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Three Part Question

In [adult burns patients] is [local cooling] an [effective analgesic]?

Clinical Scenario

A 30 year-old woman presents to A&E after having burnt her forearm on a gas stove whilst cooking dinner. She is complaining of a moderate amount of pain. You wonder whether cooling the burn will relieve some of her pain.

Search Strategy

Medline using the OVID interface 1966-06/05
[exp BURNS/ or burn$.mp. or thermal injury$.mp.] AND [cooling.mp. or cool$.mp.] AND [exp Analgesics/ or exp Pain/ or exp ANALGESIA/ or exp ANALGESICS or analgesic.mp. or analgesia.mp. or painkiller$.mp.] LIMIT to humans AND English Language
EMBASE 1980-06/05
[exp BURNS/ or burn$.mp. or thermal injury$.mp.] AND [cooling.mp. or cool$.mp.] AND [exp Analgesics/ or exp Pain/ or exp ANALGESIA/ or exp ANALGESICS or analgesic.mp. or analgesia.mp. or painkiller$.mp.] LIMIT to humans AND English Language

Search Outcome

34 papers were found in Medline of which 1 was relevant. The Embase search produced 70 papers of which 1 was relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Raghupati. N. 1968 UK	1 patient-2 partial thickness burns were produced on each forearm, one forearm was cooled, the other served as a control. 2 experiments-first, period of immersion in 17C water was 1 hour. Second, period of immersion was prolonged to two hours.		Incidence of AF	OPCAB group 40/204 (20%). CABG group 44/184 (24%). P=0.30	Only one patient used.
			Pain after 1 hour immersion	Cooled forearm felt comfortable whilst in the water but felt uncomfortable and more painful than the control when taken out of the water.
			Death, MI , stroke or renal failure	OPCAB group 6/204 (2.9%). CABG group 9/184 (4.9 %). p=0.32
			Pain after 2 hours of immersion	Less pain in cooled forearm during immersion but once it was taken out of the water burn became uncomfortable.
Werner. M, Lassen. B, Pedersen. J, Kehlet. H 2002 Denmark	24 healthy volunteers, first degree burn injuries were induced on both calves. One calf was then cooled down to 8C for 30 mins, the other acted as a control	Randomised, single-blinded study.	Combined endpoint of mortality stroke and MI, at 1 year (5 studies)	OPCAB group 23/412 (5.6%). CABG group 34/410 (8.2%). P=0.15. Odds 0.66 (0.38 – 1.15)	Study did not evaluate the analgesic effect of cooling on ongoing pain following a burn.
			Hyperalgesic response during first 2 mins of cooling	21 subjects correctly identified cooling thermode and reported less pain in this thermode.
			Hyperalgesic response overall	Cooling does not prevent or reduce this.

Comment(s)

The studies above found that cooling certainly gives immediate relief from pain but the analgesic effect quickly wears off after ceasing the cooling of the wound.

Editor Comment

Experimental studies have suggested that immediate cooling of burns may reduce the severity of tissue damage but there is no evidence of improved healing available in humans.

Clinical Bottom Line

Local cooling is an effective adjunct to other analgesia in the immediate management of patients with thermal burns.

Level of Evidence

Level 3 - Small numbers of small studies or great heterogeneity or very different population.

References

1. Raghupati. N. First-aid treatment of burns: efficacy of water cooling. British Journal of Plastic Surgery 21(1968) p68-72
2. Werner. M, Lassen. B, Pedersen. J, Kehlet. H Local cooling does not prevent hyperalgesia following burn injury in humans Pain 98(2002)p297-303