Burns management

[Melbourne MICA]

Hi troops,

Doesn't get discussed much these days - almost completely overlooked in fact, but can colleagues give me some idea how US EMS is treating burns these days especially the burn first aid aspect. This is a big issue in the UK and elsewhere relative to dressing choices like hydrogels which are still widely used and promoted in the US. My own research suggests there is paranoia about hypothermia in burns in the US driving a lot of decisions about cooling and meanwhile the likes of Water-jel are flogging product everywhere. The clinical evidence is telling us 20 mins of water cooling as a one off procedure then simple clingfilm dressing. Airway priorities, IV placement, analgesia +++ and fluid resus etc, are givens.

 

[VentMonkey]

For smaller, localized burns (think Rule of Palms) cool, sterile dressing should suffice. For larger BSA burns keeping the patient normothermic, while providing judicious volume replacement seems to still be the standard in the U.S. prehospital arena.

I do know there seems to be more emphasis on conservative fluid replacement as fluid overloading started either prehospitally, or in the ED is a real concern when admitting patients to burn units.

EMCrit recently did a podcast re: in-hospital burn management. The takeaways I got from it were utilizing the Modified-Brooke in-lieu of the old Parkland Formula, as well as starting off with a 500 ml/ hr initial fluid resuscitation approach before being able to calculate a more accurate burned BSA.

Interesting side note—the presenting physician is Canadian.

All in all, in the field these are the major changes that I know of/ have heard of in The States. So other than that it’s standard care, try not to fuid overload them (as this can truly cause more harm than good long term), keep them warm (normothermic), adequately oxygenated them, and of course keep them comfortable with proper and appropriate analgosedation.

 

[Melbourne MICA]

For smaller, localized burns (think Rule of Palms) cool, sterile dressing should suffice. For larger BSA burns keeping the patient normothermic, while providing judicious volume replacement seems to still be the standard in the U.S. prehospital arena.

I do know there seems to be more emphasis on conservative fluid replacement as fluid overloading started either prehospitally, or in the ED is a real concern when admitting patients to burn units.

EMCrit recently did a podcast re: in-hospital burn management. The takeaways I got from it were utilizing the Modified-Brooke in-lieu of the old Parkland Formula, as well as starting off with a 500 ml/ hr initial fluid resuscitation approach before being able to calculate a more accurate burned BSA.

Interesting side note—the presenting physician is Canadian.

All in all, in the field these are the major changes that I know of/ have heard of in The States. So other than that it’s standard care, try not to fuid overload them (as this can truly cause more harm than good long term), keep them warm (normothermic), adequately oxygenated them, and of course keep them comfortable with proper and appropriate analgosedation.

Thanks for the reply VentMonkey. I was angling more at the first aid issue actually. Fluid loading burns pre-hospital is a vexed problem to be sure because of very poor TBSA estimations and this is well reported in the literature. I'm not sure why there is so much attention to the formulae for calculating fluid volume when paramedics and physicians alike can't get the TBSA right to begin with.

The focus for myself and burn care colleagues overseas and at home has been the burn first aid problem because it involves EMS, ED departments and the public as well. In clinical terms it is also highly underestimated in terms of impact on patient outcomes. The US EMS/Emergency medicine scene is, firstly, dogged by paranoia about hypothermia from cooling and secondly too heavily influenced by industry lobbying especially regarding burns dressings like hydrogels and I have already written the first and only formal systematic review on hydrogel burn dressings in first aid. Water-Jel brand is the dominant player in both the US and UK where they have huge lobbying power and are not averse to using some pretty dodgy tactics to influence policy. Everyone is moving to a 20 minute single shot cooling model because its the best supported by evidence. This point is the beginning of the discussion here and I'm interested in your thoughts and those of others in EMS.

 

[Peak]

The US EMS/Emergency medicine scene is... too heavily influenced by industry lobbying especially regarding burns dressings like hydrogels and I have already written the first and only formal systematic review on hydrogel burn dressings in first aid. Water-Jel brand is the dominant player in both the US and UK where they have huge lobbying power and are not averse to using some pretty dodgy tactics to influence policy.

Honestly I had never heard of the brand. We didn't have them when I was in Fire, we didn't use them in our burn program when I worked at a level 1 pediatric trauma center, and we don't use them at my current system.

When I was in the field if they were sick after we pulled them out we put them in the bus and started transporting emergent to the flight pad where they would be flown the the regional burn unit. Minor burns could be irrigated with room temp/tepid water and then covered with sterile non-adherent pads. When I was at the level 1 peds system burns weren't really "hot" by the time they got there, but we generally dressed them with triple antibiotic soaked petrolium dressings until the burn surgeon could see them. My current system doesn't directly receive many burns from the field but we get some transfers in for hyperbaric or peds ECMO care, we basically do the same thing.

 

[Melbourne MICA]

Honestly I had never heard of the brand. We didn't have them when I was in Fire, we didn't use them in our burn program when I worked at a level 1 pediatric trauma center, and we don't use them at my current system.

When I was in the field if they were sick after we pulled them out we put them in the bus and started transporting emergent to the flight pad where they would be flown the the regional burn unit. Minor burns could be irrigated with room temp/tepid water and then covered with sterile non-adherent pads. When I was at the level 1 peds system burns weren't really "hot" by the time they got there, but we generally dressed them with triple antibiotic soaked petrolium dressings until the burn surgeon could see them. My current system doesn't directly receive many burns from the field but we get some transfers in for hyperbaric or peds ECMO care, we basically do the same thing.

Thanks for the input "Peak".

There are a dozen different models of pre-hospital first aid burn practice in US EMS guidelines and a dozen brands of hydrogel dressings. Burnshield, Burnfree, Reliburn, Water-Jel, Aquashield and so forth. But make no mistake, Water-Jel is the biggest player by far. But currently at least, and based upon the best available evidence, there is only one approach to burn first aid that clearly shows improvements in end outcomes like rate of re-epithelialisation, level of scar formation, recovery times, need for surgical interventions, length of in-hospital and ICU stay and more.

https://www.ncbi.nlm.nih.gov/pubmed/26808839

This is the 20 minutes of cooling with water as a single intervention. The value of cooling in deep burns (not large burns) remains controversial because the aim is of course to reduce progression of the burn as well as provide analgesic benefit. How can cooling benefit a burn that is full thickness already? But because there has never been a universal model of care and little interest in benefits derived from pre-hospital sector interventions the situation is a basket case (especially in the US) that rarely ever gets an airing.Given the relative cost of burns in trauma care as a subset of the total (burns are hugely over-represented) and the implications for patient outcomes there is an obvious need to push the burn first aid barrow, particularly in light of the role the public plays in applying burn first aid to good effect BEFORE any professional level of care (e.g. EMS) is involved. Here In Australia we already made the switch, and phone communications at point of call include instruction to cool for 20 mins and to wrap burns with clingfilm dressing before paramedics arrive. There are no dry dressing approaches in Australia and soon to be none in the UK, Europe, many areas of Africa, Europe and so on. Because the US philosophy is so entrenced in individualism and anything "universal" like all EMS providers applying the same guidelines is seen as some kind of socialist model we see everything from dry dressing to cooling for small burns only, use of hydrogels for cooling and dressing, cooling for 10 minutes, vague notions like "stop the burning process", cooling "till pain resolved" and on and on. I have data in abundance and have published this previously. I presented this information in detail at the 2011 ANZBA conference.

 

[RocketMedic]

Anecdote and familiarity has made me a Watergel fan. Great for everything from nasty sunburn to 2/3rd degree burns.

 

[EpiEMS]

@Melbourne MICA Apparently, the American Burn Association recommends only clean, dry dressings...

Many state protocols (NYS, for example) give two BLS treatment recommendations:

For partial-thickness burns less than 10% TBSA, moist dressings. For full-thickness burns and partial-thickness over 10% TBSA, apply dry sterile dressings.

Looking through several state protocols, there's clearly an emphasis on the hypothermia prevention, both the iatrogenic and the environmental.

 

[Melbourne MICA]

Anecdote and familiarity has made me a Watergel fan. Great for everything from nasty sunburn to 2/3rd degree burns.

Anecdote and familiarity has made me a Watergel fan. Great for everything from nasty sunburn to 2/3rd degree burns.

Hi Rocket Medic and thanks for replying.

Excuse my over zealous attitude and no offence intended - but "anecdote and familiarity" as well "great for everything" aren't really evidence based remarks supported by studies especially from a seasoned expert like your self . If you were to read my systematic review on hydrogels published in the International Wound Journal in 2015 you might understand why I cringe somewhat when my colleagues say such things. In fact, Water-jel and their ilk market based around anecdote and testimonial type information precisely because they have no evidence whatsoever to back up their clinical claims. Yet they have penetration into the EMS and first aid sectors on just about every continent. Can I suggest you watch some of their YouTube videos - jaw dropping, appalling, are you f##king kidding responses come to mind. The ones with this baldy headed guy are the funniest. His name is Paddy Bourke and he's their "Clinical educator" who has never actually seen a burn patient in his life yet is held up as an expert on pre-hospital burn management. Such is the marketing spin of Water_jel in particular. Meanwhile patients don't benefit from the approach supported by the best evidence.

 

[Melbourne MICA]

@Melbourne MICA Apparently, the American Burn Association recommends only clean, dry dressings...

Many state protocols (NYS, for example) give two BLS treatment recommendations:

For partial-thickness burns less than 10% TBSA, moist dressings. For full-thickness burns and partial-thickness over 10% TBSA, apply dry sterile dressings.

Looking through several state protocols, there's clearly an emphasis on the hypothermia prevention, both the iatrogenic and the environmental.

Thanks for the info, links and reply EpiEMS,

Burn first aid guidelines everywhere are a basket case. Almost all, except for the 20 minute cooling paradigm are unsupported by evidence - they are all either local physician creations, consensus recommendations from the associations adopted in part or full into EMS guidelines or just arbitrary conventions. There are no studies about dressing choice that indicate in-field wet or dry dressings - the best study on dressings for partial thickness injury is By Wasiak et al, a Cochrane systematic review no less. (Attached). Likewise there are absolutely no studies supporting percentage delineations on cooling/dressing choice. The only aspect of care with reams of evidence is the water cooling aspect - the most important component, yet US EMS governance all seemed spooked by the hypothermia issue despite 20 minute water cooling models being used already here in Australia (since 2012 in my service) and now in the UK.

 

[Flying]

Good to see you again. Apart from the givens regarding immediate life concerns and pain management, in my area folks are being told to estimate the burned area using the palm or the rule of nines, then proceed with the Parkland formula for fluid resuscitation. The burned area may be covered with dry sterile dressings or a clean linen sheet.

So, not much has changed regarding the problem of fluid estimates and hypothermia worries.

 

[StCEMT]

Same as what Flying said.

 

[Melbourne MICA]

Hi troops and thanks for the interest. When I speak to colleagues here in Australia and in the UK, they are gobsmacked at the absence of cooling in so many EMS protocols in the US. There are so many papers and other sources of information on the benefits of water cooling to burn patient outcomes. And I'm not referring just to immediate pain management. Histological outcomes are better, the need for surgical procedures are reduced, less time in hospital, faster recoveries, less scar tissue..........!!!!!!!! What the changes to the CPG's over here and now in the UK have shown is cooling as single block, then covering and warming can deliver all the clinical benefits of water cooling whilst mitigating the risk and onset of hypothermia.

In part the success has been achieved by recognising the lay public are part of the treatment continuum in the same way public access to AED's and early CPR have contributed to better arrest outcomes. The public are guided as soon as they call in on the 911 phone line so when paramedics arrive, cooling has already been done, even clingfilm covering sometimes. This means the crews can focus on all the other aspects of burn care especially temperature regulation. It is far easier and more effective to warm the patient in the closed environs of the truck. With IN opiates like Fentanyl this can be given as soon as you arrive by one paramedic whilst the other blanket wraps the patient gets obs etc. The IV for fluids is done in the truck. We are still working on warmed fluids for all vehicles. Not much point going to all that trouble to warm the patient then dump in winter temperature cold fluids. The cooling and the warming components of care are the key and given ongoing issues with TBSA estimations making fluids volumes from paramedics inaccurate at best, there clearly needs to be more research from US EMS. I cannot fathom how all these facts have escaped discussion and must wonder why nobody over there has drawn the same conclusions. Is it litigation nerves about hypothermia or is the discussion dominated by a particular viewpoint? I also meant to add there are some sticky problems without a resolution yet and a biggy is hypothermia induced by RSI for airway control. No thermogenesis once your paralysed. And passive warming doesn't work. I was informed about a cluster of RSI's airway burn patients who all arrived at ED cold - <35 deg C. Mostly around the 31 deg C mark. And these patients were managed by our MICA crews who did everything possible to warm the patients to no avail.

 

[EpiEMS]

@Melbourne MICA
One thing about the U.S. to keep in mind...EMS is a wretched hybrid of public safety and healthcare, and our practices (partially due to a lack of education, and partially due to what I would call "culture") tend to lag behind evidence-based-practice that the rest of the world might adopt.

 

[RocketMedic]

So I personally have been badly sunburned. Multiple times, unfortunately.

Watergel granted rapid, laying relief and made life suck a lot less as compared to dry sterile dressings used for previous sun blisters. Watergel seems to work very well.

 

[EpiEMS]

Watergel granted rapid, laying relief and made life suck a lot less as compared to dry sterile dressings used for previous sun blisters

Hey, as long as it's low TBSA, WaterJel all you like

Sidenote, seems like hypothermia is pretty rare in burn patients, except for those with high TBSA and/or deep burns...

 

[RocketMedic]

I have honestly only ever had one high-bsa major burn.

 

[RocketMedic]

To build on this: @Melbourne MICA , it's not necessarily that warming and temperature management aren't in the protocols. Is it done enough? Probably not, but it's worth noting that a fairly common layperson's response to a burn is to 'put them out' in the case of a thermal burn caused by fire, or to initiate some form of cooling if at all possible in contact/flashover scenarios. The Waterjel and other products are convenient additives to these layperson responses, not substitutes, and they seem to be pretty effective at controlling pain (beyond adaptic gauze, etc). When used in conjunction with opiates and ketamine, burn pain has been very well controlled (in my experience).

 

[Melbourne MICA]

So I personally have been badly sunburned. Multiple times, unfortunately.

Watergel granted rapid, laying relief and made life suck a lot less as compared to dry sterile dressings used for previous sun blisters. Watergel seems to work very well.

Generally speaking, EMS don't go to sunburn cases so a Water-Jel on your sunburn is a personal choice. Problem is, there are so many alternative burn remedies out there people don't discriminate about their sunburn and when the kid gets the pot of boiling water they will use their sunburn hydrogel pack or their toothpaste or potato peels, tumeric powder, vinegar on the major burn which doesn't have to have a large TBSA to be a critical injury. But the clinical outcomes are worlds apart. There is abundant evidence that the child will have a significantly better outcome when water cooling is used, yes for 20 minutes. But this won't happen on a consistent basis until a standard model of care is built into education, EMS guidelines, ED practice and lay first aid. The situation is further complicated by the relatively poor evidence base. A standard model has the added benefit of providing the perfect situation to conduct large scale clinical trials with alrge patient cohort and integrated EMS response who do the same thing as everyone else. right now its a basket case and people are getting worse outcomes becuase of it. As for the hypothermia issue Epi - did you actually read Singers study and look for other ones too? Check the limitations section at the end of Singers paper. Then read the ones by Lonnecke, Taira, Weaver etc. We should also consider why burns surgeons wear ICE vests in super-heated theatres and why patients can't be treated until their temp is above 35 deg C. The average cost for each burns patient in-hospital is around $70000 US. Roughly speaking, burns patients make up about 10% of all major trauma patients but account for more than 65% of the total trauma cost budget. Hydrogels were never purpose designed for burns -they were adapted across from fire blankets to create a new market for the companies but cannot be sustained with evidence.

 

[RocketMedic]

I think a lot of this is engineering around practical limitations. I can think of a lot of other things to be doing in 20 minutes worth of cooling, and I would rather drop a Watergel (cold, wet, contained, controlled) and crank the heater on someone than I would hit them with 20 minutes of tap water.

 

[Melbourne MICA]

I think a lot of this is engineering around practical limitations. I can think of a lot of other things to be doing in 20 minutes worth of cooling, and I would rather drop a Watergel (cold, wet, contained, controlled) and crank the heater on someone than I would hit them with 20 minutes of tap water.

I think you missed the point rocket or haven't read my posts and your answer reflects what the hydrogel companies themselves rationalise. When pressed on demonstrating better clinical outcomes, the hydrogel websites now ALL contain disclaimers referring to the superior benefits of water cooling. besides, a standard model incorporates cooling done by the public before EMS even arrive. This model is already employed and I have used it myself more than once. Hydrogels are part of the problem not the solution. The proof is in both the clinical evidence, which I have written about personally, and changes to recommendations and guidelines which we are already seeing from ANZBA, the BBA and many EMS bodies.