Burn first aid issues again-"Not seeing the forest for the trees".

Dear Doctor Wolf,

An increase in the incidence of burn injuries in the home has been reported during the COVID pandemic likely arising from prolonged isolation and avoidance of hospital visits due to fears of exposure to SARS CoV-2 [1].

In “Concerns regarding self-treatment of burns during COVID-19 lockdown” (Burns. Sep. 2020. Volume 46; 6: pp1486) Lee and George note the inclination to “self-treat” in this setting using hydrogel burns dressings may lead to preventable complications and delay expert assessment because of erroneous assumptions regarding the capacity of the user to determine burn depth [2].

In light of these concerns, closer scrutiny of commercial burn first aid “alternatives” like hydrogel burn dressings is of benefit given the poorly supported efficacy of the product in this role [(3),4] and inconsistent use across a wide spectrum of pre-hospital sectors [5,6].

For example, some EMS have discarded hydrogel burn dressings [7], others employ “hybridized” configurations such as only using the dressing function [8] or applying TBSA or age-based caveats [9] both approaches unsupported by evidence, whilst many employ hydrogel burn dressings as an option of last resort for “no water” scenarios. The technology has also been described as an “adjunct” to existing burn first aid [10].

Using hydrogel burn dressings as a contingency for “no water” burns scenarios belies the rarity of such events [11], the known delayed clinical effectiveness of water cooling [12] and the unlikely immediate availability of the product at hand for any burn emergency.

In the private sector, various water-cooling approaches are recommended by influential first aid organisations through in-house education programmes, at the same time, garnering substantial revenue through sale of “burn first aid” kits that feature hydrogel burn dressing products [13,14].

Elsewhere, hydrogel burn dressing companies exploit sponsorship pathways or benefit from promotional opportunities through private burns advocacy groups, charities and support agencies [15] or appear in local burn first aid recommendations [16].

The marketing of hydrogel burn dressings also benefits through the kudos of a continuing presence in the many commonly employed “minor” burns first aid guidelines [17] and the general appeal of “handy” consumer products [3].

At the same time, no universally accepted burn first aid model has been embraced by the expert bodies [18], including the role of hydrogel burn dressings in a cooling, dressing or dual role capacity, and only one burns association has published a formal “hydrogel position statement” outlining the preferred application of HBD in burn first aid [19].

Significant variation also exists in the hydrogel burn dressings industry itself with some manufacturers still promoting the technology as a primary burn first aid option [20], others as a complimentary adjunct to existing first aid [21] or to treat “minor” burn injuries only [22].

Hydrogel burn dressing examples above highlight just one subset of the plethora of approaches to burn first aid and the confusion such variation must inevitably generate. Of note is the fact hydrogel burn dressings is the only intervention promoted and used in both lay and professional (EMS) practice despite its lack of clinical credentials.

In real world practice, the implications for the lay responder reacting under extreme duress to potentially devastating and painful injuries to a loved one or workmate, is a split-second reflexive decision driven by fear and anxiety to choose between an hydrogel burn dressings from a kit, apply a “home remedy”, try to recall one of the innumerable recommended practices while at the same time attempting to assess the extent and severity of the burn to determine whether emergency medical care resources are required.

That an attending ambulance may well employ a completely different form of burn first aid on arrival further exemplifies the bewildering current predicament of this area of pre-hospital care.

Given compelling evidence for a 20-minute water-cooling, simple dressing model [[23], [24], [25], [26], [27], [28]] the inevitable conclusion is to see hydrogel burn dressings, like “home remedy” alternatives perpetuated by the internet commentariat [29], removed from burn first aid altogether in order to encourage use of the most effective form of care at the same time moving both the EMS and public mindset towards a standard model through innovative educational methods [30,31].

This should incorporate a redefined role for EMS focused on aggressive warming strategies to offset or prevent any cooling induced hypothermic complications, effective dressing, enhanced analgesic options and supportive managements instead of primary cooling.

The impetus to improve public education and compliance with burn first aid recommendations remains omnipresent on a global scale if further increases in preventable burn injuries are to be avoided [[32], [33], [34], [35]]. This cannot occur without broader efforts to clearly define and establish universal parameters for burn first aid.

While hydrogel burn dressings retain an important role in hospital wound management, their continued inclusion in pre-hospital recommendations and practice guidelines and in the consumer market, serves only to distract from these goals and further highlights “the urgent need for international standards” via consensus within the expert burns community [36].

Burn first aid would benefit specifically from two innovations to reach its well documented clinical potential as an acute burn care intervention on a global scale – standardization and simplification. The argument for a single water-cooling model of burn first aid in the pre-hospital setting for all thermal burns – irrespective of size or complexity, is compelling in my view. Lee and George have identified yet another reason to adopt this position and remove distracting “alternatives” like hydrogel burn dressings.

Until this milestone is reached, COVID scenarios or otherwise, the situation appears to be one of “not seeing the forest for the trees”.

Conflict of interest

The author declares no conflict of interest. The author declares no funding or sponsorship has been received.