Second-degree burns are the most common type of burn in clinical practice and hard to manage. Their treatment requires not only a consideration of the different outcomes that may arise from the dressing changes or surgical therapies themselves but also an evaluation of factors such as the burn site, patient age and burn area. Meanwhile, special attention should be given to the fact that there is no unified standard or specification for the diagnosis, classification, surgical procedure, and infection diagnosis and grading of second-degree burn wounds. This not only poses great challenges to the formulation of clinical treatment plans but also significantly affects the consistency of clinical studies. Moreover, currently, there are relatively few guidelines or expert consensus for the management of second-degree burn wounds, and no comprehensive and systematic guidelines or specifications for the treatment of second-degree burns have been formed. Therefore, we developed the Consensus on the Treatment of Second-Degree Burn Wounds (2024 edition), based on evidence-based medicine and expert opinion. This consensus provides specific recommendations on prehospital first aid, nonsurgical treatment, surgical treatment and infection treatment for second-degree burns. The current consensus generated a total of 58 recommendations, aiming to form a standardized clinical treatment plan.
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Keywords: Burns, First aid, Infection, Wound management, Consensus, Surgical procedures, Operative, Debridement.
Highlights.
This was the first clinical consensus on the treatment of second-degree burn wounds at home and abroad, covering the following four aspects: pre-hospital first aid treatment,non-surgical treatment, surgical treatment, and infection treatment of burn wounds. It aimed to form a standardized treatment plan for second-degree burns.
This consensus clarified and standardized the terminology related to second-degree burn wounds, including for the first time further dividing deep second-degree burn wounds into shallow deep second-degree and profound deep second-degree burn wounds, which provided a decision-making basis for standardizing the relevant diagnosis, classification, and treatment of second-degree burn wounds.
Based on the evidence-based medicine evidence, comprehensive consideration of the operative feasibility of the clinical practice, and the economic level of different geographic regions and cultural factors, a set of operable clinical practice guideline of second-degree burn wounds was formed.
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Background.
Burns are the fourth leading cause of injury worldwide, following car accidents, falls and interpersonal violence [1]. In clinical practice, the most common type of burn is a second-degree burn. Our initial data indicated that second-degree burns account for 85.4% of all burn cases, of which 56.3% are burns of less than 10% of the total body surface area (TBSA) [2]. Second-degree burn wounds often exhibit dynamic changes in the early postburn period, which is not only determined by their pathophysiological characteristics but is also closely related to wound intervention and other factors. Timely and reasonable prehospital first aid and appropriate wound treatment after admission are essential in preventing wound deepening. However, many variations still exist in the treatment of deep second-degree burn wounds, including the manner of conservative dressing change, choice of external dressings or medications, and indication and timing of surgery, which requires not only consideration of the different outcomes that may arise from the dressing changes or surgical treatments themselves but also an evaluation of factors such as burn site, patient age and burn area.
Therefore, we aimed to develop clinical consensus for the treatment of small- to medium-sized burn wounds caused by thermal factors, combining evidence from evidence-based medicine and expert opinions to establish standardized clinical treatment plans and provide reference opinions for health care professionals involved in burn care. This consensus develops a set of operational clinical practice guidelines in four areas: pre-hospital first aid, non-surgical treatment, surgical treatment, and infection treatment. Notably, to further standardize clinical terminology and develop treatment plans, we have further graded deep second-degree burn wounds into shallow deep second-degree and profound deep second-degree burn wounds in the process of guideline formulation for the first time. In addition, we have established grading and diagnostic criteria for burn wound infection, classifying the severity of wound infection as mild, moderate or severe based on the local and systemic clinical manifestations of the burn wound or the invasion of tissue, developed a treatment protocol for second-degree burn wounds. Finally, we have integrated the content of the four sections and developed a treatment protocol for second-degree burn wounds. This provides a basis for decision-making with strong operability and practicability for standardizing the diagnosis, classification and treatment of second-degree burn wounds Figure 1.
Figure 1.
Treatment processs for second-degree burn wounds. TBSA total body surface area.
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Methods.
Consensus working group.
The Consensus Working Group consists of relevant experts of burns surgery, plastic surgery, wound repair, statistics, and epidemiology. Moreover, the Consensus Working Group consists of Cochair, Expert Committee Group, Methodology Expert Group, Clinical Problem Solicitation Expert Group, and Writing Group. The Writing Group was divided into four subgroups, who were responsible for compiling the contents on first aid, nonsurgical treatment, surgical treatment, and wound infection treatment, respectively.
Development process.
The consensus was based on the evidence-based medicine. After 1 round of clinical questioning, 2 rounds of discussion at the expert meeting, and 3 rounds of expert review, the final expert recommendation was obtained.
Identification of clinically relevant questions.
The Writing Group wrote a proposal based on the results of the clinical question solicitation, and the clinical questions were identified in the form of PICO (P: Patient, I: Intervention, C: Comparison, O: Outcome) after a discussion with experts in the field of burns to formulate the corresponding clinical questions on what needed to be highlighted. All proposed clinical questions were further reviewed and discussed by the Writing Group, and after review and revision, all clinical questions were finalized.
Systematic literature review and level of evidence determination
The Medline, Embase, and Cochrane databases were systematically searched with the terms “burns, scald, first aid, infection, surgical, surgery, debridement, skin grafting, dressing, wound, wound management, etc.” The search period was from the establishment of the database to December 31, 2022. Systematic reviews, randomized controlled trials, observational studies (cohort studies, case-control studies, cross-sectional studies, case series reports, etc.) and expert opinion were included. Literature other than case series reports and expert opinion was systematically evaluated. The methodological quality (e.g. risk of bias) of the study designs of the included randomized controlled trials was evaluated using the Cochrane Risk of Bias tool, case-control studies and cohort studies using the Newcastle-Ottawa Scale, and cross-sectional studies, case series reports, and expert opinion using the Joanna Briggs Institute criteria. At least 2 members of the Writing Group independently completed the screening and quality assessment of the literature. Two methodologists were responsible for reviewing and evaluating each round of recommendations and their evidence, and then providing feedback to the Writing Group members for further revision. The quality of evidence was formally evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system and was classified as high, moderate, or low (including very low) (Table 1) [3]. The quality of evidence can be reduced by the presence of risk of bias, inconsistency of study results, or publication bias, or it can be raised by significant efficacy or the presence of a clear dose–response relationship.
Table
Rating of the quality of evidence based on the GRADE system.
Quality of evidenceDefinitionHigh qualityFurther research is very unlikely to change our confidence in the estimate of effect.Moderate qualityFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.Low qualityFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.Downgrading factors: risk of bias, inconsistency of results, publication bias.
Upgrading factors: the presence of a large effect size or evidence of a dose–response relationship.
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Formation of Recommendation and Determination of Recommendation Strength .
The Writing Group initially determined the recommendations for each clinical question, and then all members of the Writing Group reviewed the full text and revised it to form the first draft of the consensus. The Expert Group discussed the draft in the first round of on-site meeting and proposed revisions. Then the Writing Group revised the draft according to the experts' suggestions. The revised consensus draft was submitted to the reviewing experts in the form of an electronic questionnaire, and was reviewed by 22 experts in the first round and 67 experts in the second round. Each recommendation had two .
Recommendations for the treatment of prehospital first aid.
Clinical question 1: Prehospital first aid for thermal burn wounds .
Recommendation 1 (highly recommended). Immediately remove the victim from the heat source as soon as possible, and remove clothing and accessories from the wound surface (evidence level: low).
Rationale. Thermal burns primarily refer to burns caused by flames, hot liquids, etc. Their severity is mainly related to the temperature and the duration of contact between the heat source and the skin. Thus, the primary objective of prehospital first aid after a burn is to stop the injury process, remove the victim from the heat source and transfer them to a safe place as soon as possible while ensuring the safety of the rescue personnel [5]. In a flame-burn environment, flames tend to spread upwards. This poses a risk of flames spreading to the head, face and entire body. Therefore, the victim can adopt the ‘stop, drop and roll’ method to extinguish the flames on their body and avoid walking or running to prevent the spread of fire. Nearby water bodies such as lakes, running water or other nonflammable liquids can help extinguish the flames on the victim’s clothing [6]. In addition, clothing that scorches or retains hot liquids on the skin’s surface may act as a potential heat source, causing continuous damage to local tissues and potentially exacerbating tissue damage to the wound. Accessories on distal limbs (e.g. rings and bracelets) not only act as potential heat sources but also pose a risk of tissue ischaemic necrosis when exerting pressure on local soft tissues with oedema [7.
It should be noted that if the victim’s clothing has burned or adhered to the skin, it should be temporarily left in place until the arrival of professional medical personnel to avoid improper onsite operations that may lead to bleeding, enlargement and infection of the wound [9]. Furthermore, considering wound heat dissipation, changing into dry clothes or covering the wound with gauze or other coverings is not advisable before sufficient and effective local cooling is achieved. This avoids impeding local heat dissipation and aggravating tissue damage. It should be noted that regardless of whether the onsite rescue personnel are professional firefighters or medical personnel, they must be aware of the risk of being burned by the heat source and thus take self-protection measures as much as possible.
Recommendation 2 (highly recommended). Start cooling as soon as possible after the burn, and it is recommended to start no later than 3 h after the injury, with a cooling duration of no less than 20 min or until the pain in the wound is adequately relieved (evidence level: high).
Rationale. According to Jackson’s classical theory, early burn wounds can be divided from the inside out into a central necrotic zone, a stasis zone and a peripheral congested oedema zone [10]. Importantly, the development of the zone of stasis is dynamic and reversible, and the tissues in this zone can gradually restore perfusion and turn towards healing if timely and effective intervention is taken. Otherwise, progressive necrosis may occur, deepening the burn wound [11]. Early cooling can lower the temperature of the wound tissue below the injury temperature, thereby stopping ongoing heat damage to the tissues. Furthermore, it can alleviate tissue oedema, reduce inflammatory reactions and improve wound perfusion through pathophysiological mechanisms, effectively inhibiting burn wound progression [12–14]. Several clinical studies have demonstrated that timely, adequate and proper cooling can effectively reduce the local temperature of burn wounds and the severity of burns, thereby reducing the probability of skin grafting, areas requiring skin grafting, patient admission to the ICU and length of hospital stay [15–17]. It should be noted that appropriate measures should be taken to keep the rest of the patient’s body warm during cooling to avoid the risk of hypothermia [7].
The starting and duration of cooling are two crucial factors affecting its effectiveness. Theoretically, the earlier cooling is initiated after removal from the heat source, the better the outcome. However, the latest time to start cooling and the duration of its application remain controversial. Recent studies have shown that using running water to cool the wound for at least 20 min within 3 h after the burn significantly reduced the severity of burns and the need for skin grafting, thereby reducing mortality, shortening wound healing time and reducing the length of hospital stay [16, 18, 19]. However, another recently published systematic review reported that cooling for a duration of no less than 20 min did not exhibit significant advantages over cooling for <20 min in terms of burn size, depth, re-epithelialization and skin grafting outcomes [20]. However, this review included four observational studies and superficial second-degree burns with an average surface area of <5% TBSA. It is also important to specifically highlight that there is no evidence to suggest that cold therapy more than 3 h after a burn is non-beneficial in preventing deepening of the wound, and more high-quality RCTs are still needed to further validate this.
In summary, according to the current evidence, clear conclusions regarding the duration of cooling cannot yet be drawn. Based on existing evidence and expert opinions, we recommend starting cooling as soon as possible after the burn, no later than 3 h after the injury, with a duration of no less than 20 min. In addition, considering the analgesic value of cooling for early acute burns, the relief of local pain after stopping cooling can be considered as the duration of cooling in prehospital first aid.
Recommendation 3 (moderately recommended). For the mode and temperature of cooling, the use of running water (12–25°C) appropriate for the patient’s body temperature is recommended for wounds (evidence level: moderate).
Rationale. The use of cooling for emergency treatment of burn wounds has a long history, including cold water immersion, irrigation and spraying as well as wet towel application [6]. In theory, any method that can lower the temperature of burn wounds can be used as a form of cooling. However, the treatment effects of other liquids, such as vegetable oil, are unclear, and oily liquids have insulation properties, which may ultimately exert a counterproductive effect. Furthermore, ice cubes, which have a lower temperature, can cause vasoconstriction of the wound blood vessels, leading to ischaemic necrosis, and may also carry the risk of frostbite and hypothermia [21]; thus, they are not recommended for cooling burn wounds. Previous clinical research has reported that continuous irrigation with running water for 20 min results in a more obvious reduction in skin surface temperature and exerts a more certain analgesic effect than tea tree oil and burn cooling spray [22]. Compared with other cooling modalities, cold water irrigation can significantly reduce tissue damage and promote wound healing [23]. At present, evidence regarding the optimal temperature for cooling is insufficient, but existing studies and guidelines suggest controlling the cooling temperature between 12 and 25°C [21, 24–26]. Considering the simplicity, availability and low cost of running water, this consensus recommends using running water (12–25°C) as the first choice for the wound cooling in burn patients. In the absence of a sufficient running water source, distilled water or physiological saline can be used as alternatives.
Recommendation 4 (moderately recommended). In the absence of sufficient running water for cooling, it is recommended that wound cooling measures be taken whenever possible, including wet towel application, cold water spraying and hydrogel dressings with cooling effects (evidence level: moderate).
Rationale. The results of a clinical trial involving healthy volunteers indicated that spraying 1 l of cold water on the skin could achieve similar cooling effects to irrigation with 5 l of cold water, which lowers the risk of hypothermia due to the reduced use of water for cooling [27]. Hydrogel dressings with cooling effects have both cooling and wound-covering functions and can be applied to all body areas. Nearly 80% of fire departments in the UK reportedly use these hydrogel dressing with cold therapy effects as dressings and/or cooling agents [28]. In the UK and Australia, hydrogel dressings have been used as prehospital emergency cooling measures for many years [28–30]. However, there is a lack of supportive evidence from relevant clinical studies on the effectiveness of hydrogel dressings as first aid for burn wounds. The results of a clinical study showed that hydrogel dressings did not provide significant benefits compared with traditional polyvinyl chloride films as adjunctive analgesic treatment for acute paediatric burns [31]. Nevertheless, The 2018 International Society for Burn Injuries (ISBI) Practice Guidelines for Burn Care recommend using hydrogel dressings as alternative first aid for burn wounds without running water sources [5]. Considering the dual role of hydrogel dressings with cooling effects in wound cooling and covering, this consensus suggests that they can be used as alternative first aid without sufficient running water.
Recommendation 5 (moderately recommended). Considering the specificity of the burn site, it is recommended to use running water irrigation for limb burns, whereas alternate cold compresses with wet towels may be applied to burn sites on the head, face, trunk and groin as appropriate (evidence level: low).
Rationale. Due to the uniqueness of different body parts, running water irrigation should not be used for all burn sites. For limb burns, running water irrigation is simple, easy to operate and has a better overall cooling effect. For burns on the head and face, considering the special nature of facial organs such as the mouth and nose, patients need to maintain breathing and may develop the risk of aspiration and choking cough. In such cases where repeated cooling water irrigation is inconvenient, an alternate cold compress with wet towels to the wound is recommended. Continuous cooling on the trunk, groin and other areas can easily decrease body temperature, particularly as large skin areas are exposed, increasing the risk of hypothermia. In addition, cooling on the anterior chest area may cause complications such as reflex bradycardia and arrhythmia. Thus, considering the overall factors, it is recommended to use water irrigation for limb burns and to exercise caution in cooling for trunk and groin burns. In such cases, the possibility of hypothermia should be assessed, proper insulation measures should be provided and alternate cold compresses with wet towels should be applied to appropriately cool the wound.
Recommendation 6 (moderately recommended). Considering the risk of heat loss and concurrent hypothermia due to extensive wound exposure during cooling, caution should be exercised in patients with large burns, infants and children, elderly and frail individuals, and burn patients with shock and under cold environmental conditions (evidence level: low).
Rationale. Due to damage to the physiological structure and function of the dermis, burn wounds lose their ability to regulate skin temperature. Combined with the uncontrolled heat loss from the exposed wound surface, there is an increased risk of hypothermia in patients, particularly those with extensive burns [32]. Although some studies have demonstrated that cooling is also beneficial for patients with extensive burns [33], it may pose a higher risk of hypothermia and exacerbating shock, considering that these patients often experience hypovolemic shock and extensive wound exposure, as well as uncontrolled heat loss from the wound surface. Furthermore, infants, young children, and elderly and frail patients have weaker heat production and insulation capabilities and poorer temperature regulation abilities, making them more prone to hypothermia with prolonged irrigation or cooling [6]. It has been suggested that cooling should be used with caution in children with extensive burns [34]. Meanwhile, for paediatric patients the total burn area is greater than 10% TBSA, cooling was identified as a risk factor for hypothermia [35]. However, other clinical studies have demonstrated no significant correlation between prehospital cooling and hypothermia [36–38]. Based on the available evidence, the association between TBSA and the risk of hypothermia due to cooling remains unclear. In one study of severe burns, the experts suggested that even in the absence of shock, cooling should not be administered to paediatric patients with the total burn area greater than 10%TBSA and adult patients with the total burn area greater than 20%TBSA [39]. The ISBI Practice Guidelines for Burn Care, and other guidelines also suggest cautious cooling for patients with extensive burns, infants and young children, and elderly and frail patients in prehospital first aid [5, 40–42]. In addition, under cold conditions, skin heat loss is accelerated, increasing the risk of hypothermia for patients, cooling for wounds is not advisable.
Recommendation 7 (highly recommended). Based on the protective effect of the blister skin on burn wounds, it is recommended to preserve it as intact as possible during early prehospital first aid (evidence level: low).
Rationale. Blisters are the most common clinical manifestation of second degree burn wounds. In second-degree burns, inflammation occurs due to heat conduction to the dermis, leading to increased vascular permeability and severe tissue exudation. A large amount of exudate accumulates in the gap between the epidermis and the dermis, forming blisters [43]. Whether to remove blister skin has been a disputed focus in clinical practice. Blisters naturally provide a physical barrier that protects the wound and prevents bacterial colonization, thereby reducing the risk of wound infection [44]. They also provide pain relief by covering exposed skin nerves in the wound and provide a moist wound environment, thus potentially playing a role in promoting wound healing and preventing deepening of the wound [45–48]. Furthermore, casual removal of blister skin in prehospital settings may expose the wound bed, increasing the risk of wound infection and damage. Therefore, considering all these factors, this consensus recommends the preservation of blister skin as intact as possible in early prehospital emergency care.
Recommendation 8 (moderately recommended). It is recommended to use sterile or clean nonadherent dressings as temporary dressings to cover and protect the wound surface after cooling (evidence level: low).
Rationale. Second-degree burn wounds are characterized by epidermal loss and partial dermal damage, destroying the skin’s physical barrier and physiological structure and leaving the wound completely exposed to external pathogens. This leads to increased loss of body fluids through exudation and increases the risk of infection [49], which, combined with dry skin exposure, also tends to exacerbate tissue damage and leads to further wound deepening. Timely and effective covering with dressings after cooling can provide a temporary skin barrier, reducing the risk of trauma infection and hypothermia and alleviating pain due to nerve exposure. Several relevant guidelines, including the 2018 ISBI Practice Guidelines for Burn Care all recommend the use of clean, low-adherent dressings, such as clean cloths, to cover the wound after cooling [41]. Furthermore, nonprofessionals are not recommended to perform special wound handling, including the application of cream, butter, milk or toothpaste [14]. Coloured agents such as methyl violet solution should also be avoided on the wound surface to avoid affecting the subsequent wound evaluation after admission.
In light of the limited medical resources available in prehospital first aid, it is recommended to use any clean, low-adherence dressings, fabrics etc. as a temporary wound covering, and the patient should then be promptly transferred to the nearest hospital for further treatment.
Clinical question 2: Prehospital first aid for chemical burn wounds
Chemical burns include burns caused by acids, alkalis and other chemical substance burns. Unlike thermal burns caused by heat sources, the main mechanism of injury in chemical burns is the continuous corrosive effect of substances on the skin or mucous membranes and the thermal damage caused by chemical reactions. Acid burns can cause denaturation of skin tissue proteins and formation of scabs, presenting as coagulative necrosis, which can prevent continued penetration of acid into the skin tissue, and is thus potentially beneficial in stopping further tissue damage. Alkaline chemicals mainly cause denaturation of skin tissue proteins and saponification of lipid membranes, presenting as liquefaction necrosis. This type of necrosis consistently penetrates deep tissues and usually results in more severe damage than acid burns. On the other hand, organic solutions damage the skin by dissolving cellular lipid membranes [50]. Failure to take effective first-aid measures for chemical burns can often result in severe injury. The main factors that determine the severity of the injury are the type, character, concentration and duration of contact between the chemical substance and the skin. Thus, the general principle for prehospital first aid for chemical burns is the prompt removal of contaminated clothing and rinsing with abundant running water. In addition, based on the different properties of chemical substances, the disposal methods for chemical wounds vary and are described in more detail below.
Recommendation 9 (highly recommended). For burn wounds caused by acids, alkalis and other chemicals, it is recommended to immediately remove contaminated clothing, clear the chemical substances from the wound surface and rinse the wound as soon as possible with running water for 30 min to 2 h (evidence level: moderate).
Rationale. The nature, concentration and duration of contact between the chemical substance and the skin are the main factors that determine the severity of chemical burns. Prompt removal or dilution of chemical substances is crucial for the treatment of chemical burns. Thus, in the absence of specific information about the type of chemical substance in prehospital settings, in addition to immediate removal of chemical-contaminated clothing, the chemical substances on the wound surface should also be cleared as soon as possible to prevent further tissue damage. Studies have shown that rinsing with plenty of cold water can dilute and remove residual chemical substances on the skin surface and neutralize the dehydrating effect of chemical substances on tissues [51]. Previous systematic reviews and clinical studies have also demonstrated that early and adequate running water irrigation can effectively reduce the severity of chemical burns and shorten the hospitalization time, thus facilitating early recovery [52–55]. However, there is currently no definite standard for the optimal duration of running water irrigation. Taking into account comprehensive considerations, we recommend continuous running water irrigation for 30 min to 2 h after chemical burns, and the pH from the effluent can be monitored to judge the adequacy of irrigation if conditions permit [56]. In addition, the results of previous clinical studies have indicated that diphoterine, an amphoteric, polyvalent, chelating sterile solution, is more effective for rinsing than cold water after chemical burns [57–59]. However, this study still has limitations, such as poor methodology, small study population and heterogeneity of measurements. Taking into account comprehensive considerations, this consensus suggests that diphoterine can be used as an auxiliary first-aid measure in cases where running water is insufficient in chemical burns.
In addition to conventional chemicals, some chemicals release a large amount of heat when in contact with water or are insoluble in water. In these cases, thorough irrigation of the wound with running water should not be performed until the chemical substances are effectively cleared. Dried alkali deposits should be brushed away first, followed by rinsing with abundant running water. Hydrochloric acid and concentrated sulfuric acid also release a large amount of heat when in contact with water. After removing the remaining acid on the surface using soapy or lime water, the wound should be rinsed with abundant running water. In addition, because phenol is insoluble in water and may be more readily absorbed when diluted in a small amount of water, it should be removed using a sponge soaked in 50% polyethylene glycol or vegetable oil for prehospital first aid; if it cannot be accessed in time before rinsing, dipping a clean cloth to remove the chemical residue can be used as an alternative, followed by immediate rinsing with plenty of running water [60]. When rinsing chemicals from the skin surface, care should be taken to avoid spreading them to adjacent unburned areas, e.g. placing the patient in a bathtub for rinsing or immersion may worsen the injury. Personal protective measures should also be taken, such as wearing gloves, gowns, masks and protective goggles.
Based on the above evidence and considering the inability to clearly determine the specific type of chemical substance or the lack of corresponding emergency testing reagents in prehospital settings, this consensus recommends removing contaminated clothing immediately after chemical burns, wiping or brushing off chemical substances, promptly rinsing the burn wound with running water for 30 min to 2 h, and then immediately transferring the patient to the hospital for further treatment.
Recommendation 10 (highly recommended). It is not recommended to routinely use neutralizing agents for chemical burn wounds (evidence level: low).
Rationale. Theoretically, neutralizing agents can quickly neutralize chemical substances on the wound surface to reduce tissue damage. However, there is currently no reliable clinical research confirming that the use of neutralizing agents is more effective than cold water irrigation. In addition, most neutralizing agents are toxic and release a large amount of heat during the neutralization reaction, which can further aggravate tissue damage. For example, copper sulfate is a neutralizing agent for phosphoric acid, which can prevent oxidation of phosphorus and phosphoric acid burn and can also blacken its particles, thus facilitating the identification and removal of residual phosphorus particles on the skin. However, a systematic review showed that copper sulfate did not effectively improve tissue damage in burn wounds compared with running water [61], and copper sulfate has systemic toxicity, which may further exacerbate the patient's condition [62]. Thus, it is not recommended to use neutralizing agents as the first choice for first aid in chemical burn wounds [61–64].
It should be noted that the use of neutralizing agents is suitable for professional laboratories and chemical plants where corresponding emergency neutralizing agents and professional personnel are available. Regarding first aid for chemical burn injuries at home, immediately irrigating the burn wound with a large amount of running water and urgently transporting the patient to the hospital for treatment are recommended, considering the generally low concentration of chemical substances as well as the lack of corresponding neutralizing agents and professional personnel.
Recommendation 11 (moderately recommended). Based on the specific mechanism of hydrofluoric acid burns, it is recommended to apply topical, subcutaneous, arterial or intravenous calcium gluconate medication after adequate water rinsing, depending on its concentration, to stop the continued damage of the chemical to the wound tissue (evidence level: low).
Rationale. In addition to its corrosive properties, hydrofluoric acid exhibits metabolic toxicity. It can quickly penetrate the skin, infiltrate deeper tissues and cause liquefaction necrosis of deep tissues and systemic toxic symptoms. In particular, fluoride ions can chelate with positively charged ions, such as calcium and magnesium, leading to systemic hypocalcaemia and hypomagnesemia [65]. The key to its salvage is neutralizing and inhibiting hydrogen ion and fluoride ion uptake [66]. According to Total Burn Care, for hydrofluoric acid burns with a concentration less than 20%, thorough irrigation with running water for 30 min should be the preferred prehospital first aid, whereas for hydrofluoric acid burns with a concentration greater than 20%, after rinsing with running water for 30 min as before, the burns were further treated by topical application or subcutaneous, arterial or intravenous injection of glucose [67] to neutralize fluoride ions and prevent further damage [66].
Clinical question 3: Prehospital first aid for electrical burn wounds .
Electrical burns primarily include electrical contact burns, arc and flame burns caused by clothing or environmental fires. Electrical contact burns are direct tissue injuries caused by electric current passing through the body, which can cause damage to tissues through various mechanisms, such as electric perforation and electrochemical effects on proteins, cell membranes and other biomolecular structures, as well as tissue damage caused by heat generation [68]. Electrical contact burns are usually more severe and can affect deep tissues, muscles and even bones. Arc burns result from momentary high-temperature electric sparks burning the skin, which is similar to thermal burns. Based on the nature and severity of electrical burns, the management of these wounds also varies. Electrical burns are also the most dangerous among the burns, as the electrical current not only flows through the victim but can also be transmitted to the rescuers who come into contact with the victim, causing severe consequences such as cardiac arrest and respiratory failure. Therefore, before providing first aid for the wound, the safety of both the rescuer and the patient should be the primary concern.
Recommendation 12 (highly reommended). Ensure the safety of rescuers themselves and promptly disconnect the casualty from the power source (evidence level: low).
Rationale. The severity of the injury is determined by the intensity and nature of the current (alternating or direct current), duration of contact with the skin and resistance at the contact point [69]. Therefore, the primary principle of first aid is the prompt disconnection of the casualty from the power source. Considering that the electric current can pass from the casualty to the rescuers, direct contact with the casualty is prohibited. To minimize the continuous harm caused by the power source, prompt disconnection of the casualty from the source should be carried out while ensuring the safety of the rescuers [70]. If the injury is caused by high-voltage electricity, the power source should be turned off before approaching the casualty, emergency medical assistance should be called for immediately and help from professionals should be sought. If the injury is caused by low-voltage electricity, the power can be turned off, or nonconductive objects such as wooden sticks can be used to disconnect the casualty from the power source to prevent continuous harm caused by the electric current [6]. In addition, the burned or smoking clothing and all metal objects (jewelry or equipment) in contact with the skin of the casualty should be immediately removed [5].
Unlike other types of burns, electrical burns are particularly dangerous, as the current can easily pass through the heart, leading to arrhythmia, respiratory problems, cardiac arrest and other serious complications. Thus, after ensuring the safety of the scene, it is important to first assess the victim’s consciousness, breathing and circulation. If the victim is unconscious or experiencing respiratory or cardiac arrest, immediate CPR and emergency assistance should be provided. In the case of multiple victims, those with respiratory and cardiac arrest should be prioritized [71]. Notably, lightning injuries do not cause the spread of electricity; thus, immediate first aid can be administered. The first-aid measures can be consistent with those for electrocution, including assessment of the level of consciousness and immediate CPR if the injured person is unresponsive [69].
Recommendation 13 (highly recommended). For arc burn wounds or their secondary flame burn wounds, early first aid, the same as for thermal burn wounds described above, is recommended (evidence level: low).
Rationale. Arc burns are caused by the passage of electric current through ionized gases generated by an enormous electric field, which does not require mechanical contact, and the current can be transmitted to the victim only through the air and burns the skin through instantaneous high-temperature electric sparks [70], first-aid measures for thermal burns are typically applicable. In addition, an electrical current can cause clothing or the environment to catch fire, resulting in flame burns, which may be treated similarly to thermal burns.
Recommendation 14 (moderately recommended). For electrical contact burns, routine cooling is not recommended. Instead, the wound should be covered and protected, and the victim should be promptly transported to a hospital for treatment (evidence level: low).
Rationale. Electrical contact burns include low- and high-voltage electrical burns. Low-voltage electrical burns usually occur in household electrical accidents, resulting in localized carbonization and tissue necrosis at the contact point on the skin. High-voltage electrical burns are typically more severe, with a smaller zone of injury on the surface but a larger zone internally, spreading to the deep tissues, blood vessels, muscles and even bones; this makes judgement of the injury severity based on surface damage difficult [72]. Wounds international guidelines for wound care state that electrical burns usually affect deep tissues and should not be washed with cold water [73]. Therefore, considering the available evidence, this consensus does not recommend routine cooling for electrical contact burns. Instead, it recommends covering the wound with sterile gauze, plastic wrap or clean fabric and immediately transporting the victim to a hospital for emergency treatment. In addition, regardless of whether electrical burn patients show obvious symptoms, they should seek urgent medical attention for further examination.
Recommendations for the nonsurgical treatment of second-degree burn wounds
Clinical question 4: Diagnosis and evaluation of second-degree burn wounds
The in-depth diagnosis and area assessment of burn wounds are the cornerstone of clinical treatment decisions. Accurate depth and area diagnosis are crucial for evaluating patient conditions and formulating clinical treatment plans. Currently, second-degree burns are mainly classified into superficial and deep second-degree burns depending on the dermal involvement. This classification is significant in differentiating the pathological levels of burn injuries and guiding clinical treatment. However, the current clinical diagnosis of second-degree burns mainly relies on the physician’s subjective evaluation of the local manifestations of the wound, lacking more objective assessment tools. Additionally, for deep second-degree burns, significant differences in their healing potential and scar formation depending on the level of dermal involvement exist, thereby leading to uncertainty in clinical decision-making regarding the choice between conservative dressing changes or surgical treatment. Considering these reasons, this consensus comprehensively considers the diagnosis and assessment methods for second-degree burn wounds and further classifies the depth of deep second-degree burns, aiming to provide better guidance for clinical practice.
Recommendation 15 (moderately recommended). The depth diagnosis of second-degree burn wounds mainly relies on the local clinical manifestations of the wound, and noncontact diagnostic techniques can be used as adjunct diagnostic tools (evidence level: moderate).
Rationale. Currently, the diagnosis of burn depth is primarily based on distinguishing the involvement of different anatomical layers of the skin, and histopathological examination is the gold standard for objective diagnosis. However, histopathological examination requires consecutive skin tissue biopsies, which have drawbacks, including further damage and increased patient pain. Therefore, the current clinical diagnosis of burn depth mainly relies on the local clinical manifestations of the wound [74, 75], including wound appearance, capillary refill, sensitivity to light touch, and needle puncture [76, 77] which is known as clinical evaluation. Therefore, the development of objective diagnostic techniques or tools for the assessment of burn depth has become the main research direction in the field of burns in recent years. Some studies have reported that the accuracy rate is only between 60 and 75% [78]. The development of objective evaluation and diagnostic techniques or tools has become a major research direction. In recent years, various new auxiliary diagnostic techniques, such as laser Doppler imaging (LDI) [79, 80], harmonic ultrasound imaging [81], optical coherence tomography [82] and high-resolution infrared thermography [83], have been successively reported. However, most of them remain at the clinical research stage, and only LDI has been approved by the FDA for clinical practice. LDI has the advantages of being non-invasive and having a fast response, high sensitivity and accuracy in evaluation [84, 85]. However, disadvantages, including being affected by factors such as blistering and infection, and high equipment costs, still exist. Currently, it is used only as an auxiliary technique for burn-depth diagnosis and cannot replace a clinical evaluation.
Recommendation 16 (moderately recommended). Based on the consideration of the involved dermal pathological levels and wound healing time, it is recommended to classify second-degree burn wounds into superficial second-degree burn wounds, shallow deep second-degree burn wounds, profound deep second-degree burn wounds, and those with indeterminate depth as uncertain-depth burn wounds (evidence level: low).
Rationale. A large number of clinical practices have shown that there are great differences in the incidence of scar after healing of deep second-degree burn wounds. Some deep second-degree burn wounds involve a relatively shallow dermal level and can heal within 14–21 days with a scar formation probability of only 30%. Conversely, other second-degree burn wounds have less residual normal dermis and frequently take >3 weeks to re-epithelialize, with the risk of hypertrophic scarring increasing to 70–80% [86, 87]. Pathologically, the former usually damages the middle layer of the dermis, while the latter reaches the deep layer of the dermis. Therefore, the current diagnostic criteria of diagnosing all burn wounds with damage to the reticular layer of dermis as deep second-degree burns may lead to inappropriate clinical treatment decisions. Combined with expert opinions, this consensus classifies deep second-degree burn wounds into shallow deep second-degree burn wounds and deep second-degree burn wounds according to the pathological level of injury and wound healing time (Table 2), in order to further evaluate the healing potential and prognosis of deep second-degree burn wounds, so as to make the best clinical treatment decisions.
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