Hydrogel Burn Dressings

[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

 

[Flying]

What I've been told regarding burns and these are common points that come up whenever burns are discussed in my area:
- Covering with only a dry dressing/sheet is for the convenience of the hospitals.
- Topical treatments may obfuscate the view of the burn and will complicate debridement.
- Kits specially made for burn management are useless.
- Other coverings such as foil and plastic wrap will insulate the burn and make it worse.

I don't know how much of this is bollocks and how the local hospitals choose to manage burns. I also don't know how the last point logically follows after treating the patient by reducing the burn with water.

Below is an example protocol I was given.

 

[Akulahawk]

From my understanding, the main reason they want dry dressings on burns >20% TBSA is that if you put something wet on the burned areas, you can cause the patient to become hypothermic. For blisters, I really do like using hydrogels and I would imagine that for smaller burns, as long as you can keep infection at bay, hydrogels probably would do just fine... if you use it after the wound has been properly debrided/cleaned.

 

[Smitty213]

In 1st/minor 2nd degree burns under 20%, I have had some success with a WaterGel product that is essentially a medication/hydrogel soaked 4x4. As it was outside of the traditional EMS setting, I had a chance to monitor the pts recovery; pts reported less pain in the days following than I was accustomed to and the healing process seemed to move a bit quicker.

 

[epipusher]

We use dollar store plastic wrap. This comes from a recommendation by our local burn center.

 

[Melbourne MICA]

Thanks for your observations Flying, Akulahawk,Smitty213 and epipusher. Part of the recent paper I had published dealt with the divergence of protocols amongst not only the EMS agencies but amongst the major burns associations and resus councils. I surveyed 37 organisations for recommendations and guidelines for practice (Australia, UK/England, Ireland,Canada, US, even found one from Hong Kong!!) It was hard to find any two that were the same. Flying: all the points you mention I would suggest are in fact bollocks and I can't imagine where these ideas originated. In fact, given its 2015 I'm still gobsmacked there is basically no standard for burn first aid anywhere in the world except maybe AU where the basics are: cooling with running water for 20mins followed by clingwrap dressing. That's it folks - doesn't get much more simple. Our hydrogels are now only last resort, for a no water contingency only. The new protocol is aimed at sufficient cooling time to reduce burn progression without too big a risk of hypothermia. The clingfilm is simple, clean, the burns docs can see through it without taking it off, it adheres to the wound but is easy to remove. Once the cooling is done, the wound just needs to be covered for both pain relief (in partial thickness injury) and cleanliness. So one block of cooling (this is mostly already done before you arrive anyway with guidance from the 999 operator) cover and above all warming - heaps of it. I could write you pages and pages on this stuff -I've been at it for four years now. The hydrogels are a big issue. If you read my paper you'll discover they are not supported by any pre-hospital evidence and basically no other decent hospital or laboratory evidence either. SO why are they everywhere in EMS????

MM

 

[luke_31]

Thanks for your observations Flying, Akulahawk,Smitty213 and epipusher. Part of the recent paper I had published dealt with the divergence of protocols amongst not only the EMS agencies but amongst the major burns associations and resus councils. I surveyed 37 organisations for recommendations and guidelines for practice (Australia, UK/England, Ireland,Canada, US, even found one from Hong Kong!!) It was hard to find any two that were the same. Flying: all the points you mention I would suggest are in fact bollocks and I can't imagine where these ideas originated. In fact, given its 2015 I'm still gobsmacked there is basically no standard for burn first aid anywhere in the world except maybe AU where the basics are: cooling with running water for 20mins followed by clingwrap dressing. That's it folks - doesn't get much more simple. Our hydrogels are now only last resort, for a no water contingency only. The new protocol is aimed at sufficient cooling time to reduce burn progression without too big a risk of hypothermia. The clingfilm is simple, clean, the burns docs can see through it without taking it off, it adheres to the wound but is easy to remove. Once the cooling is done, the wound just needs to be covered for both pain relief (in partial thickness injury) and cleanliness. So one block of cooling (this is mostly already done before you arrive anyway with guidance from the 999 operator) cover and above all warming - heaps of it. I could write you pages and pages on this stuff -I've been at it for four years now. The hydrogels are a big issue. If you read my paper you'll discover they are not supported by any pre-hospital evidence and basically no other decent hospital or laboratory evidence either. SO why are they everywhere in EMS????

MM

Interesting. Do you have the paper you published available I'm certain that at least a few of us would be interested in reading it.

 

[Clare]

Hi mate, over the ditch in NZ we use very liberal cooling and glad wrap. I have heard that those fancy dressings are being looked at because they are supposedly very soothing, but very expensive so I do not think anything will be introduced soon!

Glad wrap is in the AU and UK burn treatment guidelines.

As for cooling, we are expressly told to spend 20 minutes on scene cooling with cool (but not cold) water unless there is a problem in the primary survey that requires rapid transport to hospital. We are also told the best way to cool more than small burns is with a domestic shower or hose (provided the hose water is clean). We are told not to run 0.9% NaCl over a burn because that is a waste of time, it's better to use cool water from a tap, shower or hose.

 

[Melbourne MICA]

Interesting. Do you have the paper you published available I'm certain that at least a few of us would be interested in reading it.

I do but let me check on my author privileges. I don't have open access which means they keep a stranglehold who looks at it. Check out ResearchGate instead. The title of the paper is in my first post (above). I might be able to upload a slightly older draft of the paper which doesn't breach the rules.

 

[Melbourne MICA]

Hi mate, over the ditch in NZ we use very liberal cooling and glad wrap. I have heard that those fancy dressings are being looked at because they are supposedly very soothing, but very expensive so I do not think anything will be introduced soon!

Glad wrap is in the AU and UK burn treatment guidelines.

As for cooling, we are expressly told to spend 20 minutes on scene cooling with cool (but not cold) water unless there is a problem in the primary survey that requires rapid transport to hospital. We are also told the best way to cool more than small burns is with a domestic shower or hose (provided the hose water is clean). We are told not to run 0.9% NaCl over a burn because that is a waste of time, it's better to use cool water from a tap, shower or hose.

Well howdy neighbour. That's it. Its because of ANZBA's change in guidelines - which I am egoistical enough to say I influenced with an oral presentation on Hydrogels at the ANZBA 2011 burns conference in Queensland !!! We started using hydrogels in Ambulance Victoria in 2009 without any kind of proper investigation as to their efficacy. Then in 2011 I was working in our operations/education department and was asked to check properly. The rest is history. The burn first aid situation is a mess. The interesting thing is I am yet to hear from anyone whether the new guidelines will be checked for their effectiveness. What's the point of new guidelines if you don't actually check to see if they are better than what you were doing previously?

MM

 

[Melbourne MICA]

Interesting. Do you have the paper you published available I'm certain that at least a few of us would be interested in reading it.

Trying to upload but website keeps saying there is an error. Its in PDF format. Does it have to be something else like MSWord?

 

[luke_31]

Don't know maybe one of the community mods can help.

 

[Melbourne MICA]

Well finally - have uploaded my SR on hydrogels for those interested in reading. Its the very first (English language) SR on the subject although I'm not sure there are any non-English language versions so it may well be THE first. Its an empty review -that is, no studies met inclusion criteria. This is probably the reason it was accepted by the IWJ - because there has been no research to determine if hydrogels improve patient outcome yet everyone is using them- not evidence based practice! This does not mean of course, they are of no value in pre-hospital. It just means this has not been proven one way or the other yet. Hope everyone enjoys the read. Comments most welcome.

Melbourne MICA

 

[Flying]

While I am not nearly as well-read as you are MICA, this certainly made me feel unsettled about the lack of agreement in first-aid management of burn injuries. I imagine such a sentiment would be amplified with knowledge.

Particularly interested in the reports of hydrogel+clingwrap combination potentially worsening injuries, as this seems to corroborate with the second-third hand information I receive when asking why clingwrap isn't used locally.

 

[Melbourne MICA]

Thanks for the feedback Flying. Firstly on the point of no consensus - check out the file I have uploaded - gives you an idea of the problem (see tables in the paper). These tables were culled later due to word count issues but show what we are up against.

On Clingfilm issues. The issue isn't the Clingfilm. The issue is overwrapping a hydrogel dressing for any reason. Thye work via convection AND evaporation, despite the BS claims by Waterjel that theirs only needs convection. Crap. Heat drawn from the wound has to be dispersed through another medium to change the temperature in the burned area. That being air of course. Cover the hydrogel dressing - with ANYTHING (especially if its airtight, like Clingfilm) and the heat gets trapped in the dressing - not good for the patient. Check out the Waterjel and Burnaid videos on youtube. You will ALWAYS see the patient exposed to the air.

The hydrogel companies are terrified of the shift to using something as simple and cheap as Clingfilm. You see, their product serves 2 functions - Cools the wound and provides a dressing afterwards. A good idea on the surface which is why they seem so appealing -they come in a nice easy bag you can hang on the back of the seat in the truck as well.

However, EMS is shifting (back) to water cooling (except in the US - bit slow to catch on you guys ) There goes the need to use a hydrogel for this purpose. Joe Blogs hoses down his mate who has thrown the petrol on the BB'Cue or his kid who has spilled the hot water goes in the shower. The cooling is done. You DON"T need to do any more. A single block of 20mins is all that is needed (best supported by evidence).

So you shouldn't be putting on a hydrogel to cool (again). But here's the problem. If you put it on as just a dressing it will keep cooling because the functions cannot be separated. Alternately if the cooling wasn't long enough if you put on the hydrogel you have a dilemma. Leave the patient exposed so the hydrogel works properly (not as good as running water by the way) and they get cold - fast. Hydrogels also dry out quickly and have to be renewed/replaced - you don't want to be taking dressings off a burn wound - bad idea in the field. Causes pain, risks contamination and further injury.

Now if you overwrap the dressing and the patient it will build up heat in the dressing and wound - not good to reduce burn progression. This is why a lot of EMS don't like hydrogels now - either patients get hypothermic exposed to the air, or the dressing overheats because crews want to cover them up - Waterjel says it works on convection alone and doesn't cause hypothermia so you should be able to cover it up, wrap the patient all snug and warm etc. ********. And they know it is.

And besides, from a clinical standpoint there is no evidence hydrogels improve patient outcomes better than water cooling and normal dressing. And they cost.

All this leads to the approach most major burns associations are advocating. Patients friends/relatives are told to wet down the burned patient with running water (for 20mins). So when we arrive we check the cooling period - if adequate, we dress the wound only and focus on warming, warming and more warming as well as pain relief etc. The Clingfilm is easy to put on, sticks without adhering, its cheap, simple, clean and you can see through it without having to take it off. Did you know Waterjel have changed their formulation recently to make their dressing semi-transparent? Why is that? Something to do with a competitor than comes in a box from the supermarket ?

And watch out for a certain individual from Waterjel who is their "clinical educator". He wrote a paper bagging Clingfilm in the Journal Of Paramedic Practice from around Dec last year (its total rubbish - an embarrassment) and he also goes around to every conference, "lectures" everyone, has Waterjel buy him subscriptions and memberships on just about every burn association you can name. He didn't even have the academic honesty to declare a conflict of interest in the journal given he's on the editorial board of the journal, works for Waterjel and a large Waterjel advertisement was smack bang in the middle of the article. The article, I suspect was timed to be released around the same time Waterjel announces its new "transparent" formulation. Conspiracy theory stuff.

Sorry lots of information and some political stuff as well. Complicated isn't it?

Melbourne MICA