As I travelled to work to day I heard on the radio that there had been five separate “acid attacks” in London last night. It appears that these were all perpetrated by the same assailants and the motivation for the attacks is still unclear. It is evident that assault with corrosive substances is becoming more common in the UK for a number of reasons; the ready access to the chemicals, the ease in which they can be carried and, if caught, the maximum charge of grievous bodily harm (GBH) associated with such attacks. This contrasts with a charge of attempted murder associated with knife attacks or the use of guns.
The evil nature of these attacks cannot be understated. The intent is to kill a person in terms of their identity, leaving them scarred for life and marginalized from society. Bangladesh had, at one time, the highest incidence of such attacks when looking at global figures. The basic motivation is one of three L’s: love, loans and land. Men, women and children are all victims. It took years of campaigning in Bangladesh to change the law and change the attitudes of the public. Acid assault is now regarded as a capital offence and there is a greater incentive to report such crimes as the police can no longer regard them with the former blind neglect. The incidence has dramatically reduced.
Attempts at registration of potentially harmful chemicals did not prove effective. It is possible to restrict access to high concentrations of certain acids, in particular sulphuric, nitric and hydrochloric acids. The widespread availability of weaker solutions, e.g. the 30-50% solutions of sulphuric acid used in car batteries make restricting access an impractical solution to this problem.
Having spent many years working with victims of acid assault and having worked in the Far East where acute acid assaults are more common it was apparent that standard first aid and acute management was not effective. In a paper published in the Indian Journal of Plastic Surgery in 2010 I proposed a more pragmatic approach. In selected cases, chemical assaults should be regarded as acute surgical emergencies with lavage supplemented by physical removal of chemical from the skin. The protocol was published in the 2010 and again in 2015. It requires assessment by an experienced burns surgeon who can perform the necessary tangential excision. I append the references to the two papers and include the protocol below.
The take home message is stark: chemical assaults are devastating in outcome and must be regarded in the same light as other capital offences; the intent is to destroy a person.
If an attack does occur then highly specialised acute management is required to decrease the damage and optimise the outcome.
- Burd A, Ahmed K. The acute management of acid assault burns: a pragmatic approach. Indian journal of plastic surgery: official publication of the Association of Plastic Surgeons of India 2010;43(1):29.
- Leung BC, Burd A. A case of chemical assault in Hong Kong (case report). International Journal of Surgery Case Reports 10 2015;10:223-7.
- This is an open access journal access URL http://ac.els-cdn.com/S2210261215001807/1-s2.0-S2210261215001807-main.pdf?_tid=71ed245e-689a-11e7-b06c-00000aacb35e&acdnat=1500040000_6619e35cf69e1ab4405e4e628e69155f
Protocol for acute management of acute assault burns in Prince of Wales Hospital, Shatin, Hong Kong
- Determine extent and severity of injury on admission to accident and emergency department
- Commence immediate lavage with running water
- Arrange for immediate eye consultation if eye involvement is suspected
- For confluent areas of discoloured skin in the face (>20cm2) and trunk or limbs (>100cm2), arrange for urgent examination under anaesthesia (EUA) in the operating theatres
- For smaller burns, arrange for transfer to burns unit and continue lavage
- For patients undergoing EUA, perform test shaves to determine depth of injury and shave entire area to achieve active bleeding (lacuna-like or punctate bleeding)
- Continue lavage by applying wet dressing changed every two hours for 48hours
- At 48 hours, apply porcine skin or similar product to wound to test graft bed
- After further 24-48hours, return to operating theatres for supplementary shave if necessary and definitive grafting with thick split thickness skin graft and over graft donor site