Nizamoglu et al. Burns & Trauma (2016) 4:36 DOI 10.1186/s41038-016-0060-x RESEARCH ARTICLE Open Access Cold burn injuries in the UK: the 11-year experience of a tertiary burns centre Metin Nizamoglu1*, Alethea Tan1, Tobias Vickers2, Nicholas Segaren1, David Barnes1 and Peter Dziewulski1 Abstract Background: Guidance for the management of thermal injuries has evolved with improved understanding of burn pathophysiology. Guidance for the management of cold burn injuries is not widely available. The management of these burns differs from the standard management of thermal injuries. This study aimed to review the etiology and management of all cold burns presenting to a large regional burn centre in the UK and to provide a simplified management pathway for cold burns. Methods: An 11-year retrospective analysis (1 January 2003–31 December 2014) of all cold injuries presenting to a regional burns centre in the UK was conducted. Patient case notes were reviewed for injury mechanism, first aid administered, treatment outcomes and time to healing. An anonymized nationwide survey on aspects of management of cold burns was disseminated between 13 July 2015–5 October 2015 to British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) and Plastic Surgery Trainees Association (PLASTA) members in the UK. Electronic searches of MEDLINE, EMBASE and the Cochrane Library were performed to identify relevant literature to provide evidence for a management pathway for cold burn injuries. Results: Twenty-three patients were identified. Age range was 8 months–69 years. Total body surface area (TBSA) burn ranged from 0.25 to 5 %. Twenty cases involved peripheral limbs. Seventeen (73.9 %)cases were accidental, with the remaining six (26.1 %) cases being deliberate self-inflicted injuries. Only eight patients received first aid. All except one patient were managed conservatively. One case required skin graft application due to delayed healing. We received 52 responses from a total of 200 questionaires. Ninety percent of responders think clearer guidelines should exist. We present a simplified management pathway based on evidence identified in our literature search. Conclusions: Cold burns are uncommon in comparison to other types of burn injuries. In the UK, a disproportionate number of cold burn injuries are deliberately self-inflicted, especially in the younger patient population. Our findings reflect a gap in clinical knowledge and experience. We proposed a simplified management pathway for managing cold burn injuries, consisting of adequate first aid using warm water, oral prostaglandin inhibitors, deroofing of blisters and topical antithromboxane therapy. Keywords: Cold burn, Guideline, Survey, Treatment * Correspondence: [email protected] This work has been presented at the 16th European Burn Association Congress 2015, Hannover, Germany. 1St Andrew Plastics and Burns Unit, Court Road, Chelmsford CM1 7ET, UK Full list of author information is available at the end of the article © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Nizamoglu et al. Burns & Trauma (2016) 4:36 Page 2 of 8 Background Methods Guidance for the management of thermal injuries has An 11-year retrospective analysis (1 January 2003–31 evolved accordingly with improved understanding of the December 2014) of all cold injuries presenting to a large pathophysiology of burn injuries. Extensive research has regional burn centre in the UK was conducted. All pa- been conducted to improve management of thermal tients admitted during this time period with diagnostic burns. Whist the national guidelines for burn resuscita- codes for ‘cold burns’, ‘frosbite’ and ‘cold injury’ were col- tion have been clearly outlined worldwide and taught lated onto an Excel spreadsheet. Out of a total of 11,468 through internationally recognized courses such as the burns patients treated during the study period, 23 were Emergency Management of Severe Burns (EMSB) identified as having cold injuries. The medical case notes course, we feel that national guidance for the manage- were scrutinized for accuracy of documentation of first ment of cold induced burn injuries is not widely avail- aid, patient demographics, management provided and able to clinicians. This may be partly because these defined outcomes, conservative or surgical management injuries are relatively uncommon in comparison to other and healing times. forms of burn injuries. An online anonymized national survey on aspects of Frostbite or cold burn is the medical condition in management of cold burns was disseminated nationwide which localized damage is caused to skin and other between 13 July 2015–5 October 2015 to plastic surgery tissues due to freezing. Cold burns can occur through department staff and members of the British Association of a variety of mechanisms ranging from prolonged Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) exposure in a cold environment to the self-inflicted and the Plastic Surgery Trainees Association (PLASTA). In wounds from a seemingly benign aerosol can. The total, 200 questionnaires were distributed. The survey management of these burns differs from the standard questions consisted of a subjective perception of compe- management of thermal injuries. We performed a tence to treat cold-induced burns, whether specific training study to review our experience with the assessment has been provided, the frequency of encountering cold and treatment of cold burn injuries. Additionally, a burns, awareness of any topical therapies for cold burn in- nationwide survey was disseminated to plastic juries, the need for clearer guidance on the management of surgeons in the UK to assess the current level of cold burns and lastly if further training in the management knowledge regarding managing cold burn injuries. We of this condition would be beneficial (Additional file 1). also conducted a review of current literature to pro- This piece of work has been registered with the hospital’s vide a simplified management pathway of cutaneous clinical governance department. cold injuries. Our recommendations are based on Electronic searches of MEDLINE, EMBASE and the evidence graded using the American College of Chest Cochrane Library were undertaken in Jan 2016 using dif- Physicians (ACCP) classification criteria for grading ferent combinations of the words "cold" "burns" "injury" evidence in clinical guidelines (see Table 1) [1]. This "frostbite" "management" "review" and "treatment". Rele- article focuses more on the cutaneous manifestation vant articles were independently selected from titles and and treatment of cold injury rather than deep injury. abstracts and then from the full text of the manuscript. Table 1 ACCP classification criteria for grading evidence in clinical guideline Grade Description Benefits vs. risks and burdens Methodological quality of supporting evidence 1A Strong recommendations, high-quality Benefits clearly outweigh risks and RCTs without important limitations or overwhelming evidence burdens or vice versa evidence from observational studies 1B Strong recommendation, moderate-quality Benefits clearly outweigh risks and RCTs with important limitations or exceptionally strong evidence burdens or vise versa evidence from observational studies 1C Strong recommendation, low-quality or Benefits clearly outweigh risks and Observational studies or case series very low-quality evidence burdens or vise versa 2A Weak recommendation, high-quality Benefits closely balanced with risks RCTs without important limitations or overwhelming evidence and burdens evidence from observational studies 2B Weak recommendation, moderate-quality Benefits closely balanced with risks RCTs with important limitations or exceptionally strong evidence and burdens evidence from observational studies 2C Weak recommendation, low-quality or Uncertainty in the estimates and Observational studies or case series very low-quality evidence burden; benefits, risks and burden may be closely balanced ACCP American College of Chest Physicians, RCTs randomized controlled trials Nizamoglu et al. Burns & Trauma (2016) 4:36 Page 3 of 8 Further articles that were missed by the search were This most common mechanism was deodorant sprays, identified by a manual search of the references of key followed by direct prolonged contact with ice packs. articles. Other less frequent causes were iatrogenic cryotherapy treatment for skin lesions, environmental exposure, industrial-related accidents and dry ice contact. Our Results results show that 8 (34.8 %) of patients received first aid, Our experience in the management of cold burns consisting of warm or tepid running water. Only 3 Twenty-three patients were identified from the database. (13 %) of patients wore protective equipment consisting Patient details are summarized in Table 2. Mean age was of one or more of the following; gloves, eye goggles, – 30 years (range 0.67 69 years). Mean total body surface aprons and / or protective footwear.