active cooling of burns compared to passive cooling of burns for adults and children with thermal burns
Patient or population: adults and children with thermal burns
Settings: in and out of hospital
Intervention: active cooling of burns
Comparison: passive cooling of burns
Outcomes
pain at 2 hours (Yava 2011)
VAS pain scale
Follow-up: 1 days
Illustrative comparative risks* (95% CI)
Assumed risk
Corresponding risk
Passive cooling of burns
Active cooling of burns
The mean pain at 2 hours (yava 2011) in the The mean pain at 2 hours (yava 2011) in the
control groups was
intervention groups was
34.5 mm on a 100mm VAS
0 higher
(0 to 0 higher)1
pain at 4 hours (Yava 2011)
The mean pain at 4 hours (yava 2011) in the The mean pain at 4 hours (yava 2011) in the
VAS pain score
control groups was
intervention groups was
35.5 mm on a VAS 100mm scale
0 higher
Follow-up: 1 days
(0 to 0 higher)1
pain from the burn a 24 hours (Yava The mean pain from the burn a 24 hours
The mean pain from the burn a 24 hours (yava
2011)
(yava 2011) in the control groups was
2011) in the intervention groups was
36 mm on a VAS 100mm scale
0 higher
VAS pain score (0-100mm)
Follow-up: 1 days
(0 to 0 higher)1
complication of pain from cooling
The mean complication of pain from cooling The mean complication of pain from cooling
(Werner 2002)
(werner 2002) in the control groups was
(werner 2002) in the intervention groups was
0 higher
Visual analogue scale VAS. Scale from: 0 VAS
0 to 100.
(0 to 0 higher)3
Follow-up: 30 minutes
hyperalgesia of burn and surrounds The mean hyperalgesia of burn and
The mean hyperalgesia of burn and surrounds
(Werner 2002)
surrounds (werner 2002) in the control groups (werner 2002) in the intervention groups was
0 higher
measured area of secondary
was
0 area (sq cm)
hyperalgesia
(0 to 0 higher)3
Follow-up: 160 minutes
mechanical pain threshold (Werner The mean mechanical pain threshold (werner The mean mechanical pain threshold (werner
2002)
2002) in the control groups was
2002) in the intervention groups was
0 von Frey number
0 higher
von Frey number
Follow-up: 160 minutes
(0 to 0 higher)3
mechanical pain response in burn
The mean mechanical pain response in burn area
area (Werner 2002)
(werner 2002) in the intervention groups was
0 higher
VAS
Follow-up: 160 minutes
(0 to 0 higher)3
erythema of the burn (Werner 2002) The mean erythema of the burn (werner
The mean erythema of the burn (werner 2002) in
erythema index measured on
2002) in the control groups was
the intervention groups was
0 AUC of erythema index graphs
Relative
effect
(95% CI)
No of
Participants
(studies)
Quality of the
evidence
(GRADE)
48
(1 study2,3)
⊕⊕⊝⊝
low4,5,6
48
(1 study2,3)
⊕⊕⊝⊝
low4,5,6
48
(1 study2,3)
⊕⊕⊝⊝
low4,5,6
48
(1 study7)
⊕⊕⊕⊝
moderate8
48
(1 study7)
⊕⊕⊝⊝
low8,9
48
(1 study7)
⊕⊕⊝⊝
low8,9
48
(1 study7)
⊕⊕⊝⊝
low8,9
48
(1 study7)
⊕⊕⊝⊝
low8,9
Comments
spectrophotometry
Follow-up: 160 minutes
healing time in contact burns (Cuttle The mean healing time in contact burns
2009)
(cuttle 2009) in the control groups was
6.9 days
days to re-epithelialization
healing time in scald burns (Cuttle
2009)
re-epithelial time
13
need for advanced care in flame
burns (Cuttle 2009)
number of followup hospital visits14
15
need for medical care in scald burns
(Cuttle 2009)
number of followup hospital visits
13
need for medical care in scald
patients (Cuttle 2009)
>1month scar management care
Study population
13,15
209 per 1000
0 higher
(0 to 0 higher)3,10
The mean healing time in contact burns (cuttle
2009) in the intervention groups was
6.90 lower
(9.49 to 4.31 lower)
The mean healing time in scald burns (cuttle 2009)
in the intervention groups was
0 higher
(0 to 0 higher)3
The mean need for advanced care in flame burns
(cuttle 2009) in the intervention groups was
0 higher
(0 to 0 higher)3
The mean need for medical care in scald burns
(cuttle 2009) in the intervention groups was
0 higher
(0 to 0 higher)3,16
130
(1 study11)
⊕⊝⊝⊝
very low12
224
(1 study11)
⊕⊝⊝⊝
very low12
32
(1 study11)
⊕⊝⊝⊝
very low12,14
224
(1 study11)
⊕⊝⊝⊝
very low12
207 per 1000
(115 to 373)
RR 0.99
(0.55 to
1.78)
268
(1 study11)
⊕⊝⊝⊝
very low12
94 per 1000
(37 to 236)
RR 0.88
(0.35 to
2.21)
268
(1 study11)
⊕⊝⊝⊝
very low12
13 per 100
(4 to 37)18
RR 0.15
(0.05 to
0.44)
48
(1 study2)
⊕⊕⊝⊝
low4,6
RR 0.68
(0.55 to
0.85)
695
(1 study)
⊕⊝⊝⊝
very low19
Low
13,15
burn severity all burn types (Cuttle
2009)
need for grafting
Study population
107 per 1000
Low
development of burn after
cardioversion (Yava 2011)
grading protocol for burn
Follow-up: 2 hours post burn
Study population
17
83 per 100
Low
17
development of a deep burn (Nguyen Study population
2001)
485 per 1000
assessment of burn severity
Low
18
330 per 1000
(267 to 412)
number requiring hospital admission Study population
after burn (Skinner 2003)
645 per 1000
Follow-up: 6 months
Low
355 per 1000
(271 to 471)
RR 0.55
(0.42 to
0.73)
244
(1 study)
⊕⊝⊝⊝
very low20,21
length of stay < 10 days (Sunder 1998)
length of stay < 10 days in patients admitted with <20% BSA burn
Study population
672 per 1000
887 per 1000
(732 to 1000)
RR 1.32
(1.09 to 1.6)
125
(1 study)
⊕⊝⊝⊝
very low12,19,21
Low
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk
in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
1
Median values given, not mean and SD, but significant according to the paper
Ayla Yava. Cooling after cardioversion
3
Unable to calculate mean and SD from the data given in the study
4
Risk of bias with basline care of burns as study done using resptrospective control group, ie before intervention.
5
Patients not blinded to intervention.
6
Cooling appeared to reduce not just the incidence of the burns but the severity of the burns
7
Mads Werner. Local cooling does not prevent hyperalgesia following burn injury in humans (legs burnt and cooled with probes)
8
Study only single blinded. Only subjects, not assessors, were blinded to which burns had been cooled. 21/24 subjects also correctly identified which leg burn had been cooled.
9
Study downgraded for indirectness as the burns induced were very superficial. No evidence of the burn was visible at 48 hours post burn. Size of hyperalgesic area of burn and surround
extrapolated to indicated size/breadth of burn. Results may not correspond to deeper burns.
10
Burn caused erythema. Erythema reduced in 160 minutes post burn. No difference in cooled vs control groups.
11
Leila Cuttle. An audit of first aid treatment of pediatric burns patients and their clinical outcomes.
12
Retrospective audit. Missing information.
13
Raw data not given. Study text states cooling not associated with any improved outcomes.
14
Only 2 patients in intervention group. 30 in control. Numbers too small to make conclusion
15
Raw data not given to include figures
16
Study states no difference in number of hospital visits in control and cooled group
17
Of the 20 burns in the control group, 15 were superficial and 5 were second degree
18
All burns superficial in intervention group
19
Fails to appreciate that superficial burns are more painful than deep burns so more likely to be given first aid cooling
20
Intervention was a whole burns first aid campaign. Difficult to give sole influence to the cooling information.
21
Downgraded for imprecision due to small numbers
2