Wet vs Dry dressings for burns

[ajzMICP3247]

Greetings all, I am currently dragging you into a debate that is raging in my little corner of the world.
When you have a prehospital burn pt, what do you use to dress the burns?
The EMT placed a wet dressing, since she was taught that working in the ER as a Tech. The Medic told her to remove it and use dry, since it is the book answer.
I prefer the wet, since it cools, soothes, and stops any burning that is still going on. This can also lead to lower amounts of pain meds being given, which can be an issue, as some ALS units carry limited amounts.
However, you must be careful with the wet dressings, as they pull too much heat from the body, leading to hypothermia.
What does everyone else do?
What do you docs prefer us to use?

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[Dwindlin]

Greetings all, I am currently dragging you into a debate that is raging in my little corner of the world.
When you have a prehospital burn pt, what do you use to dress the burns?
The EMT placed a wet dressing, since she was taught that working in the ER as a Tech. The Medic told her to remove it and use dry, since it is the book answer.
I prefer the wet, since it cools, soothes, and stops any burning that is still going on. This can also lead to lower amounts of pain meds being given, which can be an issue, as some ALS units carry limited amounts.
However, you must be careful with the wet dressings, as they pull too much heat from the body, leading to hypothermia.
What does everyone else do?
What do you docs prefer us to use?

My protocol was wet for 2nd or 3rd degree, dry for 1st degree (though honestly I never really did much for 1st degree unless they were in a painful spot).

 

[psychbender]

What BSA are we talking about here? Putting a wet dressing on a forearm burn is a bit different than putting a wet dressing on an extensive torso burn. Everywhere that I worked or trained had a semi-arbitrary BSA cut-off for wet vs dry dressings.

 

[leviathan]

You want to cool the burns first anyway, so I don't see how it hurts to leave a wet dressing on them. I believe the protocol was to cool a max of 20% of body surface area at any one time, although it's been awhile since I've worked in EMS and don't remember the exact number.

 

[Paseo Del Norte]

I have generally gone by a minor burn less than 10% BSA can be covered with a wet dressing. Typically, I tend to treat all burns the same in the field and cover with a dry, sterile dressing. When in doubt, go dry. Hypothermia is a real concern and we all know that a hypothermic trauma patient is generally bad news. I consider burns trauma and many burn patients also have additional traumatic injuries or comorbidities. I work under fairly liberal pain management protocols and have access to several hundred micrograms of fentanyl if needed.

 

[MediumDef]

I have generally gone by a minor burn less than 10% BSA can be covered with a wet dressing. Typically, I tend to treat all burns the same in the field and cover with a dry, sterile dressing. When in doubt, go dry. Hypothermia is a real concern and we all know that a hypothermic trauma patient is generally bad news. I consider burns trauma and many burn patients also have additional traumatic injuries or comorbidities. I work under fairly liberal pain management protocols and have access to several hundred micrograms of fentanyl if needed.

This is basically the answer. Back in the day it used to be anything less then 10% got a wet dressing and anything more got a dry dressing. Many protocols decided that it was just easier to say dry for everything since the downside of covering someones whole back with a couple sloppy wets is worse then the mild benefit of moistening someones pinky.

 

[Altruist]

This is basically the answer. Back in the day it used to be anything less then 10% got a wet dressing and anything more got a dry dressing. Many protocols decided that it was just easier to say dry for everything since the downside of covering someones whole back with a couple sloppy wets is worse then the mild benefit of moistening someones pinky.

Definitely true. It's worth remembering that many protocols are written in a certain way for simplicity's sake. From my experience, out-of-hospital, I don't remember ever wetting down a dressing to put on a burn. But in the ER (I was hospital-based and had to assist in ER when I was on back-up), I did it a few times. The largest burn I remember wetting down was on about 9% or so of a guy's body (anterior arm, forearm to shoulder, bilaterally). The pain relief he experienced from the wet dressings alone was amazing--he about kissed me--though it didn't last too long, and he still needed a boatload of narcs.

I looked in "Schwartz's Principles of Surgery, 8th Ed." It's from chapter 7, titled "Burns," in the "Emergency Care: At the Scene" section (from Stat!Ref online, so I don't have the page numbers):

Cold Application


Small burns, particularly scalds, may be treated with immediate application of cool water. It has been mathematically demonstrated that cooling cannot reduce skin temperature enough to prevent further tissue damage, but there is evidence in animals that cooling delays edema formation, probably by reducing initial thromboxane production. http://online.statref.com.lecomlrc....SessionId=1117F39FXHPNYYPY&local=true#a168281After several minutes have elapsed, further cooling does not alter the pathologic process. Iced water should never be used, even on the smallest of burns. If ice or cold water is used on larger burns, systemic hypothermia often follows, and the associated cutaneous vasoconstriction can extend the thermal damage.

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So anyway, you walk a fine line trying to cool down burns. Too much cooling, paradoxically, can increase the tissue damage. (Interestingly, I can't find anything in that chapter that says what percentage a "small burn" would be.)

In any case, the benefit of wet dressings isn't huge, and I doubt you'd ever get in trouble for going dry; so follow your protocols and use common sense.

And I should point out, I'm a med student/former medic, not a doctor (and definitely not a burn surgeon); my comments should be taken with a grain of salt.

 

[docB]

So it looks like this may be another situation where there's a right thing to do and a protocol right thing to do.

 

[Wilderness1]

I find that commercially produced wet dressings are best for minor burns. Then saline irrigation followed by a non-stick, dry, dressing afterward are best for more serious burn trauma.

 

[Paseo Del Norte]

I find that commercially produced wet dressings are best for minor burns. Then saline irrigation followed by a non-stick, dry, dressing afterward are best for more serious burn trauma.

Why irrigate more severe burns at all? I am not sure the potential benefit of pain management outweighs the risk of hypothermia. I can advocate for irrigation of chemical burns however.

 

[cheesemonkeys]

Greetings all, I am currently dragging you into a debate that is raging in my little corner of the world.
When you have a prehospital burn pt, what do you use to dress the burns?
The EMT placed a wet dressing, since she was taught that working in the ER as a Tech. The Medic told her to remove it and use dry, since it is the book answer.
I prefer the wet, since it cools, soothes, and stops any burning that is still going on. This can also lead to lower amounts of pain meds being given, which can be an issue, as some ALS units carry limited amounts.
However, you must be careful with the wet dressings, as they pull too much heat from the body, leading to hypothermia.
What does everyone else do?
What do you docs prefer us to use?

Lower BSA 1st/2nd degree burns (subjective, maybe <10-20%), I use NS with gauze. I have found cool NS to better for pain management than 10mg morphine most of the time. Larger burns I focus more on pharmaceutical management, NS bolus for real severe burns, and DRY dressings (burn pad) for temperature control and cleanliness. The best thing you can do for severe burns is get to the appropriate facility, and if anyone has stuck around to see ER techs scrubbing burns, its kinda nasty. 🙂

 

[MedicFL]

Lower BSA 1st/2nd degree burns (subjective, maybe <10-20%), I use NS with gauze. I have found cool NS to better for pain management than 10mg morphine most of the time. Larger burns I focus more on pharmaceutical management, NS bolus for real severe burns, and DRY dressings (burn pad) for temperature control and cleanliness. The best thing you can do for severe burns is get to the appropriate facility, and if anyone has stuck around to see ER techs scrubbing burns, its kinda nasty. 🙂

Lactated Ringers is a better bolus treatment option for burns....