Does cool water therapy reduce morbidity after burns?
Date First Published:
November 24, 2019
Last Updated:
December 14, 2019
Report by:
Cindy C. Bitter, MD, MPH, Assistant Professor (Saint Louis University)
Search checked by:
Stephen Sheridan, MD, Saint Louis University
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”.
Search Details:
The search yielded 312 citations
Outcome:
Twelve were relevant to the three part question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Cool running water first aid decreases skin grafting requirements in pediatric burns: A cohort study of two thousand four hundred ninety-five children. Griffin BR, Frear CC, Babl F, Oakley E, Kimble RM 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 |
| First aid is associated with improved outcomes in large body surface area burns. Harish V, Li Z, Maitz, PKM 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 |
| Human model of burn injury that quantifies the benefit of cooling as a first aid measure. Wright EH, Tyler M, Vojnovic B, Pleat J, Harris A, Furniss D 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 |
| First aid improves clinical outcomes in burn injuries: Evidence from a cohort study of 4918 patients. Harish V, Tiwari N, Fisher OM, Li Z, Maitz PKM 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 |
| Water first aid is beneficial in humans post-burn: Evidence from a bi-national cohort study. Wood FM, Phillips M, Jovic T, Cassidy JT, Cameron P, Edgar DW 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 |
| Practice of first aid in burn related injuries in a developing country. Fadeyibi IO, Ibrahim NA, Mustafa IA, Ugburo AO, Adejumo AO, Buari A. 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%) | ||||
| 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) Reidlinger DI, Jennings PA, Edgar DW, Harvey JG, Cleland MH, Wood FM, Cameron PA 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 | |||||
| An audit of first-aid treatment of pediatric burns and their clinical outcome Cuttle L, Kravchuk O, Wallis B, Kimble RM 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) | ||||
| A seven-year epidemiology study of 12,381 admitted burn patients in Taiwan - using the Internet registration system of the Childhood Burn Foundation Tung KY, Chen ML, Wang HJ, Chen GS, Peck M, Yang J, Liu CC 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 | ||||
| Burns treatment for children and adults: a study of initial burns first aid and hospital care. Skinner A, Peat B. 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 | ||||
| The importance of immediate cooling—a case series of childhood burns in Vietnam. Nguyen NL, Gun RT, Sparnon AL, Ryan P 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 | ||||
| First-aid treatment of burns: efficacy of water cooling 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 |
Author Commentary:
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.
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:
- 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.
- Harish V, Li Z, Maitz, PKM. First aid is associated with improved outcomes in large body surface area burns.
- 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.
- 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.
- 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.
- Fadeyibi IO, Ibrahim NA, Mustafa IA, Ugburo AO, Adejumo AO, Buari A. . Practice of first aid in burn related injuries in a developing country.
- 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)
- Cuttle L, Kravchuk O, Wallis B, Kimble RM. An audit of first-aid treatment of pediatric burns and their clinical outcome
- 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
- Skinner A, Peat B. . Burns treatment for children and adults: a study of initial burns first aid and hospital care.
- Nguyen NL, Gun RT, Sparnon AL, Ryan P. The importance of immediate cooling—a case series of childhood burns in Vietnam.
- Raghupati N. First-aid treatment of burns: efficacy of water cooling