The UK pre-hospital management of burn patients: current practice and the need for a standard approach

Abstract

Introduction: In any system of burn care, first-aid, packaging and transportation of the burn injured patient from outside of hospital is a most important contribution to the successful management and outcome.

This study aimed to assess the current initial care of burn patients given by the statutory ambulance services and then compare this to a survey of opinions among the plastic surgery and burns consultants in the United Kingdom (UK).

Methods: In 1999, each of the UK ambulance services was contacted via a postal questionnaire. A similar survey was sent to all of the plastic surgery consultants within the UK (taken from the specialist register) therefore, canvassing the plastic surgeons who deal less commonly with burn patients as well as the burns units.

Results: A total of 58% of ambulance services said that they had no treatment policy for burns patients; 97% sent patients to their nearest A&E department; 84% of services employed cooling; 12 different types of dressing were used for burn patients; 74% of services used nalbuphine hydrochloride and 97% used entonox; 74% services gave oxygen to all burn patients; 90% cannulated patients, with or without fluid administration.

Plastic surgical opinion indicated that the most important aspects of basic first-aid should include: stopping the burning process; cooling (15 min (median)); airway, breathing and circulation assessment; clothing removal and dressings (clingfilm). Oxygen need not be given to all patients, but they should be kept warm and administered entonox and/or intravenous morphine. Most surgeons felt that patients should be taken to the nearest A&E and the majority of surgeons caring for this large group of patients did not have good and regular liaison with their local ambulance service.

Conclusions: There seems to be a wide variation in the basic approach to the first-aid and pre-hospital care of burns patients. A significant improvement in management for this large and important group of patients is achievable, if a standard approach across all ambulance services could be achieved.

Introduction

Unfortunately in the UK at present, there is no national, co-ordinated collection of data reporting burns incidence [1]. There have been localised demographic studies published in the UK, the largest coming from Birmingham, whilst specific burns have been investigated more widely.

The report on hospital in-patient enquiry (published annually until 1985) [2] estimated total annual admissions for burn and scald injuries. These numbered approximately 11,000, although this is now old data. Within this, there is no breakdown of cause, or severity of injury, apart from in 1983 in a special survey entitled “Domestic Thermal Injuries”, which looked at 1000 burns and scalds admitted to several burns units during 1979 [3]. North American data suggests that burn injury is the third leading cause of accidental death, exceeded only by motor vehicle accidents and falls [4].

Today it is estimated that burns are responsible for 175,000 attendances at A&E departments each year and 15,000 admissions [5]. There are around 20 burns units within the UK, but no definition of what such a unit is, or facilities and staff which it should contain. A large number of patients admitted to hospital are not seen by burns trained staff and despite the size of this problem the burns community is only just beginning to address the problem on a national basis via a National Burn Care Review.

Optimal management of burned patients requires good initial treatment with collection and transport of the patient from the site of injury to hospital by ambulance personnel. The observation of cold patients with poor analgesia and dressings when they arrive at hospital in the West Midlands, suggests that this area of patient care needs examination to reach consensus guidelines for ambulance staff both locally and nationally.