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An Audit of First-Aid Treatment of Pediatric Burns Patients and Their Clinical Outcome

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An Audit of First-Aid Treatment of Pediatric Burns Patients and Their Clinical Outcome
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   An Audit of First-Aid Treatment of Pediatric BurnsPatients and Their Clinical Outcome Leila Cuttle, BSc (Hons),* Olena Kravchuk, PhD,† Belinda Wallis, BBEnv,*Roy M. Kimble, MBChB, MD* This study describes the first aid used and clinical outcomes of all patients who presented tothe Royal Children’s Hospital, Brisbane, Australia in 2005 with an acute burn injury. A retrospective audit was performed with the charts of 459 patients and information concern-ing burn injury, first-aid treatment, and clinical outcomes was collected. First aid was usedon 86.1% of patients, with 8.7% receiving no first aid and unknown treatment in 5.2% of cases. A majority of patients had cold water as first aid (80.2%), however, only 12.1% ap-plied the cold water for the recommended 20 minutes or longer. Recommended first aid(cold water for > 20 minutes) was associated with significantly reduced reepithelializationtime for children with contact injuries ( P   .011). Superficial depth burns were signifi-cantly more likely to be associated with the use of recommended first aid ( P   .03). Subop-timal treatment was more common for children younger than 3.5 years ( P  < .001) and forchildren with friction burns. This report is one of the few publications to relate first-aidtreatment to clinical outcomes. Some positive clinical outcomes were associated with recom-mended first-aid use; however, wound outcomes were more strongly associated with burndepth and mechanism of injury. There is also a need for more public awareness of recom-mended first-aid treatment. (J Burn Care Res 2009;30:1028–1034) The Australian National Health Survey found that170,800 people or 1% of the total Australian popula-tion sustained a burn or scald in the year 2001. Thisrepresented 8% of people who reported a recent in- jury, which remarkably was more common than ve-hicular injuries. 1 The estimated total number of burninjuries would be substantially larger than this; how-ever, as there are many more household burn injuriesthat go unreported.The history of the treatment for burn injury showsmanyvariedandsometimesbizarretreatments,whichhaveoftenbeenadvocatedwithlittleevidencetosup-porttheiruse. 2 Treatmentssuchasbutter,flour,veg-etable oil, plant poultices or extracts, and animal ex-crementhaveallbeenrecommendedatsomepointinthehistoryforthetreatmentofburns. 3,4 Theconceptof first aid is relatively new, having only existed sincethe late 1880s. At this time, it was predominantly recommended to relieve pain; however, more re-cently, first aid has been recognized to be importantfor reducing the progressive damage caused by burninjury. Many reports detail better clinical outcomesafter the use of first aid, 5–8 and many experimentalstudies also describe how the use of first aid leads todecreased edema, 9,10 decreased inflammation, 11 andimproved wound-healing outcomes. 12 The currentrecommendations by many regulatory bodies such astheAustralianandNewZealandBurnAssociationareto apply cold water to the wound for 20-minute du-ration and to not use ice. 13 Others recommend thatthe treatment can still be effective if applied within 3hours after the injury has occurred. 14 There are vari-ous burn and first-aid organizations, with differingrecommendations on the most appropriate tempera-ture,duration,anddelayforthefirst-aidtreatmentof burns. As well as this, the public is able to accessinformation from other sources, such as the inter- From the *Royal Children’s Hospital Burns Research Group,Department of Pediatrics and Child Health, Royal Children’s Hospital, University of Queensland, Herston, Australia; and †School of Land, Crop, and Food Science, University of  Queensland, St Lucia, Australia.Supported by the Royal Children’s Hospital Foundation and the National Health and Medical Research Council. Address correspondence to Leila Cuttle, BSc (Hons), Department of  Pediatrics and Child Health, Royal Children’s Hospital,University of Queensland, Herston Road, Herston, Queensland 4029, Australia.Copyright © 2009 by the American Burn Association.1559-047X/2009  DOI: 10.1097/BCR.0b013e3181bfb7d1 1028  net 15 or advice from friends/family regarding possi-ble treatments. Because of the availability of thesemixed messages, it is unknown what exactly the pub-lic is using for the first-aid treatment of burn injuries.The purpose of this study was to investigate the typeof first aid administered before admission to hospitaland whether this was related to the clinical outcomeof the burn wound. METHODS Patient Information This was a retrospective chart study of children whopresented to the Stuart Pegg Pediatric Burns Centreat the Royal Children’s Hospital, Brisbane in 2005 with new burns. There was no direct contact withpatients, and the study received full institutional eth-ics approval. The patients were identified throughthree different sources: the Burns Centre register, asearch of the hospital database using InternationalClassification of Diseases—10th Revision codes toidentify burns cases, and a data set collected by theburnspreventionresearcher,whichencompassedsev-eral years. Oral poisonings and inhalational injuries were excluded, but friction burn injuries (eg, fromtreadmills) were included in the data set. The follow-ing information was obtained from the written chartsby the first author: •  burn injury (% BSA, depth, and mechanism of injury); •  first aid (what first aid and duration of first aid)both at the scene, during transport, and beforeadmission to the hospital; •  treatment (whether grafting was required, whether pressure garments were required, and what dressings were used); •  outcomes (number of visits, time to completereepithelialization,whetherlongtermscarman-agement (  1 month) was required).Burn depths were reported in the charts as being:full thickness, deep partial thickness, superficial par-tial thickness, partial thickness (which could havebeen either deep partial or superficial partial) or su-perficial. The worst part of the burn injury was thedepth recorded, as this was the area that would takethe longest to heal (rather than the majority area).Throughout the year of 2005, the same burns cli-nicianstreatedallthewoundsinaconsistentmanner,in line with unit policy and using standard treatmentpractices. 16,17 Statistics Statistical analysis was performed with Minitab 15(MinitabInc.,2007).Dataexplorationofordinalandnominal data was performed, and the significance of conclusions was confirmed with individual    2 or lo-gistic regression analyses. Continuous outcome data were commonly summarized with sample means andstandard deviations; these summaries are reportedthroughout the article. The duration of the cold wa-ter first-aid treatments was reclassified into recom-mended (cold for 20 minutes or longer) and subop-timal (cold for  20 minutes) first aid. The effects of first aid on clinical outcomes (reepithelializationtime, number of visits, and requirement for grafting,garments, or long-term scar management) were ana-lyzed by binary or ordinal logistic regressions, whichalso included the mechanism of burns and burndepth. The reepithelialization time analysis was per-formed only for cases in which grafting was not re-quired. In the logistic regression, the reepithelializa-tion time was categorized into the following fourordinal classes:  7 days, 7 to 14 days, 14 to 21 days,and longer than 21 days, as these are important clin-ical time points for wound management. The signif-icance level for individual tests was assigned at 5%throughout the article. In addition, and to accountfor multiple tests, the actual  P   values of tests are re-ported in the article. RESULTS Patient Burns  Atotalof459childrenwereidentifiedwhopresented with new burns to the Royal Children’s HospitalBurns Centre in 2005. A majority of patients (62%) wereinfantsandtoddlersyoungerthan3.5years.The youngestpatientwas2monthsandtheoldestpatient14.5 years. These patients had a mean burn BSA of 2.8  4.2%(mean  SD),mostcommonlywithsuper-ficial to mid-depth partial-thickness burns. Most burns were on the limbs (58%) or in multiple locations, in-cluding the limbs (27%). Overwhelmingly, the mostcommon mechanism of injury was scald burns(48.8%), followed by contact burns (28.3%), flameburns (7.0%), campfire/burn off burns (7.2%), fric-tion burns (6.1%) and some sunburn (1.1%), chemi-cal burns (0.9%), and electrical burns (0.7%). Themajority of ungrafted burns reepithelialized in lessthanafortnight(12.6  9.8,median10.0days),withflame,campfire,andfrictionburns,andburnsinvolv-ing multiple body sites (body, face, and limbs) takingthe longest times to reepithelialize. The number of  visits, to date, for each patient varied from 1 to 27 Journal of Burn Care & Research Volume 30, Number 6  Cuttle et al   1029  (4.6  4.2 visits, median 3 visits), with flame, camp-fire,frictionburns,andburnsinvolvingmultiplebody sites requiring relatively more visits. For treatment of these injuries, 8.1% required grafting, 11.3% usedpressure garments, and 17.4% required long-term(  1 month) scar management. Significantly, moreoften grafting was required for flame and frictionburns(26and17%,respectively,comparedwith  7%for other injuries,  P   .001) and significantly, morescarmanagementwasrequiredforflame,friction,andcampfire burns (50% of flame burns and   30% of frictionandcampfireburns,comparedwith  15%forscalds and contact burns,  P   .001). First Aid First aid was used on 86.1% of patients, with 8.7%receiving no first aid and unknown treatment in 5.2%of cases (these 5.2% were excluded from all first-aidanalysis). First aid was predominantly administeredby family members to patients younger than 4 yearsand self-administered or by siblings to patients olderthan10years.Amajorityofpatientshadcoldwaterasfirst aid, either applied alone (66.4%) or in combina-tionwithanothertreatment(13.8%)suchasice(6.2%or 27 patients used cold water  ice; Figure 1). Icealone was also used (3.7%). Less common were a wetcompress or towel alone (1.6%) or application of acream/gel (1.8%), such as tea tree/Burnaid   (RyePharmaceuticals, Roseville, NSW, Australia), silversulfadiazine, papaya cream, Chinese herbal medicine,moisturizer,orVaseline  .Othertreatmentsincludedbutter(twopatients),toothpaste(twopatients),milk (one patient), warm water (one patient), and fishsauce (one patient). Aloe vera was also used alone by one patient or in combination with water by six pa-tients.BeforepresentingtotheRoyalChildren’sHospitalBurns Centre (a tertiary burns referral centre), mostpatients (70.2%) received care elsewhere, at anotherhospital, their local doctor, or from ambulance ser- vices. Hospital staff and local doctors predominantly prescribed analgesia and applied silver sulfadiazinecream and ambulance services predominantly pre-scribedanalgesiaandappliedBurnaid  ,atea-treeoil-based hydrogel dressing (Burnaid   was applied to 56patients or 12.9%).Cold water treatment was applied to 349 patients(80.2%). Unfortunately, for a large percentage of thepatientstreatedwithcoldwater(38.6%),thedurationof cold water treatment was unknown. There weresignificantly more cold water duration data missingfor partial-thickness burns (data were missing for 61burns of 120, 50%) in comparison with superficial orfull-thickness burns (  30% missing each;  P   .01).Thisdisproportion,however,wasmostlyforcampfireand contact burns. No association between missingdata and burn depth was found for scald burns. Wealsofoundnosignificantassociationbetweenmissingdata and the age of the patient, the person who ad-ministered first aid, the burn mechanism or anatom-ical position, and whether the patient presented di-rectly to the hospital. Generally, the cold waterduration data were missing at random. Incompleterecords are not uncommon for retrospective studies.In response to this missing data, the burns proforma(filledinonarrivalandplacedinthepatientchart)hasbeen revised, such that information specifically con-cerningthedurationoffirstaidwillberecordedinthefuture.Mostpatientsappliedfirstaidforadurationofonly 10 to 15 minutes (27.1% of complete records and16.6% of the total audit) or for  10 minutes (20.7%of complete records and 12.9% of the audit; Figure2). Only 19.9% (or 12.1% of the total audit) appliedfirst aid for the recommended 20 minutes or longer. A higher proportion of children younger than 3.5 years did not receive first aid or had suboptimal firstaid applied (treatment other than cold water or cold water for   20 minutes), compared with other agegroups.Amongchildrenwithscaldburns,only10.9%of children younger than 3.5 years received the rec-ommendedfirst-aidtreatmentincontrastto38.3%of older children ( P     .001). Deeper burns also had Figure 1.  The various treatments used as first aid. Themajority of patients (66.4%) used cold water alone or incombination with other treatments such as ice, cold com-presses, aloe vera, or cream (13.8%). No first aid was usedby 9.2% of patients. Journal of Burn Care & Research 1030  Cuttle et al   November/December 2009  significantlylessrecommendedfirstaidapplied,com-pared with more superficial burns ( P   .03). For ex-ample,3of40full-thicknessordeeppartial-thicknessscald burns received recommended first aid (cold wa-ter for  20 minutes), whereas 16 of 52 superficial/partial scald burns received recommended treatment.There was no significant association found betweenpatient age and the depth of burn. First-aid use wasnot found to be related to the anatomical position of theburnonthepatient’sbody(face,trunk,orlimbs). First-Aid Treatment in Relation toWound Outcome The outcomes measured (time to complete reepithe-lialization, number of visits, grafting, and scar man-agement) were most significantly associated with thedepth of the burn, and in some cases also the mech-anism of injury (Table 1). Recommended first-aidtreatment(coldwaterfor  20minutes)wasfoundtobesignificantlyassociatedwithadecreaseinreepithe-lialization time for contact injuries (from 14.0  9.4days to 7.1  4.6 days,  P   .04). Also, the incidenceoflargenumbersofvisitsweresignificantlyhigherforpatients with flame burns suboptimally treated withcold water for  20 minutes (the maximal number of  visits in that group was 27 in comparison with 16 when the recommended cold water treatment wasapplied),  P   .04. However, this finding needs to bereconfirmed using a larger sample size. Recom-mended first-aid use was not significantly associated with improved clinical outcomes for scald burns, wasnot related to shorter reepithelialization times forflame burns (despite number of visits association),and was not associated with grafting for any burns.Therewasfoundtobenooverallcorrelativerelation-shipbetweenfirst-aiddurationandreepithelialization when all burns were analyzed together and not sepa-rated into different mechanisms of injury. DISCUSSION It was positive to see in this study that first aid wasused by 86% of patients, and specifically, that 80.2%used cold water treatment as first aid, indicating thatthe message of cold water treatment for burns haspenetrated the public consciousness. This reasonably highproportionofpatientsreceivingcoldwatertreat-ment was similar to that reported for many otherstudies from high-income countries, such as theUnited Kingdom 18,19 and Australia. 14,20 However,there are still many studies that report very low use of cooling treatment for burns, especially in Asian, non-English speaking, or ethnic communities. In China,cold water treatment levels are as low as 9.84 to15.7%, 21–23 and in Africa, only one third of children inGhana, 24 and only 10.2% of patients in Enugu, Nige-ria, 25 received cool water treatment.Despitethewidespreaduseofcoldwaterasfirst-aidtreatment in this study, we saw that only 12.1% of patientshadcoldwaterappliedfortherecommended20 minutes or longer. Unfortunately, many otherstudies also report similar findings. In the UnitedKingdom, 68% of patients treated their burns withcold water in various ways (running water, immer-sion,damptowels,etc),however,only7%appliedthecoolingfor30minutesormore. 18 McCormacketal 14 reportedthat,although92%ofchildrenfromanAus-tralian pediatric hospital had some cold water appliedinitially to their burn, only 22% were given adequatefirst aid, defined as cold tap water for   20 minutesduration within 3 hours postburn. Inadequate firstaid was defined as ice or ice water, use of soakedcompressesanddurationsofcoldwater  20minutes,andwasgivento78%ofpatients.Likewise,inaWest-ern Australian hospital, 20 64% of adult patients werefound to have received cold water application, how-ever, only 39% received cold water for 20 minutes orlonger.Thisinconsistencyregardingdurationofcold watertreatmentusedbythepublicdemonstratesthatthere is little faith in the current guidelines or simply noknowledgeofthem.Also,thereisinconsistencyinthe definition of “appropriate first aid” offered by  various publications, such as cold water treatmentand not ice, 26 cold water treatment or ice or burn Figure 2.  The duration of cold water treatment applied topatients. Most patients had cold water applied for   10minutes (12.9%) or 10 to 15 minutes (16.6%), compared withtherecommended20minutes(5.7%)or  20minutes(6.4%). Unfortunately, for 38.6% of patients, the durationof cold water treatment was unknown. Journal of Burn Care & Research Volume 30, Number 6  Cuttle et al   1031  creams, 21 cold water treatment for 10 or more min-utes, 27 coldtreatmentfor15ormoreminutes, 28 cold water treatment for 20 or more minutes,  14,20 andcold water for 30 or more minutes. 18 To date, theorganizations who advise on first-aid recommenda-tions still offer conflicting advice regarding the opti-maldurationofcoldwaterfirst-aidtreatmentandthisis an area that needs further clarification.This study also identified a population of people who were using alternative first-aid treatments, suchas aloe vera and Burnaid   tea-tree oil hydro dressing. Another study has identified the widespread use of  water gel dressings by U.K. fire brigades (17 of 46U.K.firebrigadesusedwatergeldressingonpatientsinstead of cold water and 35 of 46 applied water geldressings after water treatment), 29 however, there islittle published evidence to support the use of suchdressings by local paramedic services. 2,30 In thisstudy, ice was also popular, although recent evidencesuggests it provides no benefit for wound healing. 12 There were also other household substances used ontheburns,suchasbutter,milk,toothpaste,fishsauce,and moisturizing cream. Many other first-aid studieshave reported the use of common ingredients onburn injuries such as toothpaste, eggs and butter, 26 soy sauce and oil, 31 petroleum jelly and hemorrhoidcream, 18 andhoneyandtoothpaste. 20 Studiessuchasthese highlight the fact that if people are not given Table 1.  The clinical outcomes (grafting, scar management, reepithelialization, and number of visits) for wounds separatedby mechanism of injury, depth of injury, and first-aid use Total GraftedScarManagementDays to Reepithelialize(Including Grafted Wounds)Days toReepithelialize(Excluding Grafting)No. VisitsFirst Aid > 20 min First aid Yes 395 30 71 14.4  12.5 12.4  9.8 5  4.3 55No 40 5 8 18.0  14.6 15.4  12.6 5  4.6 0Unknown 24 2 2 18.7  21.3 13.6  9.3 4  3.7 NA First-aid typeNothing 40 5 8 18.2  14.7 15.6  12.8 5  5.1 0Cold water 289 21 51 14.4  12.3 12.2  8.9 5  4.4 49Cold water  others 60 2 8 13.6  14.7 12.9  14.5 4  3.7 4Ice 16 4 5 16.6  10.2 13.5  7.9 6  5.7 1Cream 8 1 3 19.5  14.8 15.1  8.8 6  5.6 0Cold compress 7 1 3 14.0  7.4 12.8  7.4 6  5.9 1Others 14 1 1 11.2  7.7 9.3  3.1 4  3.6 0Cold durationNothing 40 5 8 18.2  14.7 15.6  12.8 5  4.6 0First aid not cold water 47 7 12 15.0  10.2 12.2  6.8 5  4.1 2Cold water  10 min 56 8 13 14.6  11.7 11.5  7.5 5  5.7 0Cold water 10–15 min 72 3 12 14.6  10.6 13.3  8.4 5  3.8 0Cold water 20 min 25 3 4 17.5  18.8 11.0  7.6 5  4.1 25Cold water  20 min 28 2 7 15.7  13.1 13.4  10.6 5  3.8 28Cold water unknownduration168 7 23 13.4  12.8 12.2  11.5 4  4.0 NA Mechanism of injury Scalds 224 11 33 14.0  13.3 12.4  9.8 4  3.8 23Contact 130 9 17 13.2  11.7 11.5  9.4 4  3.5 23Flame 32 8 15 24.1  18.5 16.8  13.9 8  6.5 2Campfire/burn off 33 3 7 17.3  10.8 14.9  7.4 5  4.5 7Friction 28 4 6 16.6  13.0 14.4  12.3 6  5.1 0Sunburn 5 0 0 11.3  4.2 11.3  4.2 2  1.2 0Chemical 4 2 3 19.5  15.2 7.0  7.1 9  7.0 0Electrical 3 0 0 14  15.1 14  15.1 5  4.7 0Depth of injury Superficial 92 0 1 7.9  6.4 7.9  6.4 2  1.3 12Superficial partialthickness103 0 6 10.6  6.7 10.6  6.7 3  2.4 15Partial thickness 120 5 15 14.4  12.3 13.6  11.5 4  3.6 12Deep partial thickness 107 10 34 17.8  11.7 16.4  10.4 6  4.6 13Full thickness 36 22 25 36.3  20.3 25.5  12.6 11  6.2 3 NA, not available. Journal of Burn Care & Research 1032  Cuttle et al   November/December 2009
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