Hydrogel dressings for burns

[Downunder]

Hi everyone,

Haven't been around for a while. Have spent the last few years in the burns area. Am interested to know how many of your local agencies employ Hydrogel burn dressings (eg WaterJel, Burnshield, Burnfree etc) as the primary first aid  treatment for your burn patients.

Cheers

 

Downunder

[trackmedic]

We have been told to keep burns dry in our area.   

[Downunder]

We have been told to keep burns dry in our area.   

Hi Trackmedic

What region of the states are you in if I may ask and does your local protocol reflect a state wide consensus or just your medical directors mandate? I am aware only 50% of US states even have statewide guidelines. I have written several documents on the burns subject including a systematic review on hydrogels in burn first aid published in the international wound journal.  On your own protocol of dry management of burns in EMS first aid -is that philosophy driven by concerns over hypothermia due to cooling?

Thanks for your reply.

Downunder

Edited August 1, 2015 by Downunder
typo

[Care]

Hydrogel dressing are usually clear or translucent and vary in viscosity or thickness. Benefits By providing moisture to the wound, hydrogel dressings create a moist healing environment, which promotes granulation, epithelialization, and autolytic debridement. The high water content of hydrogel dressings cools the wound, producing pain relief that can last up to 6 hours.

[Downunder]

Hydrogel dressing are usually clear or translucent and vary in viscosity or thickness. Benefits By providing moisture to the wound, hydrogel dressings create a moist healing environment, which promotes granulation, epithelialization, and autolytic debridement. The high water content of hydrogel dressings cools the wound, producing pain relief that can last up to 6 hours.

Hi adultcare pro,

Couldn't help but notice how much your remark sounds like a cut and paste from a hydrogel marketing spiel - no offence intended. So as we can understand why the mentioned benefits all sound good but don't really tell the whole story I'll take it one step at a time.

For starters hydrogels are opaque - at least until recently with the biggest hydrogel player in the US announcing a change to its burn dressing formulation to make it -you guessed it clear. I haven't seen them yet so don't know HOW clear they really are. Anyway, the question to ask is why clear is good as far as a burns dressing goes and why this company now decides to make their own brand this way. Clear is an advantage for visualising the burn - great for ED docs and the burns specialists so as not to unnecessarily disturb the wound. Makes sense. This particular advantage is owned by - you guessed it - Clingfilm, now the  post cooling dressing most recommended by the major burns associations.

Coincidentally, a certain "independent researcher" who happens to also be the "clinical educator" for this same company wrote a piece in the "Journal of Paramedic Practice" (Dec 2014) - (published July 2015) deriding ever so cleverly and subtly the use of Clingfilm as a dressing after you cool the burn. As academic articles go this one is a shocker. Biased, poorly referenced, misleading commentary, conclusion's drawn without substantiation from studies and evidence etc. Gee what a coincidence. You see all the major burns associations are pushing cool running water as the best cooling method - so it should be - its the best supported by evidence (going as far back as 1936 (Rose) right through to the present day - Cuttle, Bartlett, Yuan, Venter, Nguyen etc.) This means many EMS are dumping hydrogels as a first line treatment at least for cooling at this stage but many are still ignorant enough to use it as a dressing and wonder why the patient gets cold - two lots of cooling you see. Imagine what happens as EMS also drift away from hydrogels to clingfilm as the preferred dressing - its certainly way cheaper and besides - the evidence for the best pre-hospital burns dressing is non existent. (see Wasiak, Cleland et al Burns dressings for superficial and partial thickness burns 2013).

All this sounds like conspiracy stuff - sounds like a pretty good appraisal of the facts to me.

Now as for, moist healing, granulation, epithelialisation, autolytic debridement - actually hydrogels (not the same kind we use in pre-hospital) are really good for these purposes - in post acute, hospital treatment -i.e. in the days and weeks after burn injury. So these benefits have no value in pre-hospital.

As for the "high water content, cooling the wound and providing pain relief up to 6 hours":

a) clean running water has way more "water content"

b)water has been shown to cool the burn wound far more effectively than hydrogels the temperature drop in the wound almost double that of hydrogels - (see Yuan, Bartlett, Venter from memory)

c) I would be delighted if you could show me the study/studies demonstrating pain relief from hydrogels last up to 6hrs. And how the "pain relief" has been quantified. Well you need an analogue pain scale for that. Unfortunately -no-one has done one in pre-hospital and to he best of my knowledge no-one has done one in hospital (using the same kind of hydrogel dressing we use in EMS.

Zippo studies.

Now the spiel you presented comes straight from a particular "monograph" from memory and the company managed to scrounge as many articles as they could find that actually said anything good about hydrogels. Remember I said earlier - the best dressing choice is still up in the air -in hospital even (Wasiak).

Hydrogels have an important role to play don't get me wrong. They are already of much interest in hospital settings, but different types, used for different reasons.

As for pre-hospital - they may well yet serve a valuable role but at the moment there is no evidence they are better than running water and clingfilm.

In closing, I'll point you to this paper which has been published in a reputable peer reviewed 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". The International Wound Journal.

kind regards

Downunder

 

 

[Just Plain Ruff]

Every place I've ever worked for has advocated the application of a clean dry dressing.  

Many places have said it is due to hypothermia which is a burn patient's big danger apart from infection.  

I've always just put a dry sterile (if you can call it that) sheet over the burned area and transported.  

 

 I also am skeptical to think that other than covering a burn that my 30 minute or 60 minutes with them, that hydrogel over dry sterile dressings is going to show one being better than the other especially when the burn center/trauma center is probably going to remove the dressing I have put on them to put their own on.  Every burn patient I've taken into a hospital has had their dressing removed to have the one that the hospital wants to use.  So prove to me that Hydrogel in the field is better than a dry sterile dressing!!

[Downunder]

Every place I've ever worked for has advocated the application of a clean dry dressing.  

Many places have said it is due to hypothermia which is a burn patient's big danger apart from infection.  

I've always just put a dry sterile (if you can call it that) sheet over the burned area and transported.  

 

 I also am skeptical to think that other than covering a burn that my 30 minute or 60 minutes with them, that hydrogel over dry sterile dressings is going to show one being better than the other especially when the burn center/trauma center is probably going to remove the dressing I have put on them to put their own on.  Every burn patient I've taken into a hospital has had their dressing removed to have the one that the hospital wants to use.  So prove to me that Hydrogel in the field is better than a dry sterile dressing!!

Thanks Ruffmeister. The dry dressing approach seems to be unique to the US but is far from universal there -there are a multitude of approaches. SO the question really is -what is the best way? The existing evidence suggests cooling with water (for 20mins as a single block) and covering with Clingfilm ticks all the boxes. There seems to be a paranoia in the US about hypothermia in burns but this is true in all trauma of course. The problem is the pendulum has swung too far back the other way. You have to cool a burn injury for a number of reasons including pain relief, limiting burn progression and improving clinical outcomes in terms of healing and cosmetic benefits. These benefits are well demonstrated in studies. Covering the wound afterwards remains a mystery because non-one has put up the money to do some decent pre-hospital clinical trials. I'm no advocate of hydrogels in pre-hospital. They have been a runaway disaster in many respects yet they are everywhere. Why? If you refer to my post above you will see I mention a systematic review. Well I wrote it. There is no evidence to show hydrogels are better than cooling with water and dressing with Clingfilm. But dry dressing is almost as bad probably worse in fact. You achieve little by just covering a burn and pumping in loads of opiates, which will be required because of the lack of analgesic benefit from no water cooling. And the wound has to be sealed which is why Clingfilm is best. Excessive opiate use may also be contributing to fluid creep - worth a pubmed search on the subject.  The burn first aid situation is a basket case - I've been working on it for 4 years. I've presented an oral at the ANZBA conference in 2011, written a document that changed our ambulance guidelines here in Australia and in combination with the oral talk changed ANZBA's (and probably has or will influence the BBA's) guidelines as well. I've also written a 36 page burns chapter in a new paramedic textbook and done the study I mentioned. I'm also collaborating with educators in the UK who are having the same problems with burn first aid the divergence of approaches in the US also suggests. Something's got to be done because paramedics really don't have much of a clue really. There is a lot of confusion and misunderstanding of what we are trying to achieve in pre-hospital burn management. 

cheers

Downunder

[Just Plain Ruff]

Thanks Downunder,  I speak from this from being out of EMS full time for at least 4 years,  I've not really been an active EMS provider except in small circumstances for that period of time and I've actually been retired for the last 3.  I really haven't kept up with burn care for the last 4 years.  Old habits/treatment regimens die hard so to speak.  

It's good to review the current literature and best practices and this is what makes forums like this so freaking important.  

[Downunder]

Are you enjoying retirement is the only important question? Pre-hospital is a tough gig these days if for no other reason than the diabolical workload - too many people. I'd have preferred getting off the road myself (been at it 25) and had an educational deal signed and sealed. Of course my organisation had other ideas and promptly "restructured" our department. I was tossed back into road duties. Anyway. You enjoy your retirement and stay involved - there's lots of enthusiastic newbies out there who might need a steadying hand. Pearls of wisdom are hard to come by these days.

cheers

Downunder

[Rfitz57]

Arkansas where I live totally advocates cooling with water until the burning stops, them covering with a dry, sterile dressing. Never put anything on that could cause constriction due to swelling. The theory behind this is that anything put on in the field will have to be scrubbed off at the hospital plus you are sealing in residual heat and debris. If you want to receive a royal butt chewing here, aplly burn gels or ointments.