Cooling of burns - why US EMS (and first aid responders) needs to change its practices

[Melbourne MICA]

I wrote to N.A.S.E.M.S.O. recently suggesting the burn first aid component of their latest guidelines (below) should be reviewed and changed to incorporate a 20 minute water cooling model with basic dressing such as use of clingfilm wrap. There is a preponderance of dry dressing approaches among more than 20 different model used in US EMS (N.A.S.E.M.S.O.'s only recommends dry dressing).

So the question for comrades here is, show me your backing studies because of the 20 or more practiced none can be supported by the level of evidence I can produce for a 20 minute model - (and yes I am aware there are many temperature variations in different parts of the US). Any up for the challenge?

(https://nasemso.org/wp-content/uplo...-Clinical-Guidelines-2017-PDF-Version-2.2.pdf)

 

[Tigger]

Here's a little insight, lot's of our guidelines aren't supported by evidence. That doesn't mean that's how everyone practices or even that our guidelines follow that of the "national model." In fact I am not really even familiar with NAESMO model and while it might be a nice research project, I have enough trouble keeping my different individual agencies guidelines separate in my head.

Not all states have statewide treatment guidelines. Some states have a framework for what is allowed and what isn't and then leave it up to agencies to work with that. Others leave it completely up to the medical director. There are states that have burn care guidelines similar to what you put forth (Massachusetts did when I worked there) as well.

Could you post exactly what evidence you have for your treatment plan? Or what the treatment plan is? Currently we just follow the regional burn center's recommendations, which do not match yours.

 

[Melbourne MICA]

Thanks Tigger.

No insights necessary. I fully appreciate everything you have described especially the absence of anything resembling what could be described as a well accepted "standard" approach to burn first aid - unfortunately, especially in US EMS but it doesn't stop there. The experts who publish recommendations also can't make up there mind. We're talking the ABA, BBA, ANZBA, ERC, NZGG, NASEMSO, ISBI, JRCALC.

Having said that, the 20 minute water cooling approach has gained traction in the last few years with just about everybody except the US, some European countries and maybe some South American - (not sure about that). There still remains work to do among private sector groups, charities and first aid bodies and the hydrogel companies have their hooks into many sectors of pre-hospital care

So overall its still a bloody train wreck but with some promise on the horizon.

So my motivation and that of colleagues in the UK (I'm based in Australia) is to see this situation overturned - by lobbying everyone to adopt a "standard" model - simply put, the administration of a single block of 20 minutes of cooling with running water between 2-15 deg C up to 3 hrs from injury event in all thermal burns followed by covering with clingfilm or a clean sterile dressing.

That's the essence of the approach. No hydrogels, no dry dressing, no caveats like <"X" %TBSA, or age, or depth etc.

As for evidence, it will have to wait till I get home from shift. I still work with Ambulance Victoria. I have been trying to write this all day. Will update tonight my time. Cheers

 

[Melbourne MICA]

Before uploading studies that support this model I think it is important to recognize just how this process works in the chronology of care from the event itself right through to the ED door - a bit of background.

(Sorry up front if this all sounds like a bit of a story I'm throwing at readers).

The commonly held view is that EMS delivers or is responsible for first aid care and other interventions in acute burn injury. In part this has arisen perhaps because the lay public still use many unsupported, frankly idiotic measures to manage burns comfortably nestled somewhere between cultural myths and internet brain farts; toothpaste, Turmeric powder, egg whites, cow dung, potato peels, vinegar, even additional heat applied to the burn.

Most surveys show only about 20-30% apply recommended first aid (water cooling) and even then not for the recommended duration. Worse still the hydrogel companies have their noses in all the markets. First aid bodies like the Red Cross and St John Ambulance teach water cooling models of burn care and then go and stock thier for-sale first aid kits with hydrogels. And many EMS bodies have fallen for the marketing as well.

In the US as you say Tigger, there are many approaches without any consistent basis of decision making, ignoring national or state based guidelines and often coming about simply because the local medical director said so.

It's also true many EMS practice guidelines have a poor foundation in evidence.

However, this is not the case with burn first aid. In a general sense the clinical benefits for water cooling for burns have been well documented since the 1930's. The St John first aid organisation pioneered a water cooling burn first aid model in 1969 - "cool, cover and carry".

There were multiple studies between about 1936 (Rose), through the 1950's and 60's (King , Offeigson, Boykin, Shulman and others) through to the past year. Since the early 2000's there have been a number of more specific and defining studies including porcine studies by Bartlett (2008) and Cuttle (2009) that established the 20 minute cooling "sweet spot" as well as confirming the water cooling model more generally. In addition there have now been 4 large cohort studies (Wood 2016, Harish 2018, Harish 2019, Griffin 2019) one RCT (Choi 2018) verifying and demonstrating the efficacy of water cooling for 20 minutes and a number of other studies (Nguyen 2002 - case series on water as first aid, Coates 2002 - volunteer study on hydrogels for pain Mx, Tobalem - warmed water cooling in rats 2013, Wright 2015 - the mechanisms of water cooling, Goodwin 2015 - SR on hydrogels, Schnell 2008 - spray mist water cooling) and many others exploring various aspects of water cooling in thermal burn injury. I will upload all these and other files tomorrow.

So my question to US EMS is why isn't water cooling a widespread practice across your jurisdictions? (I can hear hypothermia somewhere in the responses. I will also upload the only pre-hospital studies on that as well - Weaver 2016, Lonnecke 2008, Singer 2010, Zeigler 2010 and a couple of others).

regards
Melbourne MICA

 

[DrParasite]

I haven't looked at any of the studies or what you posted, but many/most EMS places follow the direction from their nearest burn center. We (EMS people) are not the experts on burns and burn treatments; that is left up to the burn doctors, and their outreach people usually spread the word to the EMS agencies and medical directors. And yes, we do need to trust and rely on our local medical director to be up to date on the latest and greatest things that we should be doing (after all, that's why they have MD after their name, and provide us with medical direction).

I've had people tell me that says dry sterile dressing was the best, wet sterile dressing, use a firehose to rinse it off (as long as the water is running, the source doesn't matter) and then cover clean sheet; it doesn't matter, since it's just going to be coming off in the ER and then debrrided. And yes, I've heard some of the old wives tales regarding burn treatment; however, most in EMS don't follow them.

EMS will not, and should not, be the lead agency in burn treatment; that information should come from the burn experts, the burn centers doctors, and we should be following their guidance and direction.

 

[Melbourne MICA]

Hi DrParasite. I appreciate your point but its not about EMS deciding alone on treatment although plenty do this anyway. Just look look at the use of hydrogels in EMS despite the almost complete lack of evidence for their efficacy.

Problem is there has been so little attention paid to this area most likely because of the poor evidence base previously and the pragmatic attitude of most of the experts you mention who have taken a very conservative line on pre-hospital practice. Problem is even they cannot agree on the correct approach.

I have to disagree with your suggestion pre-hospital burn first aid doesn't really amount to much - "it doesn't matter, since it's just going to be coming off in the ER and then debrrided" because this is entirely at odds with the evidence. Water cooling of burns is associated with massive clinical benefits in the short and longer term and all of the studies I have cited so far and many others attest to this fact. ( I can detail further if you would like more information)

As for who should make the decisions; evidence should be the basis of decisions not expert opinion - this includes the burns associations, resuscitation councils, first aid responder organisations and major burns centres. Justification to adopt consensus positions was earlier based on the low levels of available evidence for pre-hospital practice. This position is no longer valid because we now have a solid base of information from many levels of research that not only validates water cooling as the best approach but also confirms prior studies indicating 20 minutes is the best duration for maximum clinical benefit. The 2019 Harish cohort study now also provides data demonstrating clinical benefit even in large burns. Prior evidence seemed to suggest cooling worked best in smaller TBSA burn injuries.

The fact so many EMS bodies have failed (refused) to adopt a single burn first aid model attests to the poor attention given to the evidence base in my view, so I am out there challenging them on this issue. I have also done this with NASEMSO in the US, JRCALC in the UK, the resuscitation councils, all the major burns associations and first aid groups. I have also written personally to every Australian ambulance service , charity groups and private sector bodies, as well as all the hydrogel companies who view me as the Prince of Darkness in some circles. I've cost them a lot of money your see.

But I have asked all these bodies and now my colleagues in US EMS the same question because I am certainly going to show you mine. And I have spent the better part of 8 years doing this.

 

[silver]

There were multiple studies between about 1936 (Rose), through the 1950's and 60's (King , Offeigson, Boykin, Shulman and others) through to the past year. Since the early 2000's there have been a number of more specific and defining studies including porcine studies by Bartlett (2008) and Cuttle (2009) that established the 20 minute cooling "sweet spot" as well as confirming the water cooling model more generally. In addition there have now been 4 large cohort studies (Wood 2016, Harish 2018, Harish 2019, Griffin 2019) one RCT (Choi 2018) verifying and demonstrating the efficacy of water cooling for 20 minutes and a number of other studies (Nguyen 2002 - case series on water as first aid, Coates 2002 - volunteer study on hydrogels for pain Mx, Tobalem - warmed water cooling in rats 2013, Wright 2015 - the mechanisms of water cooling, Goodwin 2015 - SR on hydrogels, Schnell 2008 - spray mist water cooling) and many others exploring various aspects of water cooling in thermal burn injury. I will upload all these and other files tomorrow.

So you are telling me there is only 1 maybe real study then?

 

[Melbourne MICA]

So you are telling me there is only 1 maybe real study then?

No and I'm not sure how you came to that conclusion. Burn care in pre-hospital has been hamstrung by orthodoxies and ambivalence. Few people have believed the pre-hospital element of burn care really amounts to much. This has meant little investment in the sector including in research which is both expensive and ethically difficult in burns - how do you have an untreated control in a burns trial of water cooling for example. So the data has come mostly from animal and experimental and observational study methodologies although we do have at least one RCT (Choi 2016). But before people say that's crappy evidence they should realise its common in burn research overall for the same ethical and practical reasons.

So it will remain up to hospital and Uni researchers for the moment to provide the research evidence.

That is, until we have a standard model of burn first aid care.

If pretty much everyone - and not forgetting EMS isn't the only provider of first aid - is applying the same treatment then we have a homogeneous cohort - a very large one at that, suitable and sufficiently cost effective for direct research by pre-hospital entities - EMS.

SO ambulance can do research into its own practices because we have tens of thousands of patients all getting the same care and tens of thousands of providers all delivering the same care - (and believe it or not I think our role is not to deliver this first aid cooling - ideally this should be done before ambulance arrives but we need to ensure this has been completed so we can move to the next elements of care).

The end result of this is to use the promotional power of EMS aided by its own research to help move the lay public to the same standard model as well. When this happens will have a seamless chronology of burn care that use all the parties involved in the process. What is the point of a lay person putting toothpaste on loved ones burns only to see the paramedic put on a hydrogel or just a sheet over the injury.

ALL burn first aid care needs to include water cooling as the evidence clearly shows its benefits are so profound hey cannot be ignored.

So my mission is not to conduct studies - I clearly can't do this as an individual.

Instead my aim is to help shape practice by changing peoples minds by challenging them to reexamine their own orthodoxies.
And my most powerful tool is evidence.

So my question again is show me your evidence. Go out and ask your medical director, or county clinical group, state body or NASEMSO what studies support their current position on burn first aid especially models that don't use or under-utilize water cooling.

- and I will tell you they are wrong and I can prove it.

 

[PotatoMedic]

I'd love to read the research on burn care that you have. Send me what they are or even the doi and I can look them up.

 

[Melbourne MICA]

I'd love to read the research on burn care that you have. Send me what they are or even the doi and I can look them up.

Just for starters. There's more - lots more.Save you the trouble of having to hunt them down. Cheers MM

 

[Rubicon Bob]

I'm very curious to hear what training and experience you have, that makes you such an expert on burns.

 

[DrParasite]

I have to disagree with your suggestion pre-hospital burn first aid doesn't really amount to much - "it doesn't matter, since it's just going to be coming off in the ER and then debrrided" because this is entirely at odds with the evidence. Water cooling of burns is associated with massive clinical benefits in the short and longer term and all of the studies I have cited so far and many others attest to this fact. ( I can detail further if you would like more information)

I think I was unclear on what you are disagreeing with.... or maybe you misunderstood.... I'm not sure. I never said the prehospital burn first aid doesn't matter; although I can see where my statement was confusing.... it is the dressing that doesn't matter. All burn patients should be treated with cool running water, to "stop the burning process." the source of the water didn't matter, as long as it was running (submerging the burned area in ice water was a no no).

Hydrogel is bad. moist dressing as bad because they can cause hypothermia. stop the burning process (using cool running water), and cover the area with a dry dressing, that will come off and be better applies in the ER or the burn center with more sterile equipment (remember, we don't do sterile in EMS (with very few exceptions), we do clean).

From the ALS perspective, this person will need fluids and pain meds, which is exactly what the ER will do for them initially.

But #1, stop the burning process.

 

[Melbourne MICA]

I'm very curious to hear what training and experience you have, that makes you such an expert on burns.

Hello Rubicon and thanks for the enquiry. I'm not the expert - the evidence is and this is the very point I have made with everyone I have spoken to about this matter.

Since you asked about my training and experience.

I started with Ambulance Victoria in 1990 and still work for them as an advanced life support paramedic. I also did 17 years on intensive care and only gave that away a few years ago. I have 6 published articles/papers on burn first aid including the only systematic review in the literature on hydrogels in burn first aid. (International Wound Journal and the Burns journal). I have made 2 presentations on burn first aid at ANZBA international burns conferences and presented at The Victorian Adult Burns Service "Grand Rounds" conference on pre-hospital burn care. (2011,2018) I was also asked to sit on the leadership group of the Victorian Adult Burns Service Burn First Aid Round Table.

I was the co-lead author of the British Burn Association burn first aid guidelines 2018 and a reviewer for the Royal College of Surgeons Faculty of Pre-Hospital Care 2018 Consensus recommendations on pre-hospital burn care. I did the research that changed Ambulance Victoria's burn first aid CPG"s to the current model. I have lobbied and written to 20 or more organisations around the world imploring the establishment of a standard model of burn first aid. Most recently I have been lobbying all Australian and UK ambulance services including to the 2 respective national bodies JRCALC and NASEMSO. I am currently writing to the American Burn Association, the CDC and AHA who all publish burn first aid guidelines in the US. I have written about 10 education packages/documents for Ambulance Victoria staff and outside bodies.

I have researched pre-hospital burn care for 9 years now and am in the process of writing a primary paper on burn first aid.

So no, I'm not a burns expert but I think I can say I have some credibility as a researcher on the burn first aid topic.

It's not easy to get people to change their minds and my most recent effort here (in the other thread) got be labelled as a troll by one of your moderators despite uploading 20 burn first aid studies and articles and daring to question the approaches on burn first aid used by US EMS - there are more than 20 used around the US BTW, none supported by evidence - if that's not a confused mess I don't know what is.

Outside here I can tell you its equally hard to do the same. I have now written to the American Burn Association 3 times with no reply. When myself and another colleague in the UK criticised aspects of the European Resuscitation Council burn first aid guidelines we were lectured on how we didn't understand the "GRADE" evidence system. In the BBA, the Water-Jel lobby group within that body threatened legal action against the BBA if they published the hydrogel position statement myself and my UK colleague had taken 2 years to formulate with the help of many in the UK burns community. Other bodies just ignore you and hope you go away especially since you are just "an interfering paramedic" as one BBA member (with connections to Water-Jel) called me.

If its not vested interests, its commercial profits or professional pride. My aim is to see burn first aid standardised around the world for patients sake (and I'm not the only one to suggest this BTW). There are some serious health care savings attached to doing this as well.

Seems like its worth enduring a few heartaches and bibes to me.

 

[Melbourne MICA]

I think I was unclear on what you are disagreeing with.... or maybe you misunderstood.... I'm not sure. I never said the prehospital burn first aid doesn't matter; although I can see where my statement was confusing.... it is the dressing that doesn't matter. All burn patients should be treated with cool running water, to "stop the burning process." the source of the water didn't matter, as long as it was running (submerging the burned area in ice water was a no no).

Hydrogel is bad. moist dressing as bad because they can cause hypothermia. stop the burning process (using cool running water), and cover the area with a dry dressing, that will come off and be better applies in the ER or the burn center with more sterile equipment (remember, we don't do sterile in EMS (with very few exceptions), we do clean).

From the ALS perspective, this person will need fluids and pain meds, which is exactly what the ER will do for them initially.

But #1, stop the burning process.

OK Agreed. The paper on burns dressings by Wasiak and Cleland from 2014 (A Cochrane systematic review no less) details how little evidence there is to guide choice especially in pre-hospital where there is almost no evidence specifically on dressings. Hydrogels, despite being a "dressing", are primarily intended as a cooling agency and no where near as good as marketed by their makers and come with way too many complications to be the preferred choice. Water-Jels claim they don't cause hypothermia because they only work by "convection" not evaporation is laughable and any 1st year science grad could tell you how that claim defies the laws of thermodynamics and energy transfer.

I hope you don't mind me saying the phrase "stop the burning process" doesn't actually refer to using water as a treatment modality but rather describes putting out the fire on the patient and such like. Unfortunately I think its use to open burn care guidelines has caused confusion because the water cooling when used as a treatment is very specific. Durations of cooling and even the use of running water, not still water, have been the subject of much study. The paper by Wright from 2015 on Mechanisms of cooling is a fascinating read on the pathophys side of things. (It is included in my uploaded documents)

Part of the reason we have so much confusion on burn first aid is not even terms are standardised. Someone can tell me for example, precisely what the universally agreed definition for "minor" burns is. This has resulted from the fact that the apparent trivial nature of burn first aid has hidden its extraordinary clinical effect and thus resulted in this area of burn care being largely ignored. Its why I have put so much time into the subject. The 20 minute cooling model (with simple dry dressing as you noted such as clingfilm) has the backing of an impressive quantity of evidence now. Changes to the chronological process of burn first aid need to be addressed to allow the maximum time frame for warming to avoid the calamity that is hypothermia. If you check out one of my uploaded PowerPoint papers from the ANZBA conference in 2018 I describe a new approach.

And believe it or not I don't think EMS should be doing the cooling.

 

[Tigger]

And believe it or not I don't think EMS should be doing the cooling.

So what, specifically, should we be doing?

Two common scenarios:

a) Seven year old pulls a pot of boiling water off the stove, sustains partial thickness to approximately half of his chest and anterior surface of the left arm. No airway involvement.

b) Adult patient removed from a house fire. Full thickness burns to both lower legs, back, and chest. Pt semi-responsive. Let's leave the airway part out and just talk about burn care.

 

[Melbourne MICA]

Well thank you Tigger for asking a pertinent question.

First, I will refer readers to the PowerPoint I uploaded in the other thread titled "Towards a standard model of burn first aid - one step forward two steps back" (and the rest of the papers if comrades are so inclined - its all the latest research on the topic). And comments here refer to thermal burns only, not chemical or electrical/other.

Secondly, current best evidence suggests 20 minutes of gentle cooling with clean running water should be applied as quickly as possible although this method is clinically effective up to 3 hrs after the burn event. (I've uploaded papers on that as well).

Thirdly, why do carers, parents, bystanders etc have to wait until EMS arrive to commence 20 mins of water cooling?

In the first scenario you suggested, parents or first responders would strip off the child's heated clothing and put them under the shower for 20 mins or until directed otherwise by EMS personnel. Having said that the ideal is 20 mins, not 5, not 10, not what the first paramedic thinks is OK. So if only 10 mins has been applied then a further 10 should be undertaken when EMS arrive.Hypothermia risk is incorporated into the management by moderating the temperature of the water, reducing cooling time if the patient shows clear signs of getting hypothermic. Some shivering is not a sign of clinical hypothermia.

Not sure about the US but in the UK and Australia and possibly elsewhere emergency call takers provided directions to first responders on scene. So the 911 call-taker should coach the parents to shower the child etc. This is key to a better model of care. At the moment so many of the lay public still put on toothpaste, potato peels, vinegar, tumeric powder and why the reason why I have hassled comrades here to be a voice for change on this issue. If we can't agree on a care model how are we going to get the public to change? (hence my commentary on the more than 20 US models of burn first aid - and yes, elsewhere as well).

On the second scenario, the same should apply although this area remains controversial. T

On the one hand, cooling is most effective in partial thickness burns so what benefit in full thickness? The other side of the coin however, is it is rare for a burn injury to be just full thickness burns - where it is with a large TBSA survivability plummets anyway. Rather, most burns are composite burns, especially fire related burns. That is, are made up of full thickness and partial thickness burns. Given the full thickness sites are not salvageable the effort should be made to preserve as much salvageable integument as possible. And there is no better way to do it than applying cooling. Cooling also benefits cosmetic outcomes including extent of scarring.

Now I can hear "what about hypothermia" coming from all sides. Firstly I would argue we don't get our definitions right and as noted above recognize actual hypothermia. We all know severe hypothermia is clinically identifiable - altered conscious state, pallor, hypopnoea, bradycardia etc. But what about in our burns. Well the starting point is obvious - lets use our technology monitor temp as soon as we arrive at scene so we can gauge where we stand? Comrades here will likely argue they all do but that's not what the literature is saying. Technically its still not even part of the vital signs survey. Ongoing temp monitoring in burns patients is also pretty average - lots of good data on this too. In fact its pretty inconsistent in all pre-hospital trauma care by EMS -the more tasks we feel we need to undertake the more likely we are to take a temp.

So in your patient the advice would still be for the first responder to cool the burn. But there is a much larger emphasis on providing the largest window of opportunity to warm the patient -hence why it should be done before we get there. Thereafter we warm, warm and warm some more, get our lines in, analgesia and fluids - and that topic will have to wait until I get the kids from school right now. Some food for thought anyway I hope.

 

[Melbourne MICA]

Back from school. There are lots of concerns about hypothermia in trauma and well there should be. The pathophys is pretty clear. In burns the hypothermia issue is even more pronounced. 1/4 degree and 1/2 degree drops are proportionally more significant in burns than all other forms of trauma injury. In respect of our practice then, as much time as possible should be devoted to warming the patient and we need tools to do that. As far as I know there few if any ambulance services that provide active warming technologies like barehuggers in their rigs although, believe it or not I came across a veterinary ambulance service that had it for its doggy patients. Go figure. There are some chemical heating blankets but these haven't been studied much. Personally I think they are sub-optimal and come with potential problems. So its passive warming and changes to the nuance and chronology of our burn care. Early cooling by parents/bystanders means we arrive needing only to assess and dress.

Thereafter we warm. Its my view a period of mild hypothermia in cooled thermal burns is inevitable and should be accepted into the mix simply because there are SO MANY benefits to cooling with water for 20. There is also little evidence to indicate a brief period of mild hypothermia (e.g. ~temp 35-36 deg C) is proportionally as clinically dangerous as the patient arriving at ED persistently or significantly hypothermic and therein lies the devil in the detail in my view. Time to surgery is crucial in the severe burns patient so delays to warm, rather than the fact the patient is hypothermic per-say is the problem. By the time the patient makes it to the burns unit too much time has passed and serious complications of burns are much more likely to have progressed.

Its why its much more preferable to warm them up in the field not later in the ED. In and of itself the double edged sword of benefits from cooling and detriment from persistent significant hypothermia will be more significant clinically than all the other pre-hospital burns treatments we provide. SO if your patient gets the full 20 and arrives normothermic at hospital as well you have given them an absolute ace in the hole. And cooling and warming have the added bonus of providing a significant pain relieving effect as well. Its +++++ all round just with this ridiculously simple approach.

So we must be prepped to warm the patient - e.g. pre-warming the rig to summertime temp before you get there (I realise there some OH&S issues there). If blankets can be pre-warmed in your rig all the better. Not much point putting on cold blankets from a rig parked in the garage at your station. Fluids should go through a warmer if you have one as well. Proper covering/dressing of the burn itself is also vital and there will be much further discussion going forward on the best way to do this. For now clingfilm or a clean lint free dry dressing is the norm and does the job. You don't want hydrogels - bad idea. They are just not up to scratch for the job. On dressing, I have also come up with a new way to apply clingfilm that means it stays on (burn pts. wriggle a fair bit while in pain), that it covers the burn and surrounding tissue as well and thus aids in retaining body heat.

That's not everything BTW. You could write volumes on this stuff - and I have. Most of it I have posted here on EMTLife for those interested.

cheers
MM

 

[DrParasite]

Secondly, current best evidence suggests 20 minutes of gentle cooling with clean running water should be applied as quickly as possible although this method is clinically effective up to 3 hrs after the burn event. (I've uploaded papers on that as well).

Thirdly, why do carers, parents, bystanders etc have to wait until EMS arrive to commence 20 mins of water cooling?

I think your comment of

And believe it or not I don't think EMS should be doing the cooling.

was not clear. You meant the cooling should be initiated before EMS arrives, and continued by EMS for a total of 20 minutes right?

Because I would totally support panicking parent initiating the cooling process (because it gives them something to focus on instead of worrying until the ambulance arrives, and prevents them from trying those home remedies), and then EMS taking over.

Not sure about the US but in the UK and Australia and possibly elsewhere emergency call takers provided directions to first responders on scene. So the 911 call-taker should coach the parents to shower the child etc. This is key to a better model of care. At the moment so many of the lay public still put on toothpaste, potato peels, vinegar, tumeric powder and why the reason why I have hassled comrades here to be a voice for change on this issue. If we can't agree on a care model how are we going to get the public to change? (hence my commentary on the more than 20 US models of burn first aid - and yes, elsewhere as well).

Much of the US has Emergency Medical Dispatchers, who deliver pre-arrival instructions to 911 callers. Here is an example of NJ's guidecards (and before you say it, yes the directions say to submerge the burn, I didn't write it, and that direction came from the department of health): https://www.nj.gov/911/home/highlights/EMD Guidecards 2020 Final.pdf

There are also 3 or 4 major commercial EMD guidecard providers, but NJ's were free and published online.

 

[Melbourne MICA]

I think your comment ofwas not clear. You meant the cooling should be initiated before EMS arrives, and continued by EMS for a total of 20 minutes right?

Because I would totally support panicking parent initiating the cooling process (because it gives them something to focus on instead of worrying until the ambulance arrives, and prevents them from trying those home remedies), and then EMS taking over.
Much of the US has Emergency Medical Dispatchers, who deliver pre-arrival instructions to 911 callers. Here is an example of NJ's guidecards (and before you say it, yes the directions say to submerge the burn, I didn't write it, and that direction came from the department of health): https://www.nj.gov/911/home/highlights/EMD Guidecards 2020 Final.pdf

There are also 3 or 4 major commercial EMD guidecard providers, but NJ's were free and published online.

Hi DrParasite.

Exactly - ideally, cooling should be done before EMS arrives. If incomplete, we do the rest of the 20. This applies in all isolated thermal burns. Obviously airway and major trauma e.g. may be priorities, but even in these circumstances a 20 minute cooling block should be attempted because it is so clinically valuable.

The hardest notion to get past EMT's is the idea to stay at the scene to do cooling and its been hard to convince many. If you can't do cooling on site it's even worthwhile loading the patient and going somewhere you can. (Obviously not if you are 10 minutes from the ED). There will be many scoffs and raised eyebrows at all these ideas I'm sure.

Tigger's example is a typical case -the hot pot of water on the child scenario. I've done this type of incident using the 20 min method. The parents had put him in the shower for 20 before we got there under 911 direction. So we just cling-wrapped the burns, gave IN Fentanyl and covered him. IV was placed and in the truck which was already pre-warmed before we got there. He arrived at ED with a temp of 37.5 deg C, calm quiet with good vitals and minimal pain. His partial thickness burns got gentle debridement under gas were dressed in Acticoat and he was discharged the same day for follow up later. Absolutely amazing. I described our management to the attending doc from the burns unit ans she called it "perfect" -exactly what they want. The Royal Children's Hospital here in Melbourne are so attached to the plan they put kids brought in by parents without cooling done in a shower in ED for 20 before they do anything.

It works. I've used it. They use it. It just needs some forethought and planning.

As for the 911 NJ guidelines - WTF?? Immersion??? The same studies are out there for everyone to read. Sometimes I get the feeling I am the only one reading them. A lot of docs don't like the fact there are few RCT's and other high level studies and this explains to a certain extent why many guidelines are consensus driven usually most influenced by perceptions of hypothermia risk. In my presentations I've put up stats on all the variations of duration, cooling temp and dressings used. (Many of them are in the documents I uploaded). The audiences seem gobsmacked. In my last I showed 24 different ambulance services around the world and a dozen expert organisations and there was almost no consistency between them.

So there is work to do. What all the latest surveys are telling us is that the public are still the biggest culprits in using dodgy methods to treat burns. I reckon part of the problem is the experts and EMS all do different things. Hence my mission to see a standard approach adopted.

cheers

MM

PS and BTW - if any other EMT's can direct me how to get copies of their local versions of 911 guide-cards used to direct callers I would love to get them. There's a whole line of data to explore and compare just in those that I haven't covered yet.

 

[Rick813P]

I wrote to N.A.S.E.M.S.O. recently suggesting the burn first aid component of their latest guidelines (below) should be reviewed and changed to incorporate a 20 minute water cooling model with basic dressing such as use of clingfilm wrap. There is a preponderance of dry dressing approaches among more than 20 different model used in US EMS (N.A.S.E.M.S.O.'s only recommends dry dressing).

So the question for comrades here is, show me your backing studies because of the 20 or more practiced none can be supported by the level of evidence I can produce for a 20 minute model - (and yes I am aware there are many temperature variations in different parts of the US). Any up for the challenge?

(https://nasemso.org/wp-content/uplo...-Clinical-Guidelines-2017-PDF-Version-2.2.pdf)

I have a question, I see this is a long string. How does a 20 minute scenario fit into a busy EMS systems role. I retired a few years back as a field supervisor. If I had a truck on the scene for 20 minutes cooling a burn and did not address it, someone was getting theirs asses chewed. We did everything we could do to keep hospital down times to 20 minutes. I maybe missing something here, like you are referring to hospitals or ICCs. If that is true, then this looks great. I really don’t think this idea is new, this is what was taught when I took first aid in the late 60s, early 70s.