Annals of Burns and Fire Disasters - vol. XXXI - n.

3 - September 2018

NURSE KNOWLEDGE OF EMERGENCY MANAGEMENT FOR BURN

AND MASS BURN INJURIES

CONNAISSANCES DES IDE CONCERNANT LA PRISE EN CHARGE EN URGENCE DES

BRÛLÉS, ISOLÉMENT ET EN CAS DE CATASTROPHE

Lam N.N.,* Huong H.T.X., Tuan C.A.

National Institute of Burns, Hanoi, Vietnam

SUMMARY. A survey was conducted on 353 registered nurses working in Emergency and Trauma departments of district and provincial
hospitals in Vietnam. Contents of the survey included first aid and initial care for burn and mass burn injuries. Only 15.3% of participants
correctly answered over 50% of the items. The average percentage of correct answers was 39.7%. For cases of mass burn injuries, 53.6% of
nurses recognized oral fluid resuscitation to be an appropriate method. Pre-transportation intubation for suspected inhalation injury was
indicated by 44.6% of participants. Meanwhile, only 5.4% of nurses gave the correct answer regarding burn triage. A significantly higher
knowledge level was recorded among nurses who had attended training courses in the past (54.8 ± 10.5% vs. 38 ± 9.7% respectively; p <
.001). Meanwhile, work experience and place did not influence knowledge level. To improve the burn emergency management of
nurses, further and continuing education is highly recommended.
Keywords: emergency burn management, mass burn injuries, nurse knowledge

RÉSUMÉ. Une étude a été réalisée auprès de 353 IDE travaillant dans des services d’urgences d’hôpitaux vietnamiens. Le questionnaire portait sur
le secourisme et les soins initiaux aux brûlés, se présentant isolément ou dans le cadre d’une catastrophe. Seuls 15,3% des par-ticipants avaient plus
de 50% de bonnes réponses, la moyenne étant de 39,7%. Cependant, 53,6% des IDE attestent que la réhydratation orale est utilisable en cas d’afflux
massif mais seuls 5,4% des réponses sur le triage étaient correctes. L’intubation prophylactique avant trans-port en cas d’inhalation de fumées était
validée par 44,6% des répondants. Les réponses étaient meilleures chez les IDE ayant bénéficié par le passé d’une formation (54,8 +/- 10,5% VS 38
+/- 9,7% ; p<0,001) alors que ni l’expérience ni le lieu d’exercice n’influençaient les connaissances. Ainsi, des plans de formation sont nécessaires
pour améliorer les connaissances des IDE sur la prise en charge des brûlés.
Mots-clés : brûlés, urgence, prise en charge, catastrophe, IDE, connaissances

Introduction
First aid and appropriate initial management are
considered to be important steps in the progress of the
management of burns, including mass burn injuries. 1,2,3 In
fact, most burned pa-tients in Vietnam are initially treated at
local emergency de-partments of district hospitals rather than
in specialized burn centers. This is most likely the case in
other countries also. After being given first aid and stabilized
at the scene, burn in-jury victim(s) are transferred to the
emergency department for initial management, prior to
referral to the closest burn unit for definitive care. In cases of
mass burn casualties, emergency de-partments will triage and
provide emergency treatment to the burned victims. Nurses
working in these departments are often required to assist the
local teams. They may be deployed to the scene. 4,5 Thus, the
knowledge and practical skills of nurses in these departments
play an important role in improving the qual-ity of burn care. 6
It is estimated that more than 90% of burn-related deaths
occur in developing or low and middle-income countries. 7 Lim-
___________
itations have been reported regarding the first aid provided
and the initial management of burned patients before they
were transferred to a specialized burn unit, such as the
Vietnam Na-tional Institute of Burns in Hanoi. This is
especially the case for mass burn injuries. 2,8 In order to
improve burn care in Viet-nam, we need to explore nurses’
knowledge of burn manage-ment practices in the Emergency
and Trauma Department of district and provincial hospitals.
This study attempts to evaluate nurses’ knowledge of
emer-gency burn management using a simple knowledge-
based ques-tionnaire.
Materials and methods
From February to June 2016, a survey was conducted on 353
registered nurses working in the Emergency or Trauma De-
partment of district or provincial hospitals in 10 provinces. The
questionnaire was delivered in person; the participant had 30
minutes to answer 11 questions (see appendix). The contents of
the survey included: (1) general information including work

Corresponding author: Nguyen Nhu Lam MD, PhD, National Institute of Burns, Hanoi, Vietnam. Tel.: +84 948316869; fax: +84.2436883180;
* email: lamnguyenau@yahoo.com
Manuscript: submitted 30/08/2018, accepted 05/09/2018

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 Annals of Burns and Fire Disasters - vol. XXXI - n. 3 - September 2018

place, working experience and previous participation in train- both adult and pediatric burned patients (22.1% and 28.6%
ing courses; (2) knowledge of first aid for thermal and eye in- re-spectively). Half of the participants recognized the
jury, calculating burn surface area, concept of the Parkland manifesta-tions of inhalation injury. Regarding fluid
formula, manifestation of inhalation injury and awareness for resuscitation methods, 53.5% of nurses provided the correct
intubation, appropriate methods of fluid resuscitation and answer. Pre-transportation intubation for suspected inhalation
injury was indicated by 44.6% of participants. Meanwhile,
triage for mass burn injuries. The percentage of correct
only 5.4% of nurses gave the correct answer regarding proper
answers was considered to represent overall knowledge level. triage proce-dures.
Data was tab-ulated and analyzed using T test and Chi Square The overall results are indicated in Table IV. Only 54
to compare mean and distribution of values between groups
nurses, accounting for 15.3% of participants, had more than
using Stata 11.0 software and p value ≤ .05 was considered a
significant level. 50% correct answers. The average percentage of correct an-
Results swers was 39.7% (ranging from 6.7 to 73.3%) of the total
ques-tions; no one achieved all the correct answers.
A total of 353 nurses participated in the survey. Character- Table IV - Overall survey results (n = 353)
istics of the participants are shown in Table I. Two hundred and
forty-seven (69.9%) were working in provincial hospitals. One Percentage of correct Number of participants Percent
answers
hundred and fifty participants (42.5%) had more than 5 years of
1 – 25% 22 6.2
working experience since graduating from nursing school. 26 – 50% 277 78.5
However, only 10.2% of participants had taken part in training > 50% 54 15.3
Average (%, 95% CI)* 39.7 ±19.9 (6.7 – 73.3)
courses for first aid and burn management. * CI: confidence interval

Table I - Characteristics of survey participants (n = 353) The relationship between overall result and proposed
crite-ria is shown in Table V. Nurses who had undertaken
Criteria Sub-groups N % training courses had a significantly higher knowledge level
Workplace Provincial hospital 247 69.9 than those who had not (54.8 ± 10.5% vs. 38.0 ± 9.7%
District hospital 106 30.0
Working experience 5 years 150 42.5 respectively; p <.001). Knowledge levels were not
< 5 years 203 57.5
Training courses Yes 36 10.2
significantly different be-tween nurses working in provincial
experienced No 317 89.8 hospitals and those in dis-trict hospitals (39.5 ± 10.6% correct
Regarding first aid, Table II indicates that 93.2% of answers vs. 40.3 ± 11.9% respectively; p=0.51) . It was also
partic-ipants knew to use fresh cool water instead of applying noted that working experi-ence was not significantly related
tradi-tional remedies such as fish sauce, butter or toothpaste, to knowledge level amongst nurses (p =0.14).
commonly used in the community. Eighty-three point six per- Table V - Relationship between overall result and proposed criteria
cent of the participants indicated they understood not to use
these traditional remedies. Correct first aid measures for eye Criteria Subgroup Mean ± SD* 95% CI** p
Workplace Provincial hospital 39.5 ± 10.6 38.2 – 40.8 0.51
injury were identified by 66.9% of the nurses surveyed. n = 247
District hospital 40.3 ± 11.9 38.0 – 42.6
Mean-while, only 7.7% of the total participants calculated n = 106
total body burn surface area correctly. Working < 5 years 40.5 ± 11.0 39.0 – 42.0 0.14
experience n = 203
Table II - First aid knowledge and ability to calculate total body surface 5 years 38.8 ± 11.0 37.0 – 40.5
n = 150
area burned (n = 353) Training No 38.0 ± 9.7 36.9 – 39 <0.001
courses n = 317
Contents of survey True False experienced Yes 54.8 ± 10.5 51.3 – 58.4
Using cool fresh water for first aid N % N % n = 36
329 93.2 24 6.8 * Percentage of correct answers; ** CI = Confiden ce interval
Materials can be applied on burn wound 295 83.6 58 16.4
First aid for eye injuries 236 66.9 117 33.1
Calculating total body surface area burned 27 7.7 326 92.3
Discussion
Table III shows that 52.4% of the participants had an un- Many burned patients admitted to the specialized Burns
derstanding of the use of the Parkland formula. On the other Hospitals in Vietnam did not receive proper first aid. Knowl-
hand, less than one third gave the correct answer regarding suf- edge and practical skills of healthcare providers play an im-
ficient urine output when performing fluid resuscitation for portant role in the success of a patient’s care. Current worldwide
reports indicate different levels of knowledge of first aid and
Table III - Knowledge of fluid resuscitation and mass burn injuries
initial management for burns amongst healthcare providers.
Insufficient knowledge of emergency burn man-agement has
Contents of survey True False been reported in developing countries. In 2005, a survey by Kut
N % N %
Parkland formula 185 52.4 168 47.6 and colleagues on knowledge among 510 oc-cupational
Required urine output for fluid resuscitation of 78 22.1 275 77.9
adult burned patient
physicians in Turkey showed that only 21.8% of total
Required urine output for fluid resuscitation of 101 28.6 252 71.4 participants had adequate knowledge of appropriate burn
paediatric burned patient
classification, and 96% had insufficient knowledge of first aid
Manifestations of inhalation injury 181 51.3 172 48.7
Appropriate method of fluid resuscitation in 189 53.5 164 46.5 for burn injuries.9 In 2016, a survey by Alomar and colleagues
cases of mass burn injuries
Triage procedures for mass burn injuries 19 5.4 334 94.6
on 408 pediatric healthcare providers in Saudi Arabia indi-cated
Indication for intubation before transportation 154 44.6 199 56.4 that 41% of participants knew to use fresh cool water for
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Annals of Burns and Fire Disasters - vol. XXXI - n. 3 - September 2018
first aid, and 97% percent had insufficient knowledge about
the duration of application. In addition, a high rate of partici-
pants answered that it is possible to use remedies such us
toothpaste, fish sauce, ice or oils to cover the burn wound.10 A
report by AL-Sudani and Ali in 2017 on the knowledge of
nurses selected from burns wards in non-teaching hospitals in
Baghdad revealed that only 8.7% passed the pretest basic
ques-tions. 11 Traditional remedies are also commonly used in
Viet-nam. According to the current results, there are still a
small number of nurses who consider using such remedies
instead of fresh water.
Similar to other developing countries, Vietnam has a limited
number of specialized burns hospitals. Most burn patients re-
ceive initial management at district or provincial hospitals prior
to transfer. Hence, it is essential that nurses in the Emergency
Department of those hospitals have adequate knowledge of ini-
tial burn management. Results of the current survey indicate that
there is a significant gap in nurses’ knowledge in terms of burn
surface area estimation, use of the Parkland formula and
required urine output for fluid resuscitation. Inappropriate es-
timation of the burned surface area as well as misunderstand-ing
of the Parkland formula may lead to over or under resuscitation
and the sequelae associated with this, such as renal failure and
other related medical issues. This not only impacts on-going care
outcomes for the patient but can significantly in-crease the cost
associated with this care.
The current study also indicates that nurses have limited
knowledge of the management of mass burn injuries, especially
in triage (only 5.4% provided correct answers), and the indica-
tion for intubation. Due to limited resources, oral fluid resusci-
tation for minor burned patients, even in mass burn injury
situations, is the recommended method in Vietnam. This has to
be carried out with care, and requires the patient to be alert and
able to follow commands. Swallowing assessment is not
available in Emergency and Trauma Departments. In order to
measure fluid input, intravenous fluid may be the preferred
method. However, it is not the only way, especially in a mass
burn injury situation with limited resources. Even severely
burned patients with TBSA over 30% can be given oral fluid
initially, so that fluid resuscitation is not delayed. 53.5% of
nurses answered this correctly. Due to swelling of the airways
and use of high doses of anesthetic drugs, some burned patients
may require intubation prior to transfer to the burns units. Not
only is respiratory function affected without intubation, but
when the procedure is done later it can definitely induce further
trauma to the airways. Lack of knowledge and insight may in-
fluence the chances of survival of these burned patients.
Knowledge can be gained by frequent exposure. Hence, a
correlation is expected between working experience and knowl-
edge. Regarding knowledge of emergency burn management, the
findings of the current study reveal that there is no signifi-cant
relationship between nurses’ knowledge and their years of
experience in emergency burn care and mass burn injury man-
agement. This implies that nurses in emergency departments are
not getting the right learning opportunities from their work-ing
environment. Delivery of knowledge may have to rely on formal
or informal learning methods.
Similar to other reports, only 15.3% of nurses from the
cur-rent survey gave more than 50% correct answers. None
of the participants were able to provide correct answers to all
the questions. Since they are the front line clinicians, there
are real concerns about the care burned patients are receiving
at such a critical stage. In addition, our results reveal that
working expe-248
rience does not affect our participants’ overall level of knowl-
edge of burn care. According to the survey, only 10.2% of par-
ticipants had undertaken training courses for first aid and burn
management. The same situation was reported in a study by
Alomar et al. (2016), conducted in Saudi Arabia, which re-
vealed that only 15% of participants had taken part in first aid
training.10 This suggests that nurses are not regularly en-gaging
in further or continuing education, or in refresher courses on the
management of acute burns and mass injuries.
In developed countries the situation is better, but still shows
limitations. For example, Rea et al. conducted a study in West-
ern Australia that showed that only 18.8% of healthcare
providers gave the right answers to questions on the burn sce-
nario.12 In 2013, Tay et al. conducted a survey in England to
assess burn first aid knowledge among healthcare workers. This
showed that 59% of participants had attended a first aid course.
However, only 16% achieved correct answers to all questions. 13
Previous studies have shown that knowledge of first aid is
correlated with first aid training courses. A study by Rea et al.
indicated a statistically significant difference between partici-
pants who had taken part in a first aid course and those who
had not.12 The current study has similar results and is in
agree-ment with that statement: nurses who undertook
training courses had a significantly higher knowledge level
(53.1%) than those who had not participated in any training
course (44.5%). Works by AL- Sudani and Ali (2017) showed
that nurses could significantly improve their knowledge from
8.7% to 100% right after attending a training couse. 11 Our
study also proved that participating in training courses is an
independent factor affecting knowledge level. These results
emphasize the importance of attending regular training
courses for healthcare providers.
One of the reasons for this gap in knowledge is a limited
educational curriculum at nursing schools, as well as a lack of
continuing medical education that focuses on burn emergency
management. Clearly, additional courses are required to fill the
gap in formal nursing education in order to update the knowl-
edge of healthcare providers. Training courses for doctors are
provided on a regular basis, and this should extend to nurses. A
survey by Meschial & Oliveira in 2014 in Brazil indicated that
only 22.4% of nursing students had adequate knowledge of ini-
tial burn management.14 In 2016, a cohort study by Kua Phec
Hui et al. at the children’s emergency department in Singapore
showed a statistically significant increase in knowledge imme-
diately after a short training course (22.9% vs. 78.3%). 15 Ahmed
and Mohamed (2016) compared nurses’ knowledge and
performance with burned children at the pediatric burn unit be-
fore and after the educational program. After the implementa-
tion of the program, over 90% of nurses showed greater
knowledge and an improved performance in pediatric burns
management.16 The role of burn training in improving nurses’
knowledge has also been reported by Tay et al., EL-Sayed et al.
and Mussa & Abass.13,17,18
Conclusion
Our study indicates insufficiencies in nurses’ knowledge
of emergency burn management and mass burn injury
response. Working experience does not correlate to level of
knowledge. Training courses significantly contribute to an
improvement in their knowledge. It is necessary to conduct
continuing medical education for nurses, regardless of their
working experience and place of work.
 Annals of Burns and Fire Disasters - vol. XXXI - n. 3 - September 2018

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nurses’ knowledge for children with burn injuries attending the Burns

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Annals of Burns and Fire Disasters - vol. XXXI - n. 3 - September 2018

APPENDIX
QUESTIONNAIRE FOR BURN FIRST AID AND INITIAL MANAGEMENT

I. General Information

Workplace: Provincial hospital District hospital

≥ 5 years
Working experience: < 5 years No
Participated in burn training course: Yes
II. Please read the following questions and choose the correct answers

Q1. Is using cool fresh water the best first aid measure for thermal injury?
Yes
No

Q2. Right after injury, should the following materials be applied to a burn wound?

a. Ice b. Toothpaste c. Fish oil

d. Honey e. None of above
Q3. If the patient has eye injuries, what is the most appropriate emergency management?

Transferring the victim to the nearest hospital as soon as possible

Finding and applying neutral agent
Irritating and continuously blinking with fresh water
Using high pressure water to clean the injured eyes
Q4. Burn surface area of an adult patient with burns on the head and neck, both upper extremities and front torso is

……….%TBSA.
Q5. Estimated Parkland formula for adults is:

a. 1ml/kg/% TBSA b. 4ml/kg/% TBSA

c. 5ml/kg/% TBSA d. 4ml/kg/h
Q6. Required urine output indicating enough fluid given to adult burn patient:

a. 3ml/kg/h b. 2ml/kg/h
c. 0.5ml/kg/h d. As much as possible
Q7. Required urine output indicating enough fluid given to pediatric burn patient:

a. 1ml/kg/h b. 2ml/kg/h
c. 3ml/kg/h d. As much as possible
Q8. Manifestation of inhalation injury: b. Face burn c. Change in voice

a. Occurred in closed space g. All the above signs

d. Difficulty breathing e. Carbonaceous h. Coma
Q9. Appropriate method of fluid resuscitation in cases of mass burn injuries:

Oral fluid resuscitation with care

Intravenous only
Q10. Transferring priority victims in cases of mass burn injuries:

First come first served

Depends on severity of victims as triage
Q11. In cases of mass burn injuries, is intubation indicated for suspected inhalation injury before transferring?

Yes
After assessing the risk during the transfer process
Only for respiratory distress Thank you!

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