Stop Cooling Those Burns

Do you ever get the feeling that everything you learned in EMT class was wrong? If you haven’t yet developed that feeling, then you probably haven’t been around long enough. Stick around. Sooner or later (depending on whether or not you are paying attention) you’ll start to feel that every treatment guideline you ever learned was somehow flawed. I’ve been in EMS education long enough now to start to feel that everything I ever taught was wrong.

Such is medicine.

And now I’m going to throw another curve ball at you. Do you remember when we told you to aggressively flush burns with copious amounts of sterile water? Yeah, well…um, stop doing that too. I’m sorry. We were apparently wrong about that.

I know. It runs counter to everything we taught you, right? I agree. I learned about aggressively cooling burns over two decades ago in my EMT class. Stop the burning process and then cool the burn by flushing it with copious amounts of water. Keep flushing until you arrive at the hospital.

Years later the treatment guideline backed off a bit on the flushing. We started emphasizing stopping the burning process and also warned students to guard the burn patient against hypothermia. It seemed that our aggressive cooling techniques were delivering a ridiculous percentage of burn patients to the hospital mildly hypothermic. Hypothermia is apparently not conducive to healing in the burn patient population.

I was just as guilty as anyone of pouring massive amounts of saline on significant burns until it ran out the back door of the medic unit and the patient shivered like they were having a seizure. So we put away our garden hoses and buckets of cold saline and transitioned to more localized cooling. Patient warm, burn cool. Got it.

Apparently that is incorrect as well.

As it turns out, burns seem to heal better when they remain warm. Our burn centers are now recognizing that burns that are cooled seem to have more extensive tissue damage and heal slower than burns that are allowed to remain at or slightly above body temperature.

The theory behind the delayed healing of excessively cooled burns is that excessive cooling may promote vasoconstriction in the region of the burn that limits the circulation of lipids, white blood cells and proteins that are essential to the healing and reconstruction of damaged tissue. Maintaining a healthy blood supply to the effected region is apparently more important than cooling the wound.

This doesn’t mean to stop putting water on burns. You still need to halt the burning process. But after the burning is stopped, further application of cool water, while it may be soothing to the patient, does not promote healing. Wrap the wound. Keep them warm. Protect the airway and transport to an appropriate facility.

Comments

  1. Hmmm. Maybe we’ll go back to applying butter to burns. Who’d have thunk it.

  2. Steve,
    Could you provide the sources of this info? I am looking at presenting this info to our medical director to update or protocol for burns and am having trouble finding anything with this info.

  3. Steve Whitehead says:

    @G G! Don’t do it! Well…not yet anyway.

    @Drew Yes, I imagined that question might be coming. Thanks for being the one to say it.

    This recommendation came from a burn unit nurse from Denver’s University Hospital Burn Unit. They are some top notch folks who do great work for us here. I learned this during a lecture series called Clinical Masters but the instructor is also a primary instructor for Advanced Burn Life Support. This is consistent with their guidelines. If you are taking this up the chain, I would use the national ABLS guidelines as your reference. Also, if you are looking to update your burn treatment protocols, get an authority from your local burn unit and a local ABLS instructor to back you up on this and review the entire protocol. Let me know how it goes.

    Check out this power point from the ABLS course and notice on the slide that says “treatment guidelines” the first bullet point says “Stop the burning process” but there is no mention of cooling. This is where our instructor gave the information about room temperature burn treatment. http://theemtspot.com/2013/03/18/stop-cooling-those-burns/#

  4. Thanks Steve

  5. Pennsylvania BLS Protocols are pretty consistent with this. Special consideration is to be taken with fire, chemical, or electricity. Wrapping the wound and preventing hypothermia has been protocol for awhile.

  6. ABLS over 20 yrs has been advocating this.

  7. Alan Rose says:

    Hmmm. And in five years this will be barbaric. FWIW when I burn myself cooking, I immediately put ice on it for a few minutes. A burn that used to blister now never even gets red or painful. Bad sunburn? I coat my skin with vinegar. It causes shivering but takes the “burn” out and in my experience has no adverse effect on healing time. I imagine the gold standard in pre-hospital burn care has yet to be identified.

  8. In Canada after the burn is cooled we wrap with Saran Wrap .

  9. Ironic that you would publish this article. My son was just burned with hot grease two days ago and is a burn unit with 12% 2nd degree burn of both his hands, both ankles, both calves, both thighs and his butt. I have been in EMS since 1998 and we have changed our treatments and changed it back again. I have been picking the brain of the burn team and have been told that the trauma surgeon hates EMS’s treatment for burns. Maybe tme for protocol changes . . .

  10. We use Saran Wrap too in my area. Came right from the Doctors at UW Madison.

  11. My father in law told me about 10 years ago to hold a burn near a light bulb, He did a lot of welding and found this Technic, that it would help. I thought he was crazy! well to say the least I got a bad burn so I decided to try it and guess what it hurt like hell!! when i did it ( placed the burn near the lamp)but it worked SO for the last ten years I’ve been sharing that story about using heat instead of cold for a burn.

  12. the emphasis of your claims (that you should not cool burns) are contrary to best available scientific evidence and can be misleading. this could lead to negative effects to patients.

    only in the last paragraph of your blog do you state you still need to cool – however this gets lost amongst the multiple parapgraphs beforehand which states strongly you should not cool burns.

    your message should be clearer “DO NOT OVERCOOL”

    as a burn clinician of 15 years, I am unaware of any scientific evidence that supports claims that burns should not be cooled. I would be grateful if you could provide references to scientific papers which suggests otherwise

    Nor am i aware of any scientific evidence which supports your claim “Our burn centers are now recognizing that burns that are cooled seem to have more extensive tissue damage and heal slower than burns that are allowed to remain at or slightly above body temperature.”

    the best available evidence (albeit not level 1 which is not available) suggests that cooling has positive effects on the inflammatory process and time to healing.

    best practice burn care based on scientific evidence recommends to cool the burn with cool running water BUT not excessively (not greater than 20 minutes) to minimise hypothermia. please let me know if you would like some scientific references to support

    cooling takes the heat out of the tissue and can help minimise damage

    warming the patient without cooling the burn first will not cause cessation of the burning process

    in australia our mantra is “cool the burn, warm the patient”

    Please refer to the plethora of scientific papers by Dr Leila Cuttle which are published in the burn scientific literature

    thanks

  13. I like Yvonne work in burns in Australia and have been for over 15 years. We are both burns nurses; are on faculty for our burn course and are on our bi-national prevention committee. We are constantly trying to educate people, clinicians and the general public, on good first aid for burns and it seems there is always a story somewhere which tries to contradict. Although you do refer to the importance of cooling at the end of the comment this is lost in the body of what you say and this can lead to confusion. Particularly evident with the comment just after about going back to using butter.
    As Yvonne said there has been a great deal of research conducted into burn first aid in Australia (by Cuttle et al). Extensive work comparing treatment options and duration. These look at the effects of first aid, including skin temperature, healing and histopathology. It has been shown that cooling for 20 mins has a beneficial effect on the burn. And keeping the mantra of “cool the burn, warm the patient” means that detrimental effects on the patient overall are minimised.
    Whilst we understand that there are many experts out there we must remember that we are doing multiple things when caring for burn patients. Obviously the first and foremost is keeping the patient alive and preventing complications. However minimising the effects of the burn is also important so the patient has the best possible outcome. By cooling the burn we stop the burning process and can salvage tissue that may have continued to convert to severe burns.
    Hopefully we can all work together to achieve the best possible option for our patients.
    Most importantly – Prevention is better than cure

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