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Cooling of burns

Question Type:
Intervention
Full Question:
Among adults and children with thermal injuries (P), does active cooling of burns by a specific technique or for any particular duration (I), compared with passive cooling (C), change pain, wound healing, complications, patient satisfaction, need for advanced medical care, rates of fasciotomy, depth or breadth of burn (Class 5) (O)?
Consensus on Science:
​After application of inclusion and exclusion criteria, the search strategy yielded 1 single-blind RCT and 5 observational studies. One of the observational studies was withdrawn from publication due to inconsistencies in data and was, therefore, withdrawn from the evidence review, leaving a total of 5 studies for inclusion.(Sunder 1998, 444; Nguyen 2002, 173; Werner 2002, 297; Cuttle 2009, 1028; Yava 2012, 544) For the critical outcome of pain, 1 RCT and 1 observational study were found. Low-quality evidence (downgraded for risk of bias) from a single RCT(Werner 2002, 297) with 24 subjects showing no benefit in reduction of tactile pain measurements in cooled versus noncooled first-degree burns (MD undeterminable). Low-quality evidence (downgraded for risk of bias) from a prospective observational study(Yava 2012, 544) with 48 subjects showing no benefit in reduction of pain at 2, 4, and 24 hours in patients with active cooling of burns caused by electric cardioversion versus those without cooling (MD undeterminable). For the important outcome of depth of burn, 1 RCT and 3 observational studies were found. Low-quality evidence (downgraded for risk of bias) from a single RCT(Werner 2002, 297) with 24 subjects showing no difference in the amount of erythema between cooled and noncooled burns (MD undeterminable). Low-quality evidence (downgraded for risk of bias) from a prospective observational study(Yava 2012, 544) with 48 patients showing a reduction in the number and depth of burns in those with cooling versus those without (12.5% versus 83.3%) (RR, 0.15; 95% CI, 0.05–0.44). Very-low-quality evidence (downgraded for indirectness) from a retrospective observational study(Nguyen 2002, 173) with 695 patients, reported an association between superficial burns and cooling and between deep burns and a lack of cooling (33.2% versus 48.5%) (RR, 0.68; 95% CI, 0.55–0.85). Very-low-quality evidence (downgraded for risk of bias) from a third observational study(Cuttle 2009, 1028) with 268 patients found no benefit in reducing depth of burns, as measured by the need for skin grafting, in the cooling versus control group (9.4% versus 10.7%; RR, 0.88; 95% CI, 0.35–2.21).Regarding the important outcome of need for advanced medical care, 3 observational studies were identified. Very-low-quality evidence (downgraded for risk of bias) from 1 observational study(Cuttle 2009, 1028) with 268 patients showing no reduction in the need for advanced medical care after scald burns (including number of follow-up visits and need for scar management) for patients who received 20 minutes or more of cooling versus those who did not (scar management 20.8% versus 20.9%; RR, 0.99; 95% CI, 0.55–1.78). Very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from another observational study(Sunder 1998, 444) comprising 125 patients, showing an association between the use of water for first aid cooling of burns and decreased average length of hospital stay (10.3 days versus 5.3 days) for patients with less than 20% body surface area burns. It also showed a higher percentage of inpatient stays of less than 10 days in patients receiving first aid cooling of burns with water (88.5% versus 67.2%) (RR, 1.32; 95% CI, 1.09–1.6). In this study, adequate cooling time was defined as 10 minutes or more. Very-low-quality evidence (downgraded for indirectness and imprecision) from a third prospective observational study(Skinner 2004, 82) enrolling 244 patients showing a benefit of cooling by demonstrating that a community and media campaign that increased use of first aid cooling for burns from 40% to 59% was associated with a decreased percentage of burns requiring hospital admission (64.4% precampaign versus 35.8% postcampaign) (RR, 0.55; 95% CI, 0.42–0.73). Regarding the important outcome of wound healing, 1 observational study was found. Very-low-quality evidence (downgraded for risk of bias) from a single observational study(Cuttle 2009, 1028) showing no benefit in reducing re-epithelialization time for patients who received 20 minutes or more of cooling versus those who did not (MD undeterminable).Regarding the critical outcome of complications, and the low-priority outcomes of patient satisfaction and rates of fasciotomy, there were no human trials found.
Treatment Recommendation:
We recommend that first aid providers actively cool thermal burns (strong recommendation, low-quality evidence).Values, Preferences, and Task Force InsightsIn making this recommendation, we place higher value on decreased burn depth over the potential risk of infection or hypothermia. • Method/temperature of cooling: Forms of active cooling evaluated in this review included cool/cold nonfreezing water and mechanical devices (eg, cold probes, cooled gel pads), but there is no evidence to recommend a specific temperature or method of cooling. • Time of cooling: Literature from this review suggests that active cooling should take place as soon as possible for a minimum of 10 minutes. The risk of hypothermia from cooling large burns or in special populations is also unknown and was a topic of discussion within the task force.
CoSTR Attachments:
Cooling of Burns GRADE evidence profile2_n.docx    
Cooling of Burns SOF table2_n.docx    

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