Elsevier

Burns

Volume 45, Issue 2, March 2019, Pages 440-449
Burns

First aid for children’s burns in the US and UK: An urgent call to establish and promote international standards

https://doi.org/10.1016/j.burns.2018.09.003Get rights and content

Highlights

  • Widely varying first aid practices were demonstrated in both the UK and USA.

  • 26% of children in Cardiff and 6% in Denver, received recommended first aid.

  • 5% of children in Cardiff and 10% in Denver received potentially harmful first aid.

  • There is a need for internationally agreed, burns first aid recommendations.

Abstract

Introduction

Appropriate first aid can reduce the morbidity of burns, however, there are considerable variations between international first aid recommendations. We aim to identify, and compare first aid practices in children who present to Emergency Departments (ED) with a burn.

Methods

A prospective cross-sectional study of 500 children (0–16 completed years) presenting with a burn to a paediatric ED in the UK (Cardiff) and the USA (Denver, Colorado), during 2015–2017. The proportion of children who had received some form of first aid and the quality of first aid were compared between cities.

Results

Children attending hospital with a burn in Cardiff were 1.47 times more likely (RR 1.47; CI 1.36, 1.58), to have had some form of first aid than those in Denver. Denver patients were 4.7 time more likely to use a dressing and twice as likely to apply ointment/gel/aloe vera than the Cardiff cohort. First aid consistent with local recommendations was only administered to 26% (128/500) of children in Cardiff and 6% (31/500) in Denver. Potentially harmful first aid e.g. application of food, oil, toothpaste, shampoo or ice was applied to 5% of children in Cardiff and 10% in Denver.

Conclusion

A low number of children received optimal burns first aid, with potentially harmful methods applied in a considerable proportion of cases. There is an urgent need for internationally agreed, evidence-based burn first aid recommendations.

Introduction

The prevalence of paediatric burns is decreasing in developed countries, yet the sequelae associated with these injuries can be life altering. Physical disability as a consequence of scarring from serious burns impacts appearance, functional status, long-term morbidity, quality of life and employment [1], [2]. Psychological sequelae, often unrelated to the severity of the burn, include anxiety, behavioural disorders and post-traumatic stress disorder [3]. Economically, burns carry a significant burden to society. Data from the United States of America (USA) in 2000 estimated the cost of caring for childhood burns was in excess of $211 million dollars [4]. In the United Kingdom (UK) in 2005 one study estimated the cost for managing burns of 2–4% TBSA in children was £1850 per case ($2543) [5], equivalent to at least £2700 ($3580) in 2018.

Appropriate first aid is an essential part of the immediate medical management of burns, aiming to reduce the severity of the injury. There is strong evidence that cooling the burn and then covering it with a non-adhesive dressing is effective. The cooling process has multiple potential benefits. It is associated with a reduction in mortality, pain relief and a reduction in cellular damage with improved wound healing [6], [7], [8], [9]. The mechanism is attributed to the prevention of tissue necrosis in the zone of stasis [10], [11]. Cooling is most effective when running water is applied promptly, to reduce the cellular damage, but can be effective if applied up to three hours after injury [12], [13]. In covering the burn with a non-adhesive dressing, air is prevented from stimulating the exposed nerve fibres and minimising pain [14]. The dressing prevents colonisation of the wound and reduces the incidence of infection. Some advocate for a translucent dressing, which allows the burn wound to be inspected without the need to remove and replace the dressing [14], [15]. Dressings that are classified as adhesive may cause further tissue damage when removed.

Bystander first aid is a crucial aspect in the emergency management of burns. The cellular damage and inflammatory cascade that ensues may occur within minutes of the injury. In these instances, it is imperative that either the injured party or a bystander administer the correct first aid, and hence improve outcomes for the child. When a child is injured it is assumed that the caregiver(s) will administer first aid.

There are discrepancies between recommendations for burns first aid as shown in Table 1, which describes cooling, covering and ‘other’ guidance. In the UK, the recommended cooling time ranges from 10 to 20 min before covering the burn with a non-adhesive dressing. In the US, recommended cooling times range from 5 to15 min before covering the burn with a non-adhesive dressing. Some US guidelines suggest antibiotic ointments, moisturisers or aloe vera lotion.

Variations in guidance coupled with circulating myths about the best remedies for burns cause confusion and may delay immediate burns first aid. Therefore, increasing public awareness and knowledge of correct burns first aid is a critical step in managing burns in children. Current literature highlights a deficiency in parental knowledge regarding first aid practice [28], [29]. A 2013 UK study identified that only 32% of parents had adequate knowledge of burns first aid, while 43% had poor or no knowledge [30]. A 2016 study in Saudi Arabia stated that only 41% of parents treated burns with cool or cold water, with 97% having inappropriate or no knowledge of the duration recommended. Moreover, 32% of parents treated their children’s burns with non-scientific remedies alone or in combination, including honey, egg white, toothpaste, white flour, tomato paste, yogurt, tea, sliced potato, butter, or ice [30]; however, many of these methods can be harmful [31].

Given the importance of appropriate and timely first aid, in the context of widely varying advice available to parents, we aim to identify and compare burn first aid practices in children who present to two different Emergency Departments (ED) with a burn injury, one in the UK and one in the USA.

Section snippets

Methods

This prospective cross-sectional study was conducted in two paediatric emergency departments: one in the UK (Cardiff) and the other in the USA (Denver, Colorado). Each hospital serves a mixed urban population, with moderate levels of deprivation. Data collection was carried out over a 30 month period, from May 2015 to October 2017.

Cases were ascertained prospectively from the Paediatric Emergency Department, University Hospital of Wales, Cardiff, Wales and the Paediatric Emergency Department,

Results

A total of 500 cases were ascertained at each site, representing 79% (500/633) and 68% (500/732) of childhood burn visits in Cardiff and Denver, respectively, during the period of the study.

Attendances at each site were similar in terms of gender and age (Table 2). Scalds were the most common burn type in both cities, and the proportion of these were similar; however, Cardiff had significantly more contact burns than Denver. Table 2 shows the differences in burn types between the two sites.

Discussion

This study has shown that there is poor application of recommended first aid for burns in two cities in high income countries. While 90% in Cardiff and 61% in Denver attempted first aid, only 26% and 6% of caregivers followed their country’s national recommendations. Even more worryingly, 5% in Cardiff and 10% in Denver administered a potentially harmful treatment. Thus, there is a clear knowledge gap around appropriate first aid, despite a willingness to apply it. These results suggest that

Conclusions

While childhood burns remain extremely common, it is clear that the type and manner of burn first aid at the immediate location of the burn injury is sub-optimal across two cities in the UK and USA. With 90% in Cardiff, and 61% in Denver attempting first aid, but only 26% and 6% respectively actually delivering first aid consistent with national recommendations, parents and young people need far better information, consistently and easily provided, to improve this standard of care. There is an

Acknowledgements

The authors wish to thank everyone who contributed data to this study.

The participating departments and lead clinicians were:

Cardiff: University Hospital of Wales Emergency Department, (Z Roberts, D Farrell) Health & Care Research Wales Research nurses (D McNee, P Jones).

Denver: Children’s Hospital Colorado Emergency Department (L Bajaj) and Burns Unit (S Moulton).

Funding

Authors from Cardiff University completed this work as part of the Centre for Children’s Burns Research, part of the Burns Collective funded by theScar Free Foundation [grant number 505345] and Health and Care Research Wales [grant number 516832] with additional funding from the Vocational Training Charitable Trust. Data collection in Denver was funded by the Colorado Firefighters Endowed Chair for Burn and Trauma Care. Dr. Lindberg was supported by a career development grant from the Eunice

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