First aid management of burns

[Melbourne MICA]

Hi all,

Haven't been on the forum for a while. Have been working on burns issues for some time and I am interested in your local regions burn first aid protocol, particularly whether you cool and/or dress burns with Hydrogel dressings (eg WaterJel, BurnShield, Burnfree). The US in particular has a number of approaches to burn first aid by EMS with no apparent standardisation at any level. (Nor do any other national EMS jurisdictions for that matter so not a dig at the US).

Have recently had published a systematic review in The International Wound Journal:
("The efficacy of hydrogel dressings as a first aid measure for burn wound management in the pre-hospital setting:a systematic review of the literature") Refer PubMed and Ovid abstract.

I am very interested to learn the rationales for dry dressing approaches in US EMS guidelines as well as any other alternative approaches and why your medical director chooses that guideline approach.

Cheers

Melbourne MICA

 

[jwk]

Not sure anything beats (preferably) a sterile dressing/cover/sheet/towel and cold saline.

 

[Ewok Jerky]

Cold saline? Aren't you worried about hypothermia?

 

[Melbourne MICA]

Cold saline? Aren't you worried about hypothermia?

What's your take on this EWOK? You obviously have a concern about hypothermia to start with. What is your local protocol? Were you aware there is basically no consensus anywhere in the world on how to manage burn first aid? In the US, there are a hundred different approaches and elsewhere its not much better. Now there are lots of suggestions about cooling the burn and dressing it but beyond the sematic exercise you won't get the same detail of exactly how much, when, on what size burn, running water, still water, hydrogels, what's the best dressing and why? etc. As an example of why these questions need answers, I've been told by the past president of the Australia New Zealand Burn Association -one of the most prominent in the world, that although burns account for less than 9% of all trauma injuries they make up over 65% of the total cost burden for all trauma care. There are very good clinical reasons to get burn first aid right. Happy to expand further if people are interested.

MM

 

[Melbourne MICA]

Not sure anything beats (preferably) a sterile dressing/cover/sheet/towel and cold saline.

Are you able to expand a little JWK. What's your local protocol? Why is it that way? Have your medical directors explained to staff why the protocol is designed that way and what is the clinical outcome being sought? In the US in particular, many EMS jurisdictions don't even cool a burn, beyond putting the fire out if someone hasn't done before the EMS arrives. Just dry dressing - paranoia around hypothermia. Personally I find this madness. Are you aware there are no pre-hospital burn first aid studies of any design whatsoever? No clinical trials, no database case studies, nothing. So no evidence. Yet ask any medical director why they assign their burn protocol for EMT's a particular way and they will all tell you its the best way. My question to them would be -"based on what evidence".
The major burns associations are trying to get standardised practice with the gold standard being 20mins cool running water, clingfilm dressing thereafter and loads of warming. But there is this hypothermia paranoia -I'm trying to understand it because not cooling the burn almost guarantees the burn will progress -get larger. This has huge ramifications for the patients recovery. Any thoughts??

MM

 

[Ewok Jerky]

Dry sterile dressing, or if large enough a burn sheet (which is dry, and sterile). +pain management.

Circumferential, facial/airway, or >9% transport to burn center.

Yeah minor kitchen burns or whatever I'm not concerned about hypothermia. But anything more than minor I am, at least to the point that I'm not going to poor cold water on them. Skin is a major thermoregulatory organ.

 

[jwk]

Are you able to expand a little JWK. What's your local protocol? Why is it that way? Have your medical directors explained to staff why the protocol is designed that way and what is the clinical outcome being sought? In the US in particular, many EMS jurisdictions don't even cool a burn, beyond putting the fire out if someone hasn't done before the EMS arrives. Just dry dressing - paranoia around hypothermia. Personally I find this madness. Are you aware there are no pre-hospital burn first aid studies of any design whatsoever? No clinical trials, no database case studies, nothing. So no evidence. Yet ask any medical director why they assign their burn protocol for EMT's a particular way and they will all tell you its the best way. My question to them would be -"based on what evidence".
The major burns associations are trying to get standardised practice with the gold standard being 20mins cool running water, clingfilm dressing thereafter and loads of warming. But there is this hypothermia paranoia -I'm trying to understand it because not cooling the burn almost guarantees the burn will progress -get larger. This has huge ramifications for the patients recovery. Any thoughts??

MM

I'm far removed from EMS days, and am not up-to-date on the most current standards, but still have occasion to be involved with burn care. Burns are a dynamic process - the damage continues and deepens past the few seconds of initial injury and continues for a surprisingly long time. Cooling the burn is still a valid and valuable treatment. Whether there is a BSA limit on that - I don't know. If someone wants to enlighten me and explain how all the fancy and expensive dressings are useful for the short period of time they're going to be on the patient (and removed in the ER for them to assess the burns) then jump right in.

http://emedicine.medscape.com/article/769193-overview

 

[Household6]

Cold saline? Aren't you worried about hypothermia?

20% of body surface is our line for cutting off water cooling.

>20%--- Withhold surface cooling with water (except in cases where clothes are still smoldering duh) Cut off all non-adherent clothing, cover pt with sterile sheet, keep warm. Obtain IV, give 500ml NS bolus, severe burns go to the burn center via HEMS.. ALS does pain management.

We don't apply dressings to burns, we cover them. The less touching, the better.

 

[Melbourne MICA]

Thanks everyone. Even just this small sample shows the diversity of views out there in EMS land. From my own research, all the approaches mentioned are unsupported by evidence. TBSA caveats on cooling are arbitrary and arise from paranoiac attitudes about hypothermia risk . If you just dry dress (that is, no cooling) this means burn progression will worsen the injury, prolong recovery and increase likelihood of complications. Of all the areas of burn first aid, cooling of the wound is best supported by studies from Rose in 1936 right up to the present.

Household6, I don't follow the differentiation between covering a burn and dressing a burn. Whilst I agree in minimal handling of burns, surely any dressing must seal the burn from air if an analgesic benefit is to be gained by doing so because burns become hyperalgesic.

No mention of hydrogels here I note. This area has interested me in particular because the technology has a cooling and dressing function combined and they are everywhere. Sounds good, but not so good it turns out - and unsupported by any pre-hospital studies and bugger all hospital or lab studies. I'm trying to upload the study I just had published but the website isn't co-operating - error message.

On the hypothermia issue - a few studies but no consensus on whether we make patients cold and worse. Raw data suggests EMS makes burn patients colder - I've seen data from two major hospital burn units one here in Melbourne and another from the UK. In Melbourne, 43% of patient came in below 36degC, 27% below 35deg C. That's was using hydrogels to cool and dress with the patient uncovered for evaporative cooling effect of the dressing. But then how many services have active warming technologies in trucks or promote warming as a treatment rather than an adjunct to care? Throw in RSI for airway burn patient and whoah - seriously cold patients.Killing off muscle thermogenesis with paralytics without backing up with active warming is a really bad combination for a procedure that isn't well supported by evidence in the first place..

Some papers on the hypothermia issue below - I always note "limitations of the study", the type etc - conclusions aren't always right:

1.Singer et al. The association between hypothermia, prehospital cooling, and mortality in burn victims. 2010
2. Weaver MD et al. Risk factors for hypothermia in EMS-treated burn patients. 2014
3. Lönnecker S et al. Hypothermia in patients with burn injuries: Influence of pre-hospital treatment. 2001
4. Bravo et al. http://www.medbc.com/annals/review/vol_16/num_2/text/vol16n2p77.asp

All burns should be cooled in my opinion but very large burns and high risk patients should have the time frame moderated by temperature readings accepting that a level of hypothermia is inevitable but correctable with aggressive warming. Patients are going to get cold from the hose down before you got there - but the benefits outweigh the risks. Burn progression can continue for up to 24hrs after the event. Our cooling may reduce that impact substantially.

As for dressing burns - at this point clingfilm is easy to store, cheap, clean, the burn specialist can see through it, its easy to put and remove, seals the wound from air so helps with pain relief and its incredibly light and gentle - minimal handling of the wound. Hydrogels are not well supported by evidence so are a last ditch contingency. Cool running water reduces the burn wound temperature twice as much as any hydrogel. (Bartlett, Venter, Cuttle).

My own mantra: is "cool rapidly, cool once, dress once". So early cooling - the earlier the better -best before ambulance arrives then all you have to do is warm and analgesics - everybody gets cooling, you do it once and once only - a single block 20mins is currently best supported by evidence, you dress straight away after cooling and never take it off - burns are sterilised by the heat source initially. Minimal handling and early dressing may help with infection rates -we don't know yet but we have to apply a process and analyze it. At the moment its a dogs breakfast.

Sorry long post. More feedback welcome. I'll endeavour to upload my paper ASAP

MM

 

[YoungMedic]

20% of body surface is our line for cutting off water cooling.

>20%--- Withhold surface cooling with water (except in cases where clothes are still smoldering duh) Cut off all non-adherent clothing, cover pt with sterile sheet, keep warm. Obtain IV, give 500ml NS bolus, severe burns go to the burn center via HEMS.. ALS does pain management.

We don't apply dressings to burns, we cover them. The less touching, the better.

pretty much what mine is, we use Parkland Formula also. RSI for face burns. Hands, groin, face, are severe. I would fly them to Vegas in my area.

 

[Melbourne MICA]

pretty much what mine is, we use Parkland Formula also. RSI for face burns. Hands, groin, face, are severe. I would fly them to Vegas in my area.

Hi young medic. The bolus Iv fluid dose from Household6 is unusual and not parkland formula. (Vol= 3-4mls/kg x TBSA% in first 24hrs) I would argue how many EMT's can get the TBSA percentage right in the first place (worth a look on line for studies telling the uncomfortable truth about our lack of precision in this area) . And TBSA caveats ( like age caveats) for cooling are entirely arbitrary and none are based on data from studies. So you have the unfortunate scenario of paramedics who don't get the TBSA right, so any fluid resus. volume is probably wrong (and may well contribute to "fluid creep" [google check]) AND the problem that many burns are worsened via burn progression because of the inane practice of not cooling burns because of hyperbolic fears about hypothermia. Throw the use of hydrogels just to complicate things. As I have said - burn first aid is a shambles.

Melbourne MICA

 

[Carlos Danger]

Hi young medic. The bolus Iv fluid dose from Household6 is unusual and not parkland formula. (Vol= 3-4mls/kg x TBSA% in first 24hrs) I would argue how many EMT's can get the TBSA percentage right in the first place (worth a look on line for studies telling the uncomfortable truth about our lack of precision in this area) . And TBSA caveats ( like age caveats) for cooling are entirely arbitrary and none are based on data from studies. So you have the unfortunate scenario of paramedics who don't get the TBSA right, so any fluid resus. volume is probably wrong (and may well contribute to "fluid creep" [google check]) AND the problem that many burns are worsened via burn progression because of the inane practice of not cooling burns because of hyperbolic fears about hypothermia. Throw the use of hydrogels just to complicate things. As I have said - burn first aid is a shambles.

Melbourne MICA

This is exactly why I think the idea of a set volume for a fluid bolus is not at all a bad one (in healthy adults I would probably go with a liter or two bolus followed by 500cc an hour, rather than just a 500cc bolus), and then let hospital personnel adjust from there based on UO.

Talk to 10 burn surgeons, and 5 of them will tell you everyone they receive is under-resuscitated and the other 5 will tell you that everyone they receive has gotten way too much fluid. And no one is good at estimating burn % unless they do it regularly.

They way things are now, we are basically guessing at how much fluid to give.....so why not use a standard ml/kg volume regardless of the size of the burn, and go from there.

 

[RedAirplane]

Lurking in the wrong forum again...

But is the cooling the burning skin in running water for 10-15 minutes minimum completely out of the picture?

 

[Household6]

I'm not quite understanding why it's necessary for an EMT to be able to accurately determine Parkland, or be worried about creep?? That's something that's beyond the scope of practice for an EMT.. I'm not going to have my patient for 24 hours, hopefully I can hand a severe burn victim off in <20 minutes.

 

[Anthony7994]

Stop the burning process, cric if there are facial/inhalation burns with airway compromise, and cover with dry dressings. We have a huge emphasis on hypothermia control as well. As far as fluid goes, 500cc challenge of LR for hypotension and follow with parkland. Some use the "rule of tens" because it is faster...but, if I'm going to be sitting with a casualty for 24 hours I think I'll have some time to do the math and be more exact. A doc was showing us the silver impregnated burn dressings, and I've heard great things about them, but we can't afford those.

 

[Melbourne MICA]

This is exactly why I think the idea of a set volume for a fluid bolus is not at all a bad one (in healthy adults I would probably go with a liter or two bolus followed by 500cc an hour, rather than just a 500cc bolus), and then let hospital personnel adjust from there based on UO.

Talk to 10 burn surgeons, and 5 of them will tell you everyone they receive is under-resuscitated and the other 5 will tell you that everyone they receive has gotten way too much fluid. And no one is good at estimating burn % unless they do it regularly.

They way things are now, we are basically guessing at how much fluid to give.....so why not use a standard ml/kg volume regardless of the size of the burn, and go from there.

Couldn't agree more REMI - which just goes to prove my point about the whole burn first aid/pre- hospital burn management scenario in the first place. Its a shambles. How many patients are we really helping? Personally I think a time factor caveat needs to be attached to fluid resus in burns not just weight and TBSA%. Clinically we know early fluid resus helps patients that's 1960's research Baxter and Shire stuff. SO, perhaps short time frames to a fluid resus needle in ED means no fluid just prep and longer times gets the fluid gig. But we still haven't solved the TBSA error problem. Fluid creep is a clinically established complication of treatment and we are just as much to blame as anyone. (we are mentioned specifically an article on fluid creep by Cancio or Cartotto et al -I'll hunt it out -"well meaning paramedics he says").

At the end of the day however what we need is research. Burns cost big bucks to health care. <~9% total of trauma pts yet >65% of total health care cost on trauma.

MM

 

[Melbourne MICA]

I'm not quite understanding why it's necessary for an EMT to be able to accurately determine Parkland, or be worried about creep?? That's something that's beyond the scope of practice for an EMT.. I'm not going to have my patient for 24 hours, hopefully I can hand a severe burn victim off in <20 minutes.

In a nutshell it's because early fluid reduces major complications related to fluid shifts resulting from burns. Baxter and Shire did a lot of work on this in the 1960's as well as others and set the paradigm that has been followed ever since. Naturally when docs realised paramedics we didn't need to be spoon fed we got a Guernsey to treat. Unfortunately, nobody researched whether all this is appropriate in the field and actually helps patients. Docs just applied ED type protocols and pre-requisites to paramedic guidelines (like estimating TBSA%). Oops - can't do it that well it turns out. So our fluid loads are wrong most of the time and also contribute to hypothermia risk especially when we decide to be heroic and prophylactically intubate for facial burns using paralytics. Oops -not supported by evidence and patient gets even colder. You see what I mean? A cycle of chaos and destruction but we feel good because we are treating

- but are we actually helping?!!!!!!!!

MM

 

[Melbourne MICA]

Lurking in the wrong forum again...

But is the cooling the burning skin in running water for 10-15 minutes minimum completely out of the picture?

Sorry I didn't respond earlier airplane. No way is cooling the burn with running water out of the picture. In fact it is THE picture. This article is a great starting point to appreciate why (you can download it below):

E.H. Wright a,*, A.L. Harris b, D. Furniss Cooling of burns: Mechanisms and models b u r n s 4 1 ( 2 0 1 5 ) 8 8 2 – 8 8 9

Although a time frame for cooling with running water remains somewhat controversial (note running water - read article to find out why this is important as well), the best current evidence suggest 20mins continuous cooling as a single block contributes to reduced burn progression, reduced mortality and morbidity, improved healing and cosmetic outcomes. When EMS providers get over the lunacy of not cooling burns and instead read the literature, basing practice on evidence, we might start to see some impetus to further research and develop protocols.

The best supported approach (in terms of evidence) for first aid for burns is 20mins cooling with running water, dressing with Clingfilm and appropriate choice of destination (based on location, type and severity of burns). Before anybody dives in and says but what about.......There are of course contingencies. This approach is the basic. I can expand in detail on alternatives and their rationales if required.

Melbourne MICA

 

[Melbourne MICA]

Stop the burning process, cric if there are facial/inhalation burns with airway compromise, and cover with dry dressings. We have a huge emphasis on hypothermia control as well. As far as fluid goes, 500cc challenge of LR for hypotension and follow with parkland. Some use the "rule of tens" because it is faster...but, if I'm going to be sitting with a casualty for 24 hours I think I'll have some time to do the math and be more exact. A doc was showing us the silver impregnated burn dressings, and I've heard great things about them, but we can't afford those.

Just in regards to silver impregnated burn dressings - check this paper out -

http://www.cochrane.org/CD002106/WO...ating-superficial-and-partial-thickness-burns

Worth looking over for some insights on Silver impregnated dressings.

Cheers

MM

 

[DrParasite]

Lurking in the wrong forum again...

But is the cooling the burning skin in running water for 10-15 minutes minimum completely out of the picture?

oh good, I thought I was the only one who still did this.

BTW, for burns, I prefer dry sterile dressing, for the simple reason that anything I apply is going to be removed as soon as possible by burn center staff, so they can put on another dressing that is applied in a more sterile environment.