Systematic reviews 

The scientific foundation for this section is based on a 2015 evidence review and 2020 scoping review from the International Liaison Committee on Resuscitation (ILCOR) First Aid Task Force, evidence summaries from the Centre of Evidence-Based Practice (CEBaP, 2019, CEBaP2020) as well as a Cochrane review.

Cooling

ILCOR identified one randomised controlled trial and four observational studies in a 2015 evidence review (Singletary, et al., 2015). Based on one randomised controlled trial and one observational study, no difference in pain could be shown in cooled versus non-cooled burns (low-certainty evidence). In the randomised controlled trial, a difference in the amount of erythema  could not be shown (low-certainty evidence). Two observational studies showed a reduction in the depth of a burn when cooling, whereas a third observational study found no benefit of cooling (low- to very low-certainty evidence). In one observational study, no benefit in reducing re-epithelialization  time was shown (very low-certainty evidence). Three observational studies looked at the need for medical care. Two studies showed a decreased length of hospital stay after a minimum of ten minutes of cooling, and a decrease in hospital admission after a media campaign about the cooling of burns, whereas the third study showed no difference (very low-certainty evidence). 

Ice

A 2019 CEBaP evidence summary revealed there is limited evidence from one observational study, neither in favour of using ice nor no treatment.  A statistically significant decrease of the need for grafts, scar management, days to re-epithelialize or number of visits, using ice compared to no treatment, could not be demonstrated. Evidence is of very low certainty and results cannot be considered precise due to a low number of events, limited sample size and large variability of results. 

Deroofing

A 2019 CEBaP evidence summary shows that there is limited evidence from one non-randomised controlled trial in favour of keeping a blister intact (i.e., not removing the top layer of skin from the blister). It was shown that keeping a blister intact resulted in a statistically significant decrease of bacteria or Staphylococcus aureus colonisation, compared to aspirating or deroofing a blister. Evidence is of low certainty and results cannot be considered precise due to limited sample size, the low number of events and lack of data. 

Burn dressings

A scoping review was conducted by ILCOR in 2020, but no studies on burn dressings were identified in the first aid setting with superficial thermal burns (Singletary et al., 2020). In addition, a Cochrane review was identified reporting on the use of dressings for superficial and partial thickness burns (Wasiak et al., 2013). Silver sulfadiazine was consistently associated with poorer healing outcomes than biosynthetic (skin substitute) dressings, silver-containing dressings and silicon-coated dressings. It was also reported that burns treated with hydrogel dressings appeared to heal more quickly than those treated with usual care. The review authors concluded that it was impossible to draw firm and confident conclusions about the effectiveness of specific dressings. A follow-up systematic review by the same group (Goodwin et al., 2016) did not find any studies on the use of hydrogel-based burn dressings in first aid practices in the pre-hospital setting. 

Alternative burn dressings (honey, fatty acids, banana leaf dressings, vaseline)

A 2020 CEBaP evidence summary identified a Cochrane systematic review and four additional randomised controlled trials about the use of honey to treat burns. It was shown that honey resulted in a statistically significant decrease in the mean time to healing and incidence of infection compared to conventional non-antimicrobial dressings. It was also shown that honey resulted in a statistically significant decrease in time to complete healing, presence and completion epithelialization, hospital stay, persistent infection and time until negative swabs compared to silver sulfadiazine. A statistically significant decrease of mean time to healing, number of healing events, incident infection, clinical infections or adverse events, using honey compared to silver sulfadiazine, could not be demonstrated. Finally, it was shown that honey resulted in a statistically significant decrease in time to complete healing, mean time to healing and persistent infection compared to potato peels. A statistically significant decrease in adverse events, using honey compared to potato peels, could not be demonstrated. Evidence is of moderate to low certainty and results cannot be considered precise due to limited sample size, a low number of events, lack of data or large variability of results.

An additional 2020 CEBaP evidence summary identified evidence about the use of fatty acids and banana leaf dressings as burn dressings. There is limited evidence from one non-randomised controlled trial in favour of fatty acids (ethyl linoleate). It was shown that adjuvant topical application of ethyl linoleate resulted in a statistically significant decrease in the narcotic pain relief requirement, time to appearance of the epithelium, the appearance of normal pigment and hair and the number of patients requiring grafts compared to standard burn management. A statistically significant decrease in length of hospital stay, amount of positive cultures, the number of patients requiring reconstructions and mortality, using adjuvant ethyl linoleate compared to standard burn management, could not be demonstrated.

There is limited evidence from two non-randomised controlled trials in favour of banana leaf dressings. It was shown that banana leaf dressings resulted in a statistically significant decreased discomfort score, dressing removal pain score, ease of dressing removal score and time to complete healing, compared to using ordinary gauze dressings. In another study, it was shown that banana leaf dressings resulted in a statistically significant decreased discomfort score 20 minutes after dressing and a statistically significant decreased pain score before dressing. A statistically significant decrease in discomfort score before and during dressing and pain score during and after dressing could not be demonstrated. A statistically significant decrease in signs of wound infection using banana leaf dressings compared to using ordinary gauze dressings could not be demonstrated. A statistically significant difference in complete epithelialisation, need for skin grafting, dressing change pain and discomfort using banana leaf dressings compared with boiled potato peel dressings could not be demonstrated. All evidence is of very low certainty and results cannot be considered precise due to limited sample size, the large variability of results and lack of data.

Another 2020 CEBaP evidence summary revealed there is limited evidence from one randomised controlled trial in favour of using vaseline. It was shown that vaseline application resulted in a statistically significant decrease of time to re-epithelialisation, adherence to the wound, time to change the dressing, and a statistically significant increase in ease of dressing removal compared to silver sulfadiazine covered with a gauze.  A statistically significant decrease in pain during dressing application, pain during dressing removal and amount of dressing changes using vaseline compared to silver sulfadiazine covered with a gauze could not be demonstrated. Evidence is of moderate certainty and results cannot be considered precise due to limited sample size. 

Plastic cling wrap

A 2019 CEBaP evidence summary could not identify any human studies on the use of cling wrap or plastic film on burn wounds. 

Chemical burn

A 2019 CEBaP evidence summary showed that there is limited evidence from two observational studies in favour of immediate irrigation of the burned skin with tap water or diphoterine. It was shown that immediate irrigation with tap water resulted in a statistically significant decrease in length of hospital stay and number of full-thickness burns, compared to no immediate irrigation with tap water or irrigation with saline, isotonic phosphate buffer or Ringer’s lactate. It was also shown that irrigation with diphoterine resulted in a statistically significant decreased proportion of severe burn wound, compared to irrigation with tap water. Evidence is of very low certainty and results cannot be considered precise due to low sample size, a low number of events, large variability in results and a lack of data.

A second 2019 CEBaP evidence summary revealed that there is limited evidence from three observational studies in favour of immediate irrigation of the burned eye with tap water or diphoterine. It was shown that immediate irrigation (with tap water) resulted in a statistically significant decrease in the proportion of severe burns, corneal and conjunctival erosion, time until healing less than seven days, and the number of eye operations needed, and a statistically significant increase in clear vision, the proportion of mild eye injuries, compared to no immediate irrigation (with tap water) or irrigation with saline, isotonic phosphate buffer or Ringer’s lactate. A statistically significant difference in the proportion of severe burn wounds after irrigation with tap water, compared to irrigation with diphoterine, could not be demonstrated. Also, a statistically significant difference in the proportion of conjunctivitis or superficial punctate keratitis after immediate irrigation, compared to no immediate irrigation, could not be demonstrated. Evidence is of very low certainty and results cannot be considered precise due to low sample size, a low number of events and large variability in results.

There is no evidence summary available on what to do if a chemical substance is ingested. 

Sunburn

A 2019 evidence summary from CEBaP found limited evidence from four experimental studies in favour of aftersun lotion and aftersun cream, and from two experimental studies in favour of aftersun gel. It was shown that aftersun lotion (Hamamelis-free lotion) and aftersun cream (aloe vera cream) resulted in a statistically significant reduction in erythema (48-54 hours after sun exposure) compared to a placebo lotion or cream or no treatment. On the other hand, in two studies with aftersun cream (Aloe Vera cream), a statistical erythema reduction 24 hours after sun exposure, compared to placebo or no treatment, could not be demonstrated. Evidence is of low certainty and results cannot be considered precise due to limited sample size, the low number of events and a lack of data.

It was shown that aftersun lotion with 0.1% diclofenac resulted in a statistically significant reduced erythema and pain, compared to a placebo gel (Kienzler 2005, Magnette 2004). Evidence is of moderate certainty and results cannot be considered precise due to limited sample size.

Education review

We initially sourced 13 papers through the education search strategy for this topic, of which we included seven. Expert reviewers added a paper, bringing the total to eight. These include the following:

• One systematic review from Nurmatov et al. (2017).
• Two literature reviews from Bitter et al. (2016) and Forjuoh et al. (2006).
• One mini meta-analysis of studies from Tanzania by Outwater et al. (2018).
• Four studies on knowledge and awareness from Alomar et al. (2016), Ghosh and Bharat (2000), Graham et al. (2011) and Wallace et al. (2013).

Language

Nurmatov et al. (2017) identified that awareness, knowledge and practise of burn first aid skills is low among caregivers worldwide; many people either do not cool the burn properly or do not cool it long enough. Public messaging adds to the confusion by providing a variety of recommendations and guidelines. This confusion was evident across the papers we reviewed where each had different “ideal” burn treatments. The review found that when public messaging appears in the local language, knowledge and behaviour change is possible. It concluded that communities with diverse languages need health messaging in each language to promote taking first aid action, quickly accessing help and reducing the use of harmful treatment alternatives.

Limited resource settings

A literature review by Bitter et al. (2016) described how, in remote communities, people had evolved self-care treatments for burns based on experimental familiarity with nature and plants. In particular, where access to clean running water may be unrealistic, first aid providers may find themselves having to adapt first aid principles. While the use of traditional remedies has a variable evidence base and may be sub-optimal, teaching those living, working or visiting remote settings about improvised remedies is important when advanced treatments are not available.

Outwater et al. (2018) provided a perspective from Tanzania on the importance of cooling a burn as early as possible. She focuses on the adaptability of providers, how they need to feel knowledgeable and empowered to use safe and appropriate alternative methods to cool a burn when clean, running water is unavailable. Outwater found that most burn injuries in Tanzania occur in the home cooking area, and most first aid providers are family members, friends and neighbours. Information on burns was most likely to come from these sources and, less often, healthcare workers or the media. The study interviewed 710 people with burns and looked at 24 different materials that had been applied to their wounds. The most common material was honey. Only 14.3% of people received the recommended form of care (application of running water). The study also found that 17.5% of people received nothing for their burns.

The study highlighted that first aid providers are very aware that burns must be cooled; however, there is still a great need to contextualise education and instil confidence to respond in communities where the availability and accessibility of clean running water may be limited. For example, suggesting the use of cold honey and emphasising the need to keep the burn site clean while monitoring for infection are important educational adaptations. 

Influence of culture and traditions

Graham et al. (2011) identified significant differences in first aid knowledge between different ethnicities attending the emergency department for burns treatment in the United Kingdom (UK). The difference could be attributed to a lack of education in languages of immigrants needing to learn about the UK healthcare system.

Ghosh and Bharat (2000) undertook a review of a burns awareness strategy over several years around a steel-producing town in India. The study found that before the awareness strategy began, the majority (68.5%) of patients admitted for burns were due to kitchen accidents, mostly of women and girls whose clothes caught fire while working in the kitchen. Inappropriate treatments, such as egg or oil, were common. They undertook a strategy which included school and community education programmes aimed to affect generational behaviour change. It included education about the structure of kitchens, as well as behaviour. Unfortunately, there has not been any strong evaluation of the different approaches used, so it is hard to identify what has worked and what has not. Overall, the strategy is seeing some success.

Alomar et al. (2016) surveyed caregivers attending four paediatric clinics in Riyadh, Saudi Arabia, using a structured questionnaire on first aid burn knowledge and the care they provided. Results showed that 41% treated the burn with water, although 97% had inappropriate or no knowledge of the recommended duration. 65% covered a pot of boiling oil that was on fire with a damp cloth, but only 24% smothered burning clothes. Using questions about where first aid providers got their knowledge from and where they preferred to get it from, the study concluded that social media and TV, as well as information provided at hospital visits, was preferred. The authors also noted a need for a nationwide education programme to raise awareness of what to do for burn emergencies. 

Context-specific learning

Wallace et al. (2013) undertook a cross-sectional study using convenience sampling of members of sporting and recreation clubs in Australia. The primary outcome measure was the proportion of correct responses to multiple-choice questions relating to the following four burn scenarios: scald, contact burn, ignited clothing, and chemical burn. This article reinforces evidence of the importance of first aid education that is tailored and responsive to the needs of particular audiences based on their possible experiences.

Forjuoh et al. (2006) provided a literature review to determine burn prevention understanding based on who gets burned and what are the causes. The review identified a common thread of characteristics such as seasons (fewer fires or heating provision in hotter climates) and gender (higher instance for boys up to four years, and then higher instance for girls as they are brought in to help in the kitchen). It found that risk factors are very context-based. Common themes of risk-based prevention were socio-economic factors, maternal education, housing improvements and increased access to water. More studies are needed to ensure data is used for targeted prevention according to the context and local practices.

 Systematic reviews
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Burns – Ice. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/

Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Burns – Deroofing or aspiration. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/

Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summary Burns – Honey. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/

Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summary Burns – Alternative burn dressings. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/

Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summary Burns – Vaseline. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/

Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Chemical burns skin – Irrigation with water. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/

Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Chemical burns eye – Irrigation with water. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/ 

Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2019). Evidence summary Sunburn –  Hydration. Available from: https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/

Goodwin, N.S., Spinks, A., Wasiak, J., Goodwin, N.S., et al. (2016). 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. International Wound Journal, 13(4), 519-525.

Nurmatov, U. B., Mullen, S., Quinn-Scoggins, H., Mann, M., & Kemp, A. (2018). The effectiveness and cost-effectiveness of first aid interventions for burns given to caregivers of children: A systematic review. Burns, 44(3), 512-523. Retrieved from
https://www.sciencedirect.com/science/article/abs/pii/S0305417917303406

Singletary, E.M., Charlton, N.P., Epstein, J.L., Ferguson, J.D., Jensen, J.L., MacPherson, A.I., Pellegrino, J.L., Smith, W.R., Swain, J.M., Lojero-Wheatley, L.F., & Zideman, D.A., (2015). Part 15: first aid: 2015 American Heart Association and American Red Cross Guidelines Update for First Aid. Circulation. S574–S589.

Singletary, E.M., Zideman, D.A., Bendall, J.C., Berry, D.C., Borra, V., Carlson, J.N., Cassan, P., … & Woodin, J.A. (2020). 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation, 142(16), S284-S334.

Wasiak, J., Cleland, H., Campbell, F., Spinks, A., Wasiak. J., et al. (2013). Dressings for superficial and partial thickness burns. Cochrane Database Systematic Reviews. 3: CD002106.

Non-systematic reviews
Alomar, M., Al Rouqi, F., & Eldali, A. (2016). Knowledge, attitude, and belief regarding burn first aid among caregivers attending pediatric emergency medicine departments. Burns, 42(4), 938-943. Retrieved from
https://www.sciencedirect.com/science/article/abs/pii/S0305417916300432

Bitter, C. C., & Erickson, T. B. (2016). Management of burn injuries in the wilderness: lessons from low resource settings. Wilderness & environmental medicine, 27(4), 519-525. Retrieved from https://www.wemjournal.org/article/S1080-6032(16)30216-2/fulltext

Forjuoh, S. N. (2006). Burns in low-and middle-income countries: a review of available literature on descriptive epidemiology, risk factors, treatment, and prevention. Burns, 32(5), 529-537. Retrieved from
https://www.sciencedirect.com/science/article/abs/pii/S0305417906001203

Ghosh, A., & Bharat, R. (2000). Domestic burns prevention and first aid awareness in and around Jamshedpur, India: strategies and impact. Burns, 26(7), 605-608. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0305417900000218

Graham, H. E., Bache, S. E., Muthayya, P., Baker, J., & Ralston, D. R. (2012). Are parents in the UK equipped to provide adequate burns first aid?. Burns, 38(3), 438-443. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0305417911002543

International Federation of Red Cross and Red Crescent Societies, (2016). International first aid and resuscitation guidelines 2016, 9, 79-80.

Outwater, A. H., Thobias, A., Shirima, P. M., Nyamle, N., Mtavangu, G., Ismail, M., … & Justin-Temu, M. (2018). Prehospital treatment of burns in Tanzania: a mini-meta-analysis. International journal of burns and trauma, 8(3), 68. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055078/

Wallace, H. J., O’Neill, T. B., Wood, F. M., Edgar, D. W., & Rea, S. M. (2013). Determinants of burn first aid knowledge: Cross-sectional study. Burns, 39(6), 1162-1169. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S030541791300048X