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Three Part Question

In [adult and pediatric patients with burn wounds], does the use of [adequate cool water therapy] in addition to standard medical care reduce [morbidity from burns]?

Clinical Scenario

A 15 year-old female presents to your emergency department after sustaining a scald burn from hot coffee. She has a mix of superficial partial thickness and deep partial thickness burns totaling approximately 15% total body surface area (TBSA). She was treated with cool water therapy (CWT) for 20 minutes in the field. You remember than CWT is recommended in first aid guidelines but also recall that not all experts are convinced of the value of the treatment. You decide to consult the literature to assess the benefits of CWT in acute burns.

Search Strategy

A literature search of PubMed was performed in November 2019 using the terms: “burns” AND “cooling”.
The search yielded 312 citations

Search Outcome

Twelve were relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Griffin et al 2019 Australia	2495 pediatric patients (0-16 yrs)	Retrospective analysis of prospectively collected cohort data	Wound depth, hospital admission, need for surgery, need for skin grafting, time to healing	Reduction in full-thickness burns (OR 0.4, 95% CI 0.2-0.6), hospital admission (OR 0.7, 95% CI 0.3-0.9), need for OR (OR 0.7, 95% CI 0.5-0.9), decreased need for skin grafting (OR 0.6, 95% CI 0.4-0.8),	Single center study, low rate of hospitalization
Harish et al 2019 Australia	390 adult (18+) patients with burns	Retrospective analysis of prospectively collected cohort data	TBSA%, hospital length of stay, percent TBSA that was full thickness (PTFI), TBSA grafted, number of re-grafts, ICU admission, ICU LOS, mortality	Reduction in TBSA (-9.8%, 95% CI -13.6% to -6.1%), lower PTFI (-12%, 95% CI -19% to -4%), lower need for regraft (-0.19, 95% CI -0.29 to -0.08)	Relatively small cohort for registry data
Wright et al 2019 UK	25 women undergoing breast reconstruction	Prospective in vivo induced burn wounds	Burn depth	25.2% reduction in burn depth	Did not include confidence intervals, description of burn depth is difficult to compare to other studies
Harish et al 2019 Australia	4918 adult (18+) patients with burns less than 10% TBSA	Retrospective analysis of prospectively collected cohort data	Wound depth, need for skin graft, healing time, TBSA not grafted	Decreased burn depth (OT 1.39, 95% CI 1.24-1.55), 10% faster healing (-1.9 days, 95% CI -2.9 to -0.9), increase in TBSA not requiring graft (0.27%, 95% CI 0.01-0.52)	Included chemical and electrical burns
Wood et al 2016 Australia and New Zealand	2897 adult (16+) patients	Retrospective analysis of prospectively collected cohort data	Need for skin grafting, mortality, hospital length of stay (LOS), need for ICU admission	13% reduction in need for skin grafting, 48% reduction in need for ICU admission, 18% reduction in hospital LOS	Only study to show prolonged CWT may worsen outcomes
Fadeyibi et al 2015 Nigeria	168 pediatric and adult patients	retrospective analysis of prospectively controlled cohort data	Complications	Lower rates of complications (35.3% vs 18.4% CWT)	small sample, single center, large proportion of non-CWT first aid treatments, long LOS, high mortality in cohort
			need for skin grafting	fewer skin grafts (68% vs 49% CWT)
			mortality	higher mortality (42.9% CWT vs 21.8%)
Reidlinger 2015 Australia and New Zealand	730 pediatric patients with scald burns	retrospective analysis of prospectively collected cohort data	Hospital LOS	Shorter LOS (0.9 days)	Low rate of adequate CWT (20%)
			need for wound closure in OR
Cuttle et al 2009 Australia	459 pediatric patients	retrospective analysis of prospectively collected cohort data	Need for skin graft	no change	Optimal CWT in 12%, duration of CWT missing in 39%
			time to healing	decreased time to healing (14.0 +/- 9.4 days to 7.1 +/- 4.5 days)
			number of outpatient visits	decreased maximum visits in flame burns (27 vs 16)
Tung et al 2005 Taiwan	12,831 pediatric and adult patients	retrospective analysis of prospectively collected cohort data	Hospital LOS	Decreased hospital LOS in patients with less than 10% TBSA (11 d vs 10.33 d) and patients with 11-20% TBSA (17.06 d vs. 14.71 d)	Defined adequate CWT as 30 minutes - longer than most recommendations. Low rate of adequate first aid (4.1%)
			mortality	not influenced by treatment
			need for surgery	not influenced by treatment
Skinner et al 2002 New Zealand	121 pediatric and adult patients	retrospective analysis of prospectively collected cohort data	need for debridement	not influenced by treatment	small sample size, single center
			need for skin graft	reduced need for skin graft (6.6% CWT vs 19.3%)
			hospital LOS	shorter LOS for pediatric patients
			cost	lower costs for patients with scald burns
Nguyen et al 2002 Vietnam	695 pediatric patients (0-14) with 10-60% TBSA burns, full thickness less than or equal to 40%	retrospective analysis of prospectively collected cohort data	burn depth	Fewer full thickness burns (OR 0.68, 95% CI 0.55-0.85)	single center, immediate cooling not defined
			need for skin grafting	reduced need for skin grafting (OR 0.60, 95% CI 0.41-0.87
Raghupati N 1968 UK	human forearm	experimental burns induced on a volunteer with brass block heated to 65 degrees C. Forearm then submerged in cool water bath for 60 minutes	Pain	pain improved while submerged in cool water bath but returned after removal	Small study on single volunteer
			blistering	not influenced by treatment
			Time to healing	not influenced by treatment

Comment(s)

Burn injuries are a significant source of morbidity and mortality world-wide, with higher rates of injury and higher mortality for a given burn wound in low-and-middle income countries. Cool water therapy was initially recommended on the basis of animal experiments. Early registry studies provided inconsistent evidence of patient benefit, but several larger registry studies and a novel intra-operative experiment published in the past few years strengthen the evidence base.

Clinical Bottom Line

The evidence suggests CWT is beneficial, particularly in reduction of burn depth, lower need for skin grafting, and shorter time to healing in patients who do not require skin grafts. Interpretation of the data is complicated by varying definitions of adequate CWT and lack of consistent study outcomes. First aid with CWT for 20 minutes is recommended for small to medium sized burns.

References

1. Griffin BR, Frear CC, Babl F, Oakley E, Kimble RM Cool running water first aid decreases skin grafting requirements in pediatric burns: A cohort study of two thousand four hundred ninety-five children. Ann Emerg Med 2019; epub ahead of print
2. Harish V, Li Z, Maitz, PKM First aid is associated with improved outcomes in large body surface area burns. Burns 2019:epub ahead of print
3. Wright EH, Tyler M, Vojnovic B, Pleat J, Harris A, Furniss D Human model of burn injury that quantifies the benefit of cooling as a first aid measure. BJS 2019;106:1472-9
4. Harish V, Tiwari N, Fisher OM, Li Z, Maitz PKM First aid improves clinical outcomes in burn injuries: Evidence from a cohort study of 4918 patients. Burns 2019;45:433-9
5. Wood FM, Phillips M, Jovic T, Cassidy JT, Cameron P, Edgar DW Water first aid is beneficial in humans post-burn: Evidence from a bi-national cohort study. PLoS One 2016;11(1):e0147259
6. Fadeyibi IO, Ibrahim NA, Mustafa IA, Ugburo AO, Adejumo AO, Buari A. Practice of first aid in burn related injuries in a developing country. Burns 2015;41:1322-32.
7. Reidlinger DI, Jennings PA, Edgar DW, Harvey JG, Cleland MH, Wood FM, Cameron PA Scald burns in children aged 14 years and younger in Australia and New Zealand - an analysis based on the Burn Registry of Australia and New Zealand (BRANZ) Burns 2015;41:462-8
8. Cuttle L, Kravchuk O, Wallis B, Kimble RM An audit of first-aid treatment of pediatric burns and their clinical outcome J Burn Care Res 2009;30:1028-34.
9. Tung KY, Chen ML, Wang HJ, Chen GS, Peck M, Yang J, Liu CC A seven-year epidemiology study of 12,381 admitted burn patients in Taiwan - using the Internet registration system of the Childhood Burn Foundation Burns 2005;31 Suppl:S12-7
10. Skinner A, Peat B. Burns treatment for children and adults: a study of initial burns first aid and hospital care. N Z Med J 2002;115:U199
11. Nguyen NL, Gun RT, Sparnon AL, Ryan P The importance of immediate cooling—a case series of childhood burns in Vietnam. Burns 2002;28(2):173-6
12. Raghupati N First-aid treatment of burns: efficacy of water cooling Brit J Plastic Surg 1968;21:68-72