FIRST-AID TREATMENT OF BURNS: WATER COOLING EFFICACY OF By N. RAGHUPATI, F.R.C.S. Registrar, Burns Unit, Birmingham Accident Hospital FIRST AID for burns at the present time is limited to reducing the period of contact between the skin and the burning agent, covering the burned part with a clean dressing, reassurance of the patient and transport to hospital. Other measures have been advocated from time to time, however, such as cold water compresses (Whitaker, I96O), immersion in cold milk (Willington, I96O), application of egg albumen (Fry, 196o) and dabbing the area repeatedly with a gauze swab soaked in surgical spirit (Thomas, 196o). The beneficial effects claimed for these procedures are the absence of subsequent blistering and disappearance of erythema. Many of the clinical burns treated in this way are trivial, and it is impossible to prove that the course would have been different in the absence of such treatment. Immersion of a recent burn in cold water certainly gives immediate temporary relief from pain (Colebrook et al., I944), and 0feigsson (1959, 1965) working with scalded rats, has presented considerable experimental evidence supporting watercooling as a means of reducing tissue damage in a~limals. But the value of cooling has not been demonstrated with certainty for burns of human skin. A limited human experiment was therefore undertaken to see if there was any obvious value in cold-water immersion as a first-aid measure in thermal burns. METHODS The volar surface of the forearm was chosen as the test site for convenience. Burning.--Square burns were produced in a human volunteer by contact with solid brass blocks heated to 65 C. by immersion in a constant-temperature water bath. The blocks were I "9 x I "9 x 3"8 cm., and the pressure of application was the weight of the block (I2O g.). The period of contact was 15 seconds. This resulted in a deep partial skin-loss burn healing in two to three weeks depending on the particular texture of the skin treated. The choice of temperature and duration was arrived at after reference to available charts relating temperature and duration of burning to depth of necrosis (Bull, 1963), due consideration being given to reproducibility. Cooling.--Two experiments were made; in each experiment two burns were produced on each forearm to eliminate chance variation ; one forearm was cooled, the other serving as a control. In the first experiment the burned forearm was immersed in cold water at 17 C. for one hour, starting one minute after burning. In the second experiment the period of immersion was prolonged to two hours, and the forearm which had been the control in the first experiment was the one burned and cooled. Water at 17 C. is easily tolerated and readily available, being only slightly colder ~ than water from the tap. The temperature of the cold-water bath was kept constant by periodic addition of ice water after removing some of the water from the bath. 68
FIRST-AID TREATMENT OF BURNS : EFFICACY OF W A T E R COOLING 69 RESULTS I. P a i n. - - T h e cooled forearm felt comfortable, while a burning sensation was experienced for about 15 minutes in the control burn. Once the cooled forearm was taken out of water the burn on it became uncomfortable and felt more painful than the control ; this lasted for about an hour. When the forearm was treated with two hours' FIG, I ( E d e m a w a s d e m o n s t r a t e d by p r e s s u r e o n t h e b u r n w i t h a glass slide. O n e h o u r after i m m e r s i o n t h e degree of cedema was less m a r k e d in t h e cooled r i g h t arm. FIG. 2, T h r e e h o u r s after b u r n i n g (and two h o u r s after cooling) t h e oedema of t h e control b u r n h a d increased, a n d t h e eedema o f t h e cooled b u r n h a d c a u g h t u p with it. immersion, the only difference noted was in the lesser degree of soreness experienced after withdrawal from cold water. 2. Redness and edema of the burn appeared within IO minutes of burning on the control forearm but were much less marked on the cooled forearm while it was still in the bath (Fig. I). This was obvious on simple inspection, but pitting produced
7o B R I T I S H JOURNAL OF P L A S T I C SURGERY by uniform pressure with a glass slide was used to demonstrate the cedema photographically. An hour after removal from the bath the degree of eedema was equal in the two burns (Fig. 2). FIG. 3 Appearance on sixth p o s t - b u m day showing loose wrinkled epidermis and scab formation in some areas. FIG. 4 Healed burns on sixteenth day. 3. Blister formation did not appear until 36 to 48 hours after burning. It was variable in extent, but there was wrinkling and loose attachment of the epidermis over the rest of the burn. Blistering was not influenced by treatment. The burns were
FIRST-AID TREATMENT OF BURNS: EFFICACY OF WATER COOLING 71 left exposed, being covered only by normal clothing. Where the loose epidermis was rubbed off due to accidental trauma a scab formed (Fig. 3). 4. Healing.--The burns on the control and cooled forearms were all healed by the I5th day, i.e. the scabs had come off and the burn was epithelialised. There was no difference in the time taken for healing (Fig. 4). The areas of burn which healed underneath unbroken though necrotic epidermis seemed to have a better texture than those where healing had occurred underneath scabs following accidental removal of epidermis during the early post-burn period. No signs of clinical infection were encountered in any of the burns. DISCUSSION Two obvious local effects following immersion in cold water were investigated in the above experiment. I. Reduction of Fluid Loss and Consequent (Edema.--Shulman and Wagner (1962) have shown in a controlled experiment using scalded rabbit's limbs, that substantial reduction of cedema occurred as a result of immersion in cold water at IO to 15 C. But to maintain this effect it is necessary to keep the parts cooled for the entire period of expected oedema formation. This observation was confirmed: although local oedema was significantly less on the cooled forearm, the effect was temporary and the oedema soon became as marked as on the control forearm when it was taken out of the bath. 2. Reduction of Damage.--Ofeigsson found a significant reduction in mortality and depth of damage especially at water temperature between 22 and 3 0 C., the duration of immersion varying from 3 minutes at 25 C. to 30 minutes at 3 C. He observed this beneficial effect even when the treatment was delayed for 15 to 45 minutes, but cooling temperatures lower than 20 C. were found to be harmful to these small animals and were attended with a high mortality varying from 5 z per cent. at 15 C. to 82 per cent. at o C. On the strength of his experimental evidence in rats and clinical impressions, he advocated cold-water immersion as first-aid treatment for burns, a procedure which has been traditional in Iceland for a long time. In the present investigation, necessarily of a limited nature, the healing time was used as a criterion for the degree of damage in control and treated (by cold water immersion) burns. No difference was noted between the two. The temperature of the cold-water bath and period of immersion can be varied endlessly, but lower temperatures than tap water and/or prolonged immersion would appear to be neither practical nor desirable, especially in burns of any great extent. There is some evidence from cell respiration studies (Lawrence and Ricketts, 1957) that skin partially damaged by heat does not sustain the total amount of damage at the time of heating, as shown by a progressive decrease in respiration. But it is debatable whether this progressive damage can be arrested by external measures such as cooling. However, it would be interesting to know the effect of cooling on skin damage at the cellular level. CONCLUSION Cold-water immersion following burns affords relief of pain and produces temporary suppression of fluid loss. Reduction in the depth of skin damage was not shown in this experiment and if it does occur is probably small and of no practical value.
72 BRITISH JOURNAL OF PLASTIC SURGERY I am grateful to Mr D. M. Jackson, for his stimulus and advice throughout the above investigation, and helpful criticism in the preparation of this article. My thanks are also due to Dr J. C. Lawrence (M.R.C. Unit) and Dr. B. E. Zawacki for their technical help during the above experiments. REFERENCES BULL, J. P. (1963). Post-grad. med. J., 39, 717. COLEBROOK, L. et al. (1944). Spec. Rep. Ser. med. Res. Coun., No. 249. FRY, A. (196o). Br. med. J., 2, 539. LAWRENCE, J. C., and RICKETTS, C. R. (1957). Expl cell Res., I2,~633. OFEIGSSON, O. J. (1959). Br. J. plast. Surg., 12, lo4. -- (1965). Surgery, 57, 391. SHULMAN, A. G., and WAGNER, K. (1962). Surgery Gynec. Obstet., I15, 557. THOMAS, K. (196o). Br. med. J., 2, 739. WHITAKER, A. J. (196o). Br. med. J., 2, 16o3. WILLINGTON, F. L. (196o). Br. reed. J., 2, 277.