What is the evidence for cold water irrigation in treating thermal burn injuries?

Cold Water Irrigation for Thermal Burns: Evidence and Recommendations

Thermal burns should be cooled immediately with clean running water for 5-20 minutes to reduce pain, depth of injury, and need for advanced medical care. 1

First Aid Treatment Recommendations

• Cooling of thermal burns should be done immediately with clean running water as the preferred method 1
• The recommended duration for cooling is 5-20 minutes 1
• Water temperature should be cool or cold (15°C to 25°C/59°F to 77°F), but not freezing 1
• Cooling with ice or ice water is not recommended as it can increase tissue damage 1
• If clean running water is not available, it may be reasonable to cool superficial burns (with intact skin) using ice wrapped in cloth 1

Benefits of Cold Water Irrigation

Cold water irrigation for thermal burns provides several important benefits:

• Reduces pain and edema 1
• Decreases depth of injury 1
• Speeds healing 1
• May reduce the need for excision and grafting of deep burns 1
• Associated with decreased percentage of burns requiring hospital admission 1

Special Considerations

Pediatric Patients

• Preadolescent children with thermal burns being actively cooled with running water should be monitored for signs or symptoms of hypothermia 1
• Children are at higher risk for hypothermia due to their larger body surface area relative to weight 1

Large Burns

• Large burns should not be cooled without the ability to monitor the victim's core temperature due to risk of hypothermia 1
• For large burns, the benefit of cooling must be balanced against the risk of inducing hypothermia 1

Post-Cooling Care

• After cooling, small partial-thickness burns being managed at home may be treated with petrolatum, petrolatum-based antibiotic ointment, honey, or aloe vera and a clean nonadherent dressing 1
• For burns awaiting professional evaluation, loosely cover with a clean cloth or nonadherent dry dressing after cooling 1
• Burn blisters should be left intact as this improves healing and reduces pain 1

When to Seek Medical Care

Burns requiring medical evaluation include those:

• With blistering or broken skin 1
• Involving the face, hands, feet, or genitals 1
• Covering >10% body surface area (>5% in children) 1
• With signs of inhalation injury (facial burns, difficulty breathing, singed nasal hairs, soot around nose/mouth) 1
• All full-thickness (third-degree) burns 1

Common Pitfalls to Avoid

• Using ice directly on burns can cause tissue ischemia and increase damage 1, 2
• Delaying cooling beyond 30 minutes after injury significantly reduces benefits 1
• Prolonged cooling of large burns without monitoring core temperature can lead to hypothermia 1
• Using very cold water (2°C) may be beneficial but increases hypothermia risk compared to cool water (15°C) 2
• Neglecting to remove jewelry before swelling occurs can lead to vascular ischemia 1

Scientific Evidence Quality

The recommendation for cold water irrigation is supported by multiple guidelines and research studies:

• Meta-analysis of observational data (7 studies, 11,383 adults and children) shows decreased need for subsequent care in patients with thermal burns who receive immediate cooling with clean running water 1
• Evidence from retrospective studies and animal experiments demonstrates that cooling with water at room temperature within 30 minutes reduces pain, depth of injury, and need for grafting 1
• Experimental studies show that ice or ice water cooling can increase tissue damage compared to cool water 1, 2
• The optimal temperature appears to be around 15°C (cool tap water), though 2°C water may also be beneficial; ice should not be used 2