Giving adequate pre-hospital first aid in thermal burns before referring the patient to a health facility can provide excellent outcomes. This treatment is carried out after ensuring that there are no life-threatening injuries. A good outcome is assessed by decreasing the patient's morbidity and mortality rate and the optimal wound healing both functionally and aesthetically.

In addition to general practitioners, non-professional lay workers such as friends, relatives, or people around the scene can provide first aid in acute burns. Immediately giving first aid plays an important role in managing burns. Therefore, first aid measures must be taken uniformly, as soon as possible after the onset, and by anyone.

Fast and Proper

Because burns are chronic injuries, proper knowledge of chronic wound dressing is needed in the initial burns treatments. In a Vietnam study, only 27.2% of pediatric patients with burn injuries received proper first aid. While as many as 25.5% of patients still received therapy with household ingredients such as toothpaste, animal oil, grass, cooking spices, etc. Use household as therapy is typical in burns management in developing countries.

Pre-Hospital First Aid for Burn Injury, Running water for burn injury
Running water for Burn Injury

First aid, when at the scene, includes three aspects: stop the burning process, cool the burn temperature, and avoid hypothermia.

1. Stop the Burning Process

The action to stop the process of burns aims to minimize tissue damage due to heat. The first treatment for a burn is to stop a heat source such as fire or hot water. In theory, fire requires three elements, namely oxygen, fuel, and ignition. Elimination of one of these elements can stop the fire.

In the case of burns caused by fire, the human body acts as a fuel element, so the patient must be separated from the heat source and taken to a safe place. One technique designed for burn patients is Stop Drop Cover (face) and Roll. The patient stops moving, lies down, covers the face, and rolls to fire. Patients are required to release all heat-conductive elements, such as clothing and jewelry. This action aims to help with an accurate assessment of injuries and follow-up procedures.

The clothes with adherent material (such as nylon) should be attached if the fabric melts and attaches to the patient.

2. Cool the Burns

Efforts to cool burns aim to reduce inflammatory mediators' production and maintain the viability of the stasis zone. Following the recommendations of the Australian and New Zealand Burn Association (ANZBA), first aid is continued by cooling the burn with running water for 20 minutes as soon as possible.

Cohort Study Regarding the Advantages of Cooling Using Running Water
A cohort study reported that cooling for 20 minutes with running water before referral to a hospital reduced the likelihood of skin reconstruction (skin graft) surgeries by 13%, reduced transfer to ICU care by 48%, and shortened hospitalization duration by 18%.

Nguyen et al. revealed the same that Pediatric patients with deep burns who received irrigation therapy had a 32% lower need for skin grafting surgery and underwent shorter treatments. Also, cooling provides an effective analgesic effect. Cooling action is still effective if performed within 3 hours after the onset.

In vivo studies showed that cooling for 20 and 30 minutes results in a smaller increase in temperature after cooling is stopped and better histological improvement than groups that receive cooling for 5 and 10 minutes. Cooling for a shorter duration (5 and 10 minutes) had an analgesic effect. In contrast to the long duration (30 minutes), it did not show significant improvement.  It raised hypothermia risk, especially in patients with extensive burns (> 25% body surface area) and pediatric patients, so that 20 minutes remains the optimal duration of cooling.

The cooling process with running water cleanse wounds and rinse harmful agents, reduce inflammatory reactions by stabilizing mast cells and release histamine or cytokines, and stop necrosis progression in the stasis zone. Cooling the burn maintains the cytoplasm structure and the basement membrane. It annunciates epidermal regeneration. This speeds up the healing process, which is more adequate and minimizes surgery needed and pathological scar formation.

The recommended water temperature to cool the wound is 15 degrees celsius, and not recommended to use ice water or ice cubes. Extreme cold temperatures cause vasoconstriction and deepen tissue injury. Cooling burns in pigs with ice or cold water (1 - 8 degrees celsius) produces more severe tissue damage. Also, patients are at risk of suffering from hypothermia, which can increase mortality.

Other methods can be used if there is limited flowing water, such as spraying water or squeezing water from a sponge. However, it is not as effective as running water. The wet cloth also does not have optimal efficiency because it cannot reach the entire burn area. Besides, the temperature of the wet cloth quickly rises because of its position close to the body. When using the wet cloth compress method, the cloth needs to be replaced frequently.

A study by Yuan compared various methods of cooling burns in pigs. Experimental animals were subjected to burns with hot water, cooled for 20 minutes, then clinical and histological photographs of tissue were examined on days 1 and 9. The control group (without cooling treatment) showed burns with a persistent or worsening depth. Results in the wet cloth and water spray group showed variability. The group treated with running water showed consistent improvement in wound depth.

Effectiveness of Hydrogel as a Cooling Agent
Hydrogel, which is dressings with 96% water, is also effective as an option to reduce wound temperature and produce a cure compared to the water compress method. Until now, there have been no studies that support the effectiveness of hydrogel as cooling agents. Hypothetically, the hydrogel is capable of evaporative cooling agents. But its workings have not been specifically studied.

Although the price is higher and not freely available, hydrogel application can be performed less frequently than compressed water (usually, the hydrogel dries 1 hour after application). However, based on ANZBA guidelines, hydrogel should not be used in first aid. It is used as dressings for transportation if other first-line therapies are not available. The hydrogel is useful as a dressing with an analgesic effect. However, it carries the risk of causing hypothermia in extensive burns and pediatric patients.

3. Prevent hypothermia

Burn patients have a risk of hypothermia, especially in pediatric populations, due to the large surface area compared to fluid volume. Keep patients warm and dry whenever possible. Maintaining euthermia in burn patients aims to reduce mortality and morbidity in burn cases. Hypothermia can increase wound infections, prolong the duration of hospitalization, and worsen post-surgery.

In post-cooling burns, the pain reappears after the running water is stopped, and there are no other factors that hinder the action. Giving running water can be continued to obtain an analgesic effect. The cooling process should not cause the patient to shiver.

Initial Management of Burns Wound

In the initial management of burns, it is necessary to estimate the patient to be prepared for transfer to adequate health facilities in severe burns. ANZBA provides several referral criteria, such as:
  • Adult patients with burns> 10% Total Body Surface Area (TBSA)
  • Pediatric patients with burns> 5% TBSA
  • Burns on the face, hands, feet, genitals, perineum, major joints, and circumferential burns on the legs or chest
  • inhalation injury
  • Burn patients with comorbidity
  • Burns with multiple injuries
  • Burns at a very young and old age

Patients without comorbidities can be considered for outpatient management. When in doubt, consult or refer the patient to a local burn unit or plastic surgery facility.

General practitioners can calculate burn area by the rule of nine, Lund and Browder charts, or palmar techniques. After knowing the burn's extent, an initial resuscitation can be performed using the Parkland formula 3-4 mL x Kgweight x burn area.

Before referring the patient to an adequate health facility and first aid is given, it is better to wash the burn using water, saline, or 0.1% aqueous chlorhexidine solution with soap. The wound dressing in the initial phase adjusts the transport time to the destination health unit. If the patient could arrive at the referral unit within 8 hours of onset, use polyvinyl chloride plastic wrap (cling film) or other clean and dry dressing to cover burns. Give serum anti-tetanus injection to burn patients with extensive tissue injury.

Plastic wrap is recommended because it is sterile, available in large sizes, does not stick to wounds, is easily shaped, transparent (making it easier to inspect wounds), and reduces evaporation and loss of body heat. If the transportation time is prolonged, the topical antimicrobial dressing can be used. The dressing may not constrict or surround the extremities.

The injured area should be elevated during initial management and transportation. Elevation can reduce edema that inhibits perfusion and delivery of tissue nutrients, thereby increasing the likelihood of tissue survival and delaying or avoiding the need for escharotomy.

Source: Alomedika
Writer: dr. Sandy S Sopandi
Source picture:

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