Burn Dressings for Superficial Burns for First Aid (FA): Scoping Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: None

Task Force Scoping Review Citation

Markenson D, Berry DC, Douma M, Singletary E, Zideman D, on behalf of the International Liaison Committee on Resuscitation (insert) First Aid Task Force(s). Burn Dressings for First Aid Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force, 2019 December 29. Available from: http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process started with a scoping review of Burn Dressings for Superficial Burns for First Aid conducted by the ILCOR First Aid Task Force Scoping Review team. Evidence for adult and paediatric literature was sought and considered by the First Aid Task Force.

In 2015, the International Liaison Committee on Resuscitation (ILCOR) Consensus on First Aid Science with Treatment Recommendations (CoSTR) found no evidence that a wet dressing compared with a dry dressing is beneficial for the care of a burn {Singletary 2015 S299; Zideman 2015 e229}. One additional study showed no benefit for a topical penetrating antibacterial compared with petrolatum gauze or for a topical nonpenetrating antibacterial versus dry dressing {Heinrich 1988 253}. Because of ambiguity in the wording of the 2015 PICO (‘wet’ compared with ‘dry’ dressings), the review was retired and replaced with the current PICOST. This scoping review only evaluated first aid management, focusing on superficial burns as deeper burns would require debridement and other advanced interventions outside the scope of traditional first aid in the first aid setting.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs, and Timeframe):

Population: Among adults and children with superficial thermal injuries

Intervention: does any specific type of dressing applied in the first aid setting

Comparators: compared with another type of dressing

Outcomes: any clinical outcome

Study Designs: Randomized controlled trials (RCTs), controlled clinical trial, clinical trial, comparative study, non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, case-control, cross-sectional, epidemiologic), case series (n>5), survey and retrospective are eligible for inclusion. Unpublished studies (eg., conference abstracts, trial protocols), editorials, commentary, case reports, and animals were excluded.

No study design restrictions were applied for the grey literature search.

Timeframe: All available dates included in EMBASE, Medline, Cochrane, EBM reviews and NHS Economic.

Search Strategies

Database(s): MEDLINE (Ovid), Embase (Ovid), Cochrane Database of Systematic Reviews (Ovid)

ACP Journal Club (Ovid), Database of Abstracts of Reviews of Effects (Ovid), Cochrane CENTRAL Register of Controlled Trials (Ovid), Cochrane Methodology Register Database (Ovid)

Health Technology Assessment Database (Ovid), National Health Service Economic Evaluation Database (Ovid) and CINAHL (Ebsco)
Search Strategy:

A secondary literature search was conducted on December 21, 2019, using Google Chrome to identify relevant literature not published in the four database searches above. Keyword search string included “Superficial burn AND First Aid AND Dressing." No date or country restriction were applied. However, websites were limited to accessible PDF documents, resulting in 387,000 hits. Fifty-three websites were reviewed for relevant literature. The literature search was updated to December 22, 2019.

Inclusion and Exclusion Criteria

Inclusion criteria

• Randomized controlled trials (RCTs), controlled clinical trial, clinical trial, comparative study, non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies, case-control, cross-sectional, epidemiologic), case series (n>5), survey and retrospective
• Adults and pediatric (> 1-year-old) subjects with a superficial burn
• Assessment and care in the prehospital or first aid environment
• Assessment and care by non-healthcare providers or that provided by healthcare providers if within the scope of first aid
• Available abstract

Exclusion criteria

• Unpublished studies (e.g., conference abstracts, trial protocols), editorials, commentary, case reports, and animals are excluded in only search strategy one
• Partial and full-thickness burns
• Management in the emergency department

Data Tables

Database(s): EBM Reviews - ACP Journal Club 1991 to October 2019, EBM Reviews - Cochrane Central Register of Controlled Trials November 2019, EBM Reviews - Cochrane Database of Systematic Reviews 2005 to December 4, 2019, EBM Reviews - Cochrane Methodology Register 3rd Quarter 2012, EBM Reviews - Database of Abstracts of Reviews of Effects 1st Quarter 2016, EBM Reviews - Health Technology Assessment 4th Quarter 2016, EBM Reviews - NHS Economic Evaluation Database 1st Quarter 2016, Embase 1974 to 2019 December 06, Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily 1946 to December 06, 2019

Search Strategy:

CINAHL

N.B. No limiters applied

Top of Form

Bottom of Form

Table 1. Grey Literature Search of Google Chrome PDF Documents and Hand Search.

*Restricted to PDF documents

Table 2. Grey Literature and Hand Search Results.

Task Force Insights

1. Why this topic was reviewed.

Home incidents, mass trauma, and disasters such as explosions and fires can cause a variety of serious injuries, including burns (CDC 2019). These can include thermal burns, which are caused by contact with flames, hot liquids, hot surfaces, and other sources of high temperatures, as well as chemical burns and electrical burns. Regardless of the etiology, burns are potentially devastating injuries with numerous consequences ranging from physical, functional, and occupational to cosmetic and psychosocial damage {Kattan 2016 2}. Proper and immediate care can reduce suffering and can be lifesaving, and it is therefore vital that first aid providers understand how to evaluate and manage minor burns in the first aid setting as well as the indications for referral to the emergency department {Lloyd 2012 25}.

Burns are usually classified by depth. In this scoping review, a superficial burn (previously known as first-degree burn) involves only the epidermis, which remains intact. These burns are erythematous, painful, and dry {Lloyd 2012 26; Yastı 2015 79}.

First aid providers are often faced with situations where they must decide what advice to offer an individual following a thermal burn {Singletary 2015 S574, Zideman 2015 278}. However, despite the myriad of treatment recommendations for superficial burns, there is still limited data as to which type of dressing is most effective after cooling a superficial burn, especially in the first aid environment {Singletary 2015 S299; Zideman 2015 e229}.

In 2015, the International Liaison Committee on Resuscitation (ILCOR) Consensus on First Aid Science with Treatment Recommendations (CoSTR) yielded no recommendation relative to the usage of wet dressings compared with dry dressings for thermal burns in the first aid setting {Singletary 2015 S300; Zideman 2015 e229}. There were no studies comparing plastic wrap, considered a dry dressing, with a wet dressing which met the inclusion criteria {Singletary 2015 S292; Zideman 2015 e229}. The 2015 CoSTR did acknowledge that further research was needed on the use of burn dressings in the prehospital setting. Specifically, it is unknown what type of dressing is optimal for use by first aid providers.

Therefore, the topic was chosen for review by the First Aid Task Force originally in 2015 and again for 2020 because of the ongoing risk of thermal injuries and the need to evaluate which dressing type is most effective and available in the first aid setting for the treatment of superficial thermal burns.

2. Narrative summary of evidence identified

Our extensive database search strategy yielded many publications; however, a subsequent review resulted in the selection of no published manuscripts which compared the unique effects or demonstrated efficacy of burn dressings applied in the first aid setting by first aid providers for superficial thermal burns. We did identify other types of interventions applied to thermal burns, but these did not meet the inclusion criteria for this PICO and did not involve a direct comparison between dressings. Many of the studies involved dressings that were applied to partial thickness or full thickness burns following admission to the emergency department or upon transfer to a burn unit. There was literature that discussed the risks and management of continued burning and heat entrapment with the use of hydrogel dressings. Lastly, there were a significant number of articles on the benefits of honey in the use of acute wound management, including burns.

The grey search literature yielded 21 informational (basic care for thermal, chemical, and electrical injuries) documents, 15 guidelines and position statements, and 8 additional manuscripts. All 44 documents addressed burns from superficial to full-thickness in some capacity. Only four documents {Edwards 2013 7; Lloyd 2012 25; Varley 2015, Varley 2016 571} provided any primary or secondary references relative to any type intervention (ie., not just dressings) possibly applied to a superficial burn in the first aid setting. Nine documents were excluded as they made reference to thermal injury care (any depth) following admission to the emergency department or upon transfer to a burn unit or upon arrival at home for follow-up care.

The grey literature search yielded several different therapeutic interventions used in the first aid setting; some include multiple interventions such as dry dressings with topical aloe vera (National Association of State EMS Officials ND 3) or a dry dressing with topical antibiotic ointment (Boy Scouts of America ND 22). In some cases, the information was not clear as to which was applied first, or under what conditions. The most commonly discussed (but not necessarily referenced) intervention in the first aid setting included the application of a dry dressing (n=16; 29.6%) normally after cooling the superficial burn with water. Further common interventions included cling wrap (n=10; 18.5%), cotton sheet (n=4; 7.4%), aloe vera (n=3, 5.5%), antibiotic ointment, dressing non-descriptive, petroleum in combination with gauze dry gauze and other alternatives ( n=2; 3.7%), and honey, paraffin gauze, and burn gel (n=1; 1.8%). The majority of the intervention recommendations originated in the United States (n=20; 46.5%), Australia (n=8; 18.6%), and United Kingdom (n=6; 13.9%). Other represented Countries included Africa, Canada, New Zealand, India, Turkey.

The joint 2015 American Red Cross-American Heart Association first aid guidelines update recommended that “… after cooling of a burn, it may be reasonable to loosely cover the burn with a sterile, dry dressing (Class IIb, LOE C-LD)” {Singletary 2015 S580}. Additionally, it was recommended that “… it may be reasonable to avoid natural remedies, such as honey or potato peel dressings (Class IIb, LOE C-LD). However, in remote or wilderness settings where commercially made topical antibiotics are not available, it may be reasonable to consider applying honey topically as an antimicrobial agent (Class IIb, LOE C-LD)” {Singletary 2015 S580}.

3. Narrative Reporting of the task force discussions

Task force discussions underscored concern for the consequences of failure to properly treat a superficial burn in the first aid setting, and the need for an effective treatment strategy. Failure to properly recognize thermal burn can result in a delay or absence of referral for definitive initial and follow-up evaluation and medical care; or in some cases inappropriate release to activity (eg, work, driving, school, sport), which has the potential to exacerbate poor outcomes.

It was recognized that immediate and effective cooling of the burn is still the primary intervention with proven efficacy and should be performed first, once the patient is removed from the thermal source. As cooling times may encompass the entire first aid treatment timeframe, further interventions may not occur. Active cooling should take place as soon as possible with most first aid organizations recommending that this cooling should be undertaken for at least 20 minutes using cool/cold but nonfreezing water.

The Task Force acknowledged that the literature search highlighted that no dressing was evaluated uniquely in the first aid setting for superficial thermal burns; rather the literature focused on dressings as part of on-going burn medical care. In addition, the published literature focused predominantly on partial and full-thickness burns. The Task Force also recognized the literature which had been previously identified highlighted the potential risks from heat entrapment and continued burning with hydrogel dressings. While this was not the focus of this review it has been recognized before and should be part of first aid training. A future systemic review may be warranted.

Further Task force discussions focused on the efficacy, accessibility and feasibility of the application of cling film as a dressing in the first aid setting after immediate cooling of the burn. While discussion was not unique to burns, some believe that cling film is an ideal temporary dressing for a burn (not for facial thermal injuries) as it protects the wound, reduces heat and evaporation, reduces pain, and also allows the wound to be visualized for a more accurate evaluation by the burn team later {Hettiaratchy 2004 1557}. Concern was raised about the sterility of the cling wrap and its storage in a first aid kit, as well as how many layers are required. However, Liao {Liao 2014 443} found that the potential for plastic wrap to act as a fomite when used as an acute burn wound dressing is extremely low.

Lastly, Task force discussions focused on the efficacy, accessibility, and feasibility that the use of honey may serve as a topical therapy in the first aid setting after immediate cooling of the burn. Lloyd {Lloyd 2012 25} states, “Superficial burns can be treated with topical application of lotion, honey, aloe vera, or antibiotic ointment”. It is postulated that the lipid component of these treatments accelerates the repair of damaged skin and reduces drying, however, limited information on how to apply the honey (with or without a dressing) exists or whether honey prepared as a medicinal compound versus commercially available as a food product is more effective. Concern was raised about storage in a first aid kit, application, the need for consideration of an expiration date.

There may be benefit from a systematic review of the risks of the use of hydrogel dressings in the first aid setting. Whilst not directly part of this scoping review, the evidence found could warrant a systematic review of alternative therapies following active cooling for superficial thermal burns, such as honey and aloe vera.

Knowledge Gaps

This scoping review highlights significant gaps in the research related to superficial burn care by a first aid provider for both adults and pediatrics.

It is unknown whether a first aid provider can properly determine the depth of thermal burn in a first aid setting in order to be able to render appropriate care in the first aid setting.

It is unknown what first aid intervention is most appropriate in the first aid setting for managing a thermal burn with an unknown depth.

There is an urgent need for identification of superficial thermal interventions compared with other interventions, not just dressings, and whether first aid providers have the ability to use these.

There is a need for more thorough explanations of the application of alternative thermal injury interventions (ie, application of honey or aloe vera, with or without dressing and bandage) and whether first aid providers have the ability to use these.

References

Boy Scout of America (BSA). Wilderness first aid curriculum and doctrine guideline. https://fortdrum.isportsman.net/files/Documents%2Fbsa-wilderness-first-aid-curriculum.pdf Accessed December 23, 2019

Centers for Disease Control and Prevention. Burns.

https://www.cdc.gov/masstrauma... Accessed December 22, 2019.

Edwards V. Key aspects of burn wound management. Wounds UK. 2013;9(3-suppl):6-9.

Heinrich JJ, Brand DA, Cuono CB. The role of topical treatment as a determinant of infection in outpatient burns. J Burn Care Rehabil. 1989;9:253-257.

Hettiaratchy S, Papini R. Initial management of a major burn: I—overview. BMJ. 2004;328(7455): 1555–1557. doi: 10.1136/bmj.328.7455.1555

Kattan AE, AlShomer F, Alhujayri AK, Addar A, Aljerian A. Current knowledge of burn injury first aid practices and applied traditional remedies: a nationwide survey. Burns Trauma. 2016;4:37. eCollection 2016. doi: 10.1186/s41038-016-0063-7

Lloyd EC, Rodgers BC, Michener M, Williams MS. Outpatient burns: prevention and care. Am Fam Physician. 2012;85(1):25-32.

Liao AY, Andresen D, Martin HC Harvey JG, Holland AJ. The infection risk of plastic wrap as an acute burns dressing. Burns. 2014 May;40(3):443-5. doi: 10.1016/j.burns.2013.08.006. Epub 2013 Sep 6.

National Association of State EMS Officials. https://nasemso.org/wp-content... firefighter: burn injury guidelines for care. Accessed December 22, 2019.

Singletary EM, Zideman DA, De Buck EDJ, Chang WT, Jensen JL, Swain JM, Woodin JA, Blanchard IE, Herrington RA, Pellegrino JL, Hood NA, Lojero-Wheatley LF, Markenson DS, Yang HJ; on behalf of the First Aid Chapter Collaborators. Part 9: first aid: 2015 International Consensus on First Aid Science With Treatment Recommendations. Circulation. 2015; 132(suppl 1):S269–S311. doi: 10.1161/CIR.0000000000000278

Singletary EM, Charlton NP, Epstein JL, Ferguson JD, Jensen JL, MacPherson AI, Pellegrino JL, Smith WR, Swain JM, Lojero-Wheatley LF, Zideman DA. Part 15: first aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid. Circulation. 2015;132(suppl 2):S574–S589.

Varley A, Sarginson J, Young A. British Burn Association: First aid position statement. http://79.170.40.160/britishburnassociation.org/wp-content/uploads/2017/06/BBA_First_Aid_Position_Statement_final_25.8.15.pdf Reviewed 2015, Accessed December 23, 2019.

Varley A, Sarginson J, Young A. Evidence based first aid advice for paediatric burns in the United Kingdom. Burns. 2016;42(3)571-577.

Yastı AÇ, Şenel E, Saydam M, Özok G, Çoruh A, Yorgancı K. Guideline and treatment algorithm for burn injuries. Ulus Travma Acil Cerrahi Derg. 2015 Mar;21(2):79-89. doi: 10.5505/tjtes.2015.88261.

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