Journal Of Paramedic Practice - The use of polyvinyl chloride film (clingfilm) with burn injury in the pre-hospital setting

Abstract

Responding to burn patients within the pre-hospital setting, ‘stop the burning process, cool the burn injury, assess and then cover’ is the recommended management procedure included in the standard trauma protocol pathway, endorsed by international burn associations throughout the world. However, the introduction of the use of polyvinyl chloride film (clingfilm) in the pre-hospital setting continues to generate considerable confusion among emergency medical and rescue practitioners responding to burn-injured patients. The use of polyvinyl chloride film (clingfilm) does have a supportive role in burn injury management—just not in the immediate phase of emergency burn care.

This paper provides an overview of the clinically-evidenced pathway for the potential use of polyvinyl chloride film (clingfilm), as advocated by leading international emergency burn care and trauma associations.

Serious burn injuries are devastating events that leave patients with long-term physical and psychological challenges that are recognised by paramedics worldwide as one of the most horrific and challenging injuries known to the emergency medical and rescue services (Bourke and Dunn, 2013).

Burn-injured patients who enter the in-hospital management pathway are extremely expensive for their local healthcare system to repair and support as they progress through the burn care system towards repatriation with their families, hopefully with a positive re-introduction into civilian life.

At the time of incident, a burn-injured patient may be severely stressed, possibly going into shock (depending on the source and severity of the burn injury), and in considerable pain (both physical and psychological). Their current method of assisted cooling by family, friends or members of the public may not be the most efficient or effective (more than likely the case with children and the elderly), as their burn injuries continue to damage their integumentary structure.

All of the above will continue until the arrival of the health professional on scene, when they expect from the moment of their arrival onward, everything is going to get better.

However, the introduction of the use of polyvinyl chloride film (clingfilm) in the pre-hospital setting continues to generate considerable confusion among emergency medical and rescue practitioners responding to burn-injured patients—‘Do I put clingfilm on first?’ ‘Do I put it on after?’ ‘Do I put one layer on top of the other?’ ‘Do I wrap it around the burn injury and how many times?’ ‘Do I use strips?’ ‘Can I layer the strips?’ ‘Will it stay on if it is windy?’ ‘Will it stay on if I wrap the patient in warm blankets?’ ‘Can I use it on the head and face?’ ‘Can I use it on the groin region?’ ‘How do I use it for hand burns?’ ‘What happens if it shrinks onto the burn injury?’ ‘This is how we were told to do it.’ ‘I have never been trained on its use.’ ‘We were told to use it because it is cheaper and will save money for the ambulance service’ etc.

The use of polyvinyl chloride film (clingfilm) does have a supportive role in burn injury management—just not in the immediate phase of emergency burn care.

Plasticised polyvinylchloride as a temporary dressing for burns

In 1987 the use of clingfilm gained early research exposure by Wilson and French. In their abstract they state:

‘Plasticised polyvinylchloride film has been used in this burns unit for a long time for dressings before the ward round, before surgery, and when the burned patient is transferred from the casualty department to the burns unit. Plasticised polyvinylchloride film is easy to use, safe, and causes no pain. Most importantly, in the present financial climate, it is cheap’ (Wilson and French, 1987).

Uses

Wilson and French (1987) outlined their use of plasticised polyvinylchloride in three circumstances:

For the ward round—They explain how their burns unit has a policy of dressing all burns except those on the face. When a wound is to be viewed on the doctors' round there may be some delay before it is seen, particularly if there are several dressings for the nurses to take down. A sheet of polyvinylchloride film is wrapped around the wound and sealed to itself

Before operation—If a burns dressing has been inspected on the morning of surgery or if the dressings are particularly offensive and the patient is to be bathed before the operation the wound is wrapped in polyvinyl chloride and left undisturbed until the patient is anaesthetised

Transfer of burns patients—For the past 12 months the burns of patients who have been transferred from the region's casualty departments have been dressed with plasticised polyvinylchloride

In 2004, a consensus statement from the Faculty of Pre-hospital Care mentioned that the use of polyvinyl chloride film (clingfilm) is for potential use after the burn injury has been effectively cooled (Allison and Porter, 2004) (note: this paper is quoted as a reference support document [ref#771] to the current UK Ambulance Services Clinical Practice Guidelines).

The advice offered by the consensus statement is as follows:

Stop the burning process

The burning process should be stopped/extinguished and the patient should be removed from the burning source etc. (Allison and Porter, 2004).

Cool the burn wound

There is often confusion over this process and how long it should last for. It is suggested that the ambulance service despatch system will advise the ‘999’ caller to cool the burn area for up to 10 minutes. Cool running tap water is sufficient and ice cold water should not be used etc. (Allison and Porter, 2004).

Dressings

Dressings are important to help the patient's pain control and to keep the burnt area clean.

The burnt area should be covered with a cellophane type wrap clingfilm, remembering the possible constricting effect of wrapping; smaller pieces are perhaps better than circumferential sheet. The patient should be wrapped up in blankets or a duvet etc. (Allison and Porter, 2004).

The Management of Burns and Scalds in Primary Care manual (New Zealand Guidelines Group, 2007) endorsed by the Australian and New Zealand Burn Association (ANZBA) (also referenced by the UK Ambulance Services Clinical Practice Guidelines [ref#757]), dedicates a complete page to the use of polyvinyl chloride film (clingfilm) for use with burn injuries.

The second chapter—which looks at first aid—begins with the internationally recognised burn injury pathway of stopping the burning process and cooling, which is supported with evidential statements covering almost three pages. This in turn leads on to initial coverings after the cooling process is complete (New Zealand Guidelines Group, 2007: 31–33).

Polyvinyl chloride film (clingfilm) recommendations

Following cooling, polyvinyl chloride (PVC) film may be used as a temporary cover prior to hospital assessment. It should be applied by persons knowledgeable in its use.

PVC film should be layered onto the wound and not applied circumferentially around a limb.

Good practice point: PVC film should not be used as a substitute for a dressing product.

‘It should be applied by persons knowledgeable in its use.’ This statement alone raises a further issue, if you are currently being encouraged to employ the use of polyvinyl chloride film (clingfilm) for immediate emergency burn management in the pre-hospital setting; are you trained on its correct use and timing to ensure best possible outcome for your burn patient?

Two of the world's most renowned burn care associations, The Australian and New Zealand Burn Association (ANZBA) and the British Burn Association (BBA), formed an alliance to advance the standards of burn care in their respective regions, by sharing a common understanding and teaching through their internationally recognised burn course, the ‘Emergency Management of Severe Burns UK Course Pre Reading’ (EMSB) (ANZBA, 1996), which is taught throughout the United Kingdom. This emergency burn course is considered one of the very best available to educate emergency department (ED) nurses and doctors onward into theatre.

Under the chapter concerning management of the burn wound (ANZBA, 1996: 53), it is clear that the recommended pathway is concurrent with international thinking, i.e. stop the burning process, cooling the burn surface and then into early management.

It advises that in preparation for transport the patient may need a dressing on the burn wound. Depending on the time between injury and transport and the expected time taken during the transport process, it may be necessary to apply something more that simply wrapping the area in a clean cloth. Plastic clingfilm can be used and is particularly useful in children because it limits evaporation and, hence, heat loss.

The Victorian Adult Burns Service, Alfred Hospital Melbourne Australia and the Royal Children's Hospital Melbourne Australia perform first aid for burns as per the ANZBA Guidelines, and indicate that after cooling the wound should be covered with a sterile dressing, and that clean plastic film wrap should be used if no dressings are available (Victorian Adult Burns Service at the Alfred and The Royal Children's Hospital Melbourne, 2012).

They advise that where the surface is blistered and/or raw, the wound should be covered with a dressing (Victorian Adult Burns Service at the Alfred and The Royal Children's Hospital Melbourne, 2012). In the absence of any wound dressings, cover the wound with plastic film wrap or clean cloth to keep the burn wound clean until definitive management can occur. Plastic film wrap is a suitable dressing for patients being transferred to the burn service within 6 hours. Avoid wrapping affected area circumferentially with plastic film wrap as this can have a tourniquet effect as oedema worsens.

In 2009, an article by Enoch et al (2009) provided a consensus summary on first aid management (pre-hospital care) for burns (see Box 1).

Box 1.

Faculty of Pre-hospital Care consensus guidelines for pre-hospital management of burns

Approach with care and call for help

Stop the burning process

Help the person to ‘drop and roll’ if the clothing is alight

Turn the power off if electricity is involved

Assess patient as per guidelines for emergency management of severe burns and manage appropriately

Cool the area but prevent hypothermia

Assess burn severity

Cover or dress the area with clingfilm or cellophane

Suspect inhalation injury in burns sustained in an enclosed area, facial burns, or when nasal hair has been singed.

Early intubation may be needed if there is evidence of inhalation injury

Cannulate and administer fluids (Hartmann's solution or Ringer's lactate)

Provide adequate analgesia

Transfer to appropriate hospital or burns care centre

From: Enoch et al, 2009

It also showed that the recommended pathway for immediate emergency burn care management is to stop the burning process, cool the burn injury, and then after cooling, cover if required, with clingfilm.

In the interest of their patients, emergency medical practitioners around the world strive to be the very best in their chosen field of emergency medicine. To maintain these standards, they must continue to study and up skill regularly with the best available resources of teaching and learning. There are numerous recognised advanced trauma and paramedic manuals published by international authors who continue to excel in their field of emergency medicine; Trauma Care (Greaves et al, 2009) is one such manual being referenced by paramedics and advanced clinicians on a regular basis to further their skill set.

In this manual, on the chapter dealing with injuries due to burns and cold, the same pathway is advocated: safety, stop the burning process, cooling followed by covering/dressing (Greaves et al, 2009: 224). It proposes that at the point of injury, the burning process should be stopped as quickly as possible by removing the patient from the source through smothering, ‘drop and roll’ or irrigation.

The wound should be cooled, ideally under running water for 10–20 minutes. This acts as an analgesic and decreases the inflammatory reaction associated with the injury. Clingfilm is ideal as a non-stick, temporary dressing prior to transfer.

Current international burn care protocols

Globally, current recommended burn management protocols remain the same. In Wounds International, an online practice-based journal for clinicians worldwide, it is shown, under the top ten tips on the management of burn wounds, that the use of clingfilm should be considered if transferring to a burns unit as a temporary dressing (McRobert and Stiles, 2014). It goes on to advise that clingfilm should be only one layer thick and never used on face burns.

The following pathway is recommended by online advisory website NHS Choices for the treatment of burns and scalds: stop the burning process, remove any clothing and jewellery, cool the burn, keep the patient warm. This is followed by the advice to cover the burn with clingfilm (NHS Choices, 2013).

A similar pathway is advocated in the burns and scalds entry by NHS Direct Wales: immediately get the person away from the heat source, cool the burn, remove any clothing and jewellery, make sure the patient is kept warm, and cover the burn by placing a layer of clingfilm over it (NHS Direct Wales, 2014).

The use of clingfilm for burns is included within the UK Ambulance Services Clinical Practice Guidelines 2013 (Association of Ambulance Chief Executives (AACE), 2013). Within these Guidelines there are 16 steps laid out for the correct pathway of burn-injured patient management in the pre-hospital setting. After the initial assessment of the patient it is advised that (AACE, 2013: 240–1; 243–4):

Supplemetal oxygen should be administered via a non-breathing mask

The burn should be cooled/irrigated with copious amounts of water for a maximum of 20 minutes (gel-based dressings may be used but water treatment is preferred)

The burn size should be assessed

The burn should be dressed. Use small sheets of clingfilm—do not wrap around limbs but layer the film. In the absence of clingfilm use a wet non-adherent dressing. N.B. do not apply creams/ointments; they interfere with the assessment process

Depending on burn surface area fluids should be administered (refer to intravascular therapy guideline)

If the patient is wheezing as a result of smoke inhalation, nebulised salbutamol should be administered

The need for analgesia should be assessed

Documentation should be carried out and should include how the patient was burned, time of burn, temperature of the source of burning, whether first aid was undertaken, and time and volume of infusions

Patient should be transferred to further care etc.

‘The use of polyvinyl chloride film (clingfilm) does have a supportive role in burn injury management—just not in the immediate phase of emergency burn care’

It is clearly shown from these Guidelines that clingfilm may be used after the burn injury has been cooled.

Within the same manual under Update Analysis (xxvii), the duration of irrigation of burns with water has changed to 20–30 minutes; irrigation can be undertaken up to three hours post injury. Water gel dressings are advocated in absence of water for irrigation. (AACE, 2013: Update Analysis xxvii).

The papers, training manual references and clinical practice guidelines (CPG) referenced in this article show clearly the recommended clinically-evidenced pathway for the use of polyvinyl chloride film (clingfilm), should it be required, for the secondary management of burn wounds and onward transfer to a higher clinical intervention, and suggest that polyvinyl chloride film (clingfilm) should not be used as a substitute for a dressing product.

Once this confusion has been addressed, and the correct clinical pathway evidenced to the satisfaction of all, the following concerns, relating the use of clingfilm in the immediate stage for emergency burn management, should also be considered:

Were the burn injuries sufficiently cooled prior to application of the clingfilm strips (running cool clean water for a minimum period of 20–30 minutes)?

Did you use single strips only as directed or accidentally wrap it circumferentially?

Has the clingfilm strip location tape been applied over an area of burnt tissue, and is it constrictive?

Did you remember to dispose of the first 10–20 cm (4–8 inches)?

Is your roll CE approved as a medical device for use on potential open wounds?

Is it being stored correctly according to manufacturer's guidelines?

Does it have an expiry date?

Have you been trained in its correct use?

Conclusions

The application of polyvinyl chloride film (clingfilm) onto a hot burn injury should be supported by clinically-evidenced documentation for it to be implemented as an emergency treatment protocol for burns in the pre-hospital setting. To date, after many months of research it has not been possible to locate any clinically-evidenced training manual, research paper or international burn association advocating the use of polyvinyl chloride film (clingfilm) for the immediate emergency management of a hot burn injury in the pre-hospital setting, irrespective of location on the human body or age group.