlated with injury severity, reinforcing the importance of early rinsing. A prospective cohort from Das et al. (2015) observational evidence that first aid water irrigation reduces burn depth and subsequent scarring in victims of acid assault (Das 2015 484). Among 126 patients with acid burns, those who received immediate water irrigation (n=93) had significantly lower rates of hypertrophic scarring (11.4% vs 48.5%) with a relative risk of 0.24 (95% CI 0.13–0.47). Water-irrigated patients more frequently presented with superficial or superficial partial-thickness injuries, requiring fewer surgical interventions. A controlled porcine skin model (Matar 2024 1968) demonstrated that water-based decontamination (wet or combined dry-then-wet) performed within 10 seconds of acid exposure improved receptor chamber pH and reduced sulfur content. Delayed irrigation (>30 seconds) resulted in loss of benefit, reflecting the extremely narrow window before irreversible tissue damage occurs. A case series by Kessel in 2015 describes severe ammonium hydroxide ocular injuries among 13 patients (Kessel 2015 e230). Although saline irrigation was used initially, the authors did not evaluate its effectiveness relative to other treatments. Outcomes appeared primarily driven by initial injury severity; many eyes progressed to evisceration or phthisis. Several case reports and case series (Kadivar 1991 171; Satbir 2025 11; D'Alessandro 2020 e123; Leung 2015 223) document irrigation as either a first aid measure or initial hospital treatment, However, due to the nature of these reports, it is not possible to draw conclusions from these articles.
Across the non-randomized, observational, and case-based literature, there is consistent but very low-certainty evidence that immediate and copious water irrigation reduces burn severity, limits tissue destruction, and improves clinical outcomes following acid and alkali chemical exposures to the skin or eyes. Evidence pertaining to specialized irrigation solutions (Diphoterine®) is limited but suggests potential benefit in certain ocular alkali injuries. Given limited data, it is felt that a more specific systematic review would not identify additional information or lead to increased science or recommendations on the topic.
3. Narrative Reporting of the Task Force Discussions
The Task Force discussed that there is only low level evidence identified in this review, primarily derived from cohort studies, case reports/case series, and animal studies, making it difficult to draw definitive conclusions from the data. However, while data is limited, early, copious irrigation appears to be beneficial and a consistently used modality in the treatment of caustic injury to the skin and eyes.
Of the data discussed, the strongest quantitative evidence comes from a prospective cohort of acid assault victims in which prompt first aid water irrigation was associated with a markedly lower risk of hypertrophic scarring (Das 2015 484). Multiple case reports and case series document early self-initiated or hospital initiated irrigation, however it is not possible to draw conclusions from this data due to a lack of controls. Animal data support this mechanistic rationale, showing that even brief delays in irrigation sharply diminish its protective effect.
Human and animal data suggests that immediate irrigation is of primary importance, with first aid irrigation being associated with a decreased risk of hypertrophic scarring in one study (RR 0.2440 (95% CI 0.1265 -0.4706) (Das 2015 484). In addition, an animal study demonstrated that pH improvement was significant when commenced within 10 seconds of exposure, however this effect was lost when treatment was delayed by 30 seconds or more. Therefore, the task force emphasizes the importance of immediate decontamination of the individual. Irrigation should occur as soon as possible after the event.
The Task Force believes that water is likely the most available decontamination substance worldwide. Some individuals or hospitals may have more access to physiologic solution/normal saline. Evidence pertaining to specialized irrigation solutions (Diphoterine®) is limited coming from a single study, but suggested improved outcomes in ocular alkali injuries. Diphoterine® is an amphoteric, hypertonic rinsing solution designed for the emergency decontamination of chemical splashes on the skin or in the eyes. While there may be some benefit of commercial agents, such as Diphoterine®, over other irrigation media in some instances or for some chemicals, these agents may not be readily available to most individuals and recommending such substances may increase health disparities.
While little data is available to support the efficacy of removing contaminated clothing, clothing, shoes, and jewelry that are contaminated with corrosive substances, these itemscan continue to deliver the chemical to the skin, deepening tissue injury and extending exposure time. Therefore, contaminated items should be carefully removed as soon as possible, ideally while ensuring that individuals avoid secondary contamination.
While no studies assess the benefit of contact lens removal from the eyes following caustic exposure, similar to clothing removal, the prompt removal of contact lenses is expected to decrease the chemical contact with the eye. During initial eye irrigation, lenses should be removed as soon as feasible, to ensure thorough decontamination of the entire ocular surface. If removal is difficult, continuous irrigation should not be delayed, but efforts to safely remove the lenses should continue once adequate flushing has begun.
The Task Force discussed the lack of available evidence based recommendations for the treatment of caustic attack and acknowledges that the lack of such recommendations may lead to the improper first aid treatment, including decontamination, of the individual. Olaitan and Jiburum discuss the use of improper decontamination agents in their 2008 article (Olaitan 2008 20). In this study, raw eggs, palm oil, gentian violet and engine oil were the agents that were improperly used for decontamination. While some improperly used decontamination agents may not effectively remove the caustic, some, such as neutralizing substances, may generate heat through a chemical reaction and worsen the chemical injury. The Task Force recognizes that there are many gaps in the current literature, including the optimal agent for decontamination, the rapidity of which decontamination needs to be performed, and what importance removal of clothing plays in the decontamination process. Although the studies included in this review are limited by methodological weaknesses, the body of evidence indicates that rapid water irrigation is a critical early intervention that likely improves outcomes in chemical burns. Caustic attack is a substantial problem throughout the world, causing marked morbidity to those victims and the Task Force believes that worldwide morbidity can be improved by making evidence-based treatment recommendations.
Therefore, the Task Force chooses to issue the following good practice statement:
Good Practice Statement
Following a caustic attack, immediately irrigate the injured person’s affected area with copious amounts of water or saline.
Knowledge Gaps
There were few studies identified that assessed the use of irrigation in the first aid setting.
Only two controlled trials were identified.
Only one study was identified that evaluated commercial decontamination products.
No studies were identified that directly assessed the timing of decontamination.
No studies assessed the importance of removal of contaminated clothing.
No studies assessed alternative treatment options in the event that clean water was not available in low resource settings.
References
Acid Survivors Trust International. (2018). Retrieved November 11, 2025, from https://asti.org.uk/
Atley K, Ridyard E. Treatment of hydrofluoric acid exposure to the eye. Int J Ophthalmol. 2015 Feb 18;8(1):157-61. doi: 10.3980/j.issn.2222-3959.2015.01.28. PMID: 25709926; PMCID: PMC4325260.
Burd A, Ahmed K. The acute management of acid assault burns: A pragmatic approach. Indian J Plast Surg. 2010 Jan;43(1):29-33. doi: 10.4103/0970-0358.63952. PMID: 20924446; PMCID: PMC2938618.
D'Alessandro AD, Sikon JR, Lacy AJ, et al. Vitriolage by Sulfuric Acid: Unique Challenges and Considerations in Patient Resuscitation. J Emerg Med. 2020 Oct;59(4):e123-e126. doi: 10.1016/j.jemermed.2020.06.038.
Das KK, Olga L, Peck M, et al. Management of acid burns: experience from Bangladesh. Burns. 2015 May;41(3):484-92. doi: 10.1016/j.burns.2014.08.003.
Grundlingh J, Payne J, Hassan T. Attacks with corrosive substances are increasing in UK. BMJ. 2017 Aug 2;358:j3640. doi: 10.1136/bmj.j3640. PMID: 28768634.
Hardwicke J, Hunter T, Staruch R, Moiemen N. Chemical burns--an historical comparison and review of the literature. Burns. 2012 May;38(3):383-7. doi: 10.1016/j.burns.2011.09.014. Epub 2011 Oct 28. PMID: 22037150.
Kadivar H, Adams SC. Treatment of chemical and biological warfare injuries: insights derived from the 1984 Iraqi attack on Majnoon Island. Mil Med. 1991 Apr;156(4):171-7.
Kessel L, Lindegaard J, Boberg-Ans G, et al. Assault cases involving ammoniumhydroxide - a series of 19 eye alkali eye injuries. Acta Ophthalmol. 2015 May;93(3):e230-1. doi: 10.1111/aos.12539.
Leung BC, Burd A. A case of chemical assault in Hong Kong (case report). Int J Surg Case Rep. 2015;10:223-7. doi: 10.1016/j.ijscr.2015.03.059.
Mannan A, Ghani S, Clarke A, White P, Salmanta S, Butler PE. Psychosocial outcomes derived from an acid burned population in Bangladesh, and comparison with Western norms. Burns. 2006 Mar;32(2):235-41. doi: 10.1016/j.burns.2005.08.027. Epub 2006 Jan 31. PMID: 16448773.
Mannan A, Ghani S, Clarke A, Butler PE. Cases of chemical assault worldwide: a literature review. Burns. 2007 Mar;33(2):149-54. doi: 10.1016/j.burns.2006.05.002. Epub 2006 Nov 13. PMID: 17095164.
Matar H, Vuddanda PR, Chilcott RP. Evaluation of emergency skin decontamination protocols in response to an acid attack (vitreolage). Burns. 2024;50(8):1968-1976.
doi:10.1016/j.burns.2024.07.003
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(2):205-211. doi:10.1016/j.burns.2004.09.001
Milton R, Mathieu L, Hall AH, Maibach HI. Chemical assault and skin/eye burns: two representative cases, report from the Acid Survivors Foundation, and literature review. Burns. 2010 Sep;36(6):924-32. doi: 10.1016/j.burns.2009.10.020. Epub 2010 Jan 18. PMID: 20080356.
Olaitan PB, Jiburum BC. Chemical injuries from assaults: An increasing trend in a developing country. Indian J Plast Surg. 2008 Jan;41(1):20-3. doi: 10.4103/0970-0358.41106. PMID: 19753196; PMCID: PMC2739541.
Satbir SG, Fatimah MJ, Ahmad SH, et al. Unmasking the silent threat: deep tissue impacts of chemical burns – a case report. Burns Open. 2025;11:100412. doi.org/10.1016/j.burnso.2025.100412.