The efficacy of Aloe vera, tea tree oil and saliva as first aid treatment for partial thickness burn injuries

Many alternative therapies are used as first aid treatment for burns, despite limited evidence supporting their use. In this study, Aloe vera, saliva and a tea tree oil impregnated dressing (Burnaid^®) were applied as first aid to a porcine deep dermal contact burn, compared to a control of nothing. After burn creation, the treatments were applied for 20 min and the wounds observed at weekly dressing changes for 6 weeks. Results showed that the alternative treatments did significantly decrease subdermal temperature within the skin during the treatment period. However, they did not decrease the microflora or improve re-epithelialisation, scar strength, scar depth or cosmetic appearance of the scar and cannot be recommended for the first aid treatment of partial thickness burns.     

The optimal temperature of first aid treatment for partial thickness burn injuries

Using our porcine model of deep dermal partial thickness burn injury, various cooling techniques (15 °C running water, 2 °C running water, ice) of first aid were applied for 20 minutes compared with a control (ambient temperature). The subdermal temperatures were monitored during the treatment and wounds observed and photographed weekly for 6 weeks, observing reepithelialization, wound surface area and cosmetic appearance. Tissue histology and scar tensile strength were examined 6 weeks after burn. The 2 °C and ice treatments decreased the subdermal temperature the fastest and lowest, however, generally the 15 and 2 °C treated wounds had better outcomes in terms of reepithelialization, scar histology, and scar appearance. These findings provide evidence to support the current first aid guidelines of cold tap water (approximately 15 °C) for 20 minutes as being beneficial in helping to heal the burn wound. Colder water at 2 °C is also beneficial. Ice should not be used.     

Acute effects of local cold therapy in superficial burns on pain,in vivo microcirculation,edema formation and histomorphology

Background

Local cold therapy for burns is generally recommended to relief pain and limit tissue damage, however, there is limited data of its physiological benefit. This study aimed to evaluate pathophysiological effects of cold therapy in superficial burn on microcirculation, edema formation, and histomorphology.

Methods

In 12 volunteers (8f, 4m; aged 30.4 ± 14.1 years) circumscribed superficial burn was induced on both hand back and either left untreated as control (control-group) or treated by local-cold-application (cold-treatment-group). Prior to burn (t0), immediately (t1), 15 min (t2), and 30 min (t3) following cold therapy, following parameter was evaluated using intravital-microscopy; epidermal-thickness (ET), granular-cell-size (GCS), individual-blood-cell-flow (IBCF), and functional-capillary-density (FCD).

Results

Both ET and GCS increased significantly more in control-group and slightly in cold-treatment-group in t1, while turns to insignificant t2 onwards. IBCF and FCD raised up in control-group compared to dramatically decrease in cold-treatment-group in t1. In t2 both parameter remains in control-group and increased in cold-treatment-group. Comparison of both groups for IBCF and FCD indicates significant difference in t1 and t2, however, insignificant in t0 and t3.

Conclusions

Microcirculation, edema formation, and histomorphology of superficial burn has been significantly influenced through immediate cold therapy, however, this alterations are transient and turns to ineffective after 30 min.     

The evaluation of a clinical scar scale for porcine burn scars

This study describes the evaluation of a clinical scar scale for our porcine burn scars, which includes scar cosmetic outcome, colour, height and hair, supplemented with reference porcine scar photographs representing each scar outcome and scar colour scores. A total of 72 porcine burn scars at week 6 after burn were rated in vivo and/or on photographs. Good agreements were achieved for both intra-rater reliability (correlation is 0.86–0.98) and inter-rater reliability (ICC = 80–85%). The results showed statistically significant correlations for each pair in this clinical scar scale (p < 0.01), with the best correlation found between scar cosmetic outcome and scar colour. A multivariate principle components analysis revealed that this clinical scar assessment was highly correlated with scar histology, wound size, and re-epithelialisation data (p < 0.001). More severe scars are clinically characterised by darker purple colouration, more elevation, no presence of hair, histologically by thicker scar tissue, thinner remaining normal dermis, are more likely to have worse contraction, and slower re-epithelialisation. This study demonstrates that our clinical scar scale is a reliable, independent and valuable tool for assessing porcine burn outcome and truthfully reflects scar appearance and function. To our knowledge, this is the first study demonstrating a high correlation between clinical scar assessment and scar histology, wound contraction and re-epithelialisation data on porcine burn scars. We believe that the successful use of porcine scar scales is invaluable for assessing potential human burn treatments.     

Duration of cooling with water for thermal burns as a first aid intervention: A systematic review

BackgroundCooling thermal burns with running water is a recommended first aid intervention. However, guidance on the ideal duration of cooling remains controversial and inconsistent across organisations.AimTo perform a systematic review of the evidence for the question; Among adults and children with thermal burn, does active cooling using running water as an immediate first aid intervention for 20 min or more, compared with active cooling using running water for any other duration, change the outcomes of burn size, burn depth, pain, adverse outcome (hypothermia) or complications?MethodWe searched Medline, Embase, Cochrane Database of Systematic Reviews and used ROBINS-I to assess for risk of bias. We used Grading of Recommendations, Assessment, Development and Evaluation methodology for determining the certainty of evidence. We included all studies that compared the selected outcomes of the duration of cooling of thermal burns with water in all patient ages. (PROSPERO registration number: CRD42021180665). From 560 screened references, we included four observational studies. In these studies, 48% of burns were cooled for 20 min or more. We found no benefit for a duration of 20 min or more of cooling when compared with less than 20 min of cooling for the outcomes of size and depth of burn, re-epithelialization, or skin grafting. The evidence is of very low certainty owing to limitations in study design, risk of bias and indirectness.ConclusionThe optimal duration of cooling for thermal burns remains unknown and future prospective research is indicated to better define this treatment recommendation.     

Tissue expansion for correction of scars due to burn and other causes: A retrospective comparative study of various complications

Background

Tissue expansion is associated with a relatively high complication rate. The aim of this study was to quantify the complication risk of burn scar patients who underwent tissue expansion in comparison to patients with other indications such as skin tumors. Furthermore it was attempted to compare the complication rates in children and adults.

Methods

A retrospective analysis was performed on 148 expanders implanted in 73 patients during the years 1994–2011. Two patient cohorts (burn scar cohort n = 31 and other indication cohort n = 42) were identified and analyzed.

Results

27 male and 46 female patients with a median age of 21 years were included. No statistically significant difference for complication risk between the burn and other indication cohorts could be found (p = 0.1412). Statistical analyses revealed a higher complication rate (52%) in the lower limb compared to all other anatomic sites (29%) (p = 0.1746). In addition, statistical analyses revealed a significantly higher total complication rate in children younger than 10 years (p = 0.0043). Moreover a greater TBSA was accompanied by a higher complication rate (p = 0.0258).

Conclusion

This set of data suggests that the burn scar patient is at no greater risk to suffer complications from tissue expansion. Other factors like age, TBSA and anatomical site have far more influence on the expander complication rate than the initial indication for tissue expansion.     

Free medial thigh perforator flap for reconstruction of the dynamic and static complex burn scar contracture

Introduction

Dynamic and static complex scar contractures after burn commonly cause tendon adhesion, deep adipose tissue stiffness and further limitation of major joints motion. Skin autografting or locoregional flaps are not adequate reconstructive options, because of the easy recurrence and limitation of donor sites. Therefore, free perforator flaps are playing increasing role in reconstruction of complex scar contractures.

Patients and methods

The free medial thigh perforator (MTP) flap is an addition to the reconstructive armamentarium and is particularly useful since the medial thigh is commonly spared in burn injury. Between December 2001 and October 2005, eight patients with severe post-burn scar contractures received free MTP flaps treatment in the Linkou Burn Center. The free MTP flap harvest was modified to enhance its reliability and versatility. Flap sizes ranged from 5 × 15 cm to 8 × 24 cm. The follow-up period was from 12 to 26 months. Flap harvest is rapid, averaging 37.8 min.

Results

The significantly improved range of motion of the contracture joints approximated to normal activity at 6–22-month follow-up (p < 0.05). No free major MTP flap complication was noted, except for mild marginal necrosis in one case.

Conclusion

The free MTP flap with new modified harvest is a good choice for dynamic an static complex scar contractures of major joints, due to short harvesting time and few variations of the pedicle. However, thick skin paddle was considered in secondary hand reconstruction.     

Moderate systemic hypothermia decreases burn depth progression

Background

Therapeutic hypothermia has been proposed to be beneficial in an array of human pathologies including cardiac arrest, stroke, traumatic brain and spinal cord injury, and hemorrhagic shock. Burn depth progression is multifactorial but inflammation plays a large role. Because hypothermia is known to reduce inflammation, we hypothesized that moderate hypothermia will decrease burn depth progression.

Methods

We used a second-degree 15% total body surface area thermal injury model in rats. Burn depth was assessed by histology of biopsy sections. Moderate hypothermia in the range of 31–33 °C was applied for 4 h immediately after burn and in a delayed fashion, starting 2 h after burn. In order to gain insight into the beneficial effects of hypothermia, we analyzed global gene expression in the burned skin.

Results

Immediate hypothermia decreased burn depth progression at 6 h post injury, and this protective effect was sustained for at least 24 h. Burn depth was 18% lower in rats subjected to immediate hypothermia compared to control rats at both 6 and 24 h post injury. Rats in the delayed hypothermia group did not show any significant decrease in burn depth at 6 h, but had 23% lower burn depth than controls at 24 h. Increased expression of several skin-protective genes such as CCL4, CCL6 and CXCL13 and decreased expression of tissue remodeling genes such as matrix metalloprotease-9 were discovered in the skin biopsy samples of rats subjected to immediate hypothermia.

Conclusions

Systemic hypothermia decreases burn depth progression in a rodent model and up-regulation of skin-protective genes and down-regulation of detrimental tissue remodeling genes by hypothermia may contribute to its beneficial effects.     

“Is the length of time in acute burn surgery associated with poorer outcomes?”

Background

Acute wound closure surgery improves outcomes, after burn particularly mortality, but also imposes physiological stress on the patient. The duration of surgery is associated with adverse outcomes in other populations. This study aimed to examine if extended acute burn surgery duration was associated with poorer in-hospital outcomes.

Methods

This retrospective cohort study included adult burn patients who required a single wound closure surgery at Royal Perth Hospital between 2004 and 2011. Multivariable regression analyses were used to assess the influence of patient and injury factors on surgery duration and length of stay (LOS).

Results

Surgery duration independently increased LOS (incidence rate ratio [IRR] = 1.004, p < 0.001). This translates to a predicted 13% increase in LOS for a 30 min increase in surgery ‘knife to skin’ time. Total body surface area (TBSA) was identified as a significant predictor of surgery duration (IRR = 1.047, p < 0.001), estimating that a 10% TBSA increase results in a 59% increase in surgery duration.

Conclusion

The results show that surgery duration is associated with LOS after adjusting for size of burn and other factors. The study justifies the need to explore strategies to reduce acute burn surgery duration.     

The correlation of in vivo burn scar contraction with the level of α-smooth muscle actin expression

This study describes the direct association of in vivo burn scar contraction with the level of α-smooth muscle actin (α-SMA) in scar tissue, in a porcine burn model. The expression of α-SMA was investigated in 100 biopsies from 44 6-week old burn scars and in 85 biopsies from 16 2-week old burn wounds. Statistical analysis showed that the levels of α-SMA in 6-week old scars were significantly negatively correlated to scar size (r = −0.68) and the higher levels of α-SMA were observed in smaller scars. Moreover, α-SMA was also found to be significantly positively correlated to re-epithelialisation time (r = 0.57) and scar thickness (r = 0.58) and higher levels of α-SMA were detected in thicker scars with delayed wound closure. Further statistical analysis revealed that scar contraction can be explained best by the level of α-SMA expression and partially by scar thickness. Other variables, such as different dressings and individual pig, may also partly contribute to scar contraction. At week 2 after-burn, the level of α-SMA expression in 16 burn wounds was significantly related to the depth of burns and wound healing outcome. To our knowledge, this is the first study to provide in vivo evidence of the association of α-SMA expression with scar contraction, scar thickness, re-epithelialisation time and the depth of burn in a large animal burn model with scars similar to human hypertrophic scar.     

Chemical burn to the skin: A systematic review of first aid impacts on clinical outcomes

Chemical burns can cause deep injury and subsequently significant scarring to the skin. The mechanism and pathophysiology of chemical burns is distinct to thermal burns, and recommended first aid approaches are consequently different. Twenty minutes of cool running water is an effective first aid measure to improve outcomes after thermal burn. For chemical burns to the skin, the recommendations are immediate water lavage for 60 min, removal of contaminated clothing if not stuck to the skin and then covering the wound with a sterile dressing. This review assesses the peer-reviewed literature to find the evidence behind the efficacy of cutaneous chemical burn first aid on short term outcomes such as length of hospital stay, depth of burn and longer-term outcomes such as scarring; in particular, the effect of immediate or early water lavage, and the effect of the duration of water lavage. Ocular chemical burns were not included in this review. The review suggests some evidence to support that the early application of cool water irrigation may reduce length of hospital stay and the extent of scarring. Community education should emphasize that water irrigation is recommended and that the earlier this happens, the better.     

Detection of changes of scar thickness under mechanical loading using ultrasonic measurement

The intervention of pressure therapy on management of hypertrophic scar (HS) after burn is based on the theoretical assumption that the mechanical force added onto the scar tissue will reduce the growth of myofibroblasts which create the collagen clusters and the interstitial space, and to realign fibrous tissues, thus reducing the thickness of HS. In this experimental study, a high frequency ultrasound imaging system (12 MHz) was applied to measure the real time changes of thickness of the post burn HS under a mechanical loading system with similar pressure generated to the scar tissue. The validity of the ultrasound system in measurement of the changes of scar thickness underneath the tissue was tested on the porcine skin in vitro followed by measurement of human skin in vivo. Results showed that the ultrasound measurement of thickness had both good validity (r² = 0.98, p < 0.0001) and good intra-rater reliability (ICC = 0.89). Then, the system was used to test the thickness of 14 human HS samples in vivo among 7 subjects. External loading force with similar pressure range (10–45 mmHg) was then applied to these scar samples via ultrasound probe with rectangular contacting area at 4 cm² and each loading force was maintained unchange for 2 min over the scar tissue. The real time scar thickness was documented. Results showed that the mean scar thickness was found to be significantly decreased when the loading force applied was increased from 5 to 35 mmHg (with 10 mmHg interval) (p < 0.001). A significant negative correlation between the pressure level and scar thickness was observed (r² = 0.96, p = 0.005). The decline of thickness was found more significant between 0 mmHg and 15 mmHg. The findings were in line with the postulate that pressure therapy is effective in reducing the thickness of HS. A long term followup study should be administered to determine the prolonged effect of pressure intervention.     

Burns in rural Kwa-Zulu Natal: Epidemiology and the need for community health education

Introduction

Burns are one of the leading causes of accidental deaths in South Africa. The northern Kwa-Zulu Natal (KZN) area, in which this study was conducted, has a population at high risk of burn. A large proportion of the population of KZN live in rural settlements and use traditional methods of cooking and heating. Children are often unsupervised or looked after by only slightly older children. This study investigates the need and potential focus of a health education programme within the setting of rural KZN.

Method

Examination of epidemiological data collected on 423 cases admitted to the Ngwelezana Hospital Burns Unit from 2008 to 2010.

Results

Children under the age of 12 were most at risk, making up 69.5% of all admissions. Most burns were caused in the home by incidents involving hot water and food (69.5%). Direct flame burns accounted for 19.6% of injuries and were more common with increasing age. Of the direct flame burns, 20.5% occurred during an epileptic seizure. Non-accidental injury accounted for 8.7% of burns.Public health awareness was assessed by investigating the use of first aid treatments, and the time delay between burn and presentation to hospital. First aid provision was attempted in 53.1% of cases. Only 1.1% of burn victims were treated with running water for 10 min or more. Other products commonly applied to the burn wound (31.7% of cases) included oil, ice or eggs, some of which are known to be harmful.The time from burn to presentation at hospital varied greatly. The median time of presentation for local residents was only 6 h; however, the median referral delay from a district hospital was 6 days. These factors have important consequences on the outcome of burns.

Conclusion

The implementation of a community health education programme which focuses on adults as well as children, has the potential to decrease both the incidence and morbidity associated with burns in rural KZN. The pattern of burns is similar to that seen in urban areas (mostly children, and mostly around the home), emphasising common risk factors and the potential for wide application of such a programme.     

Ultrasound assessed thickness of burn scars in association with laser Doppler imaging determined depth of burns in paediatric patients

This study describes the ultrasound assessment of burn scars in paediatric patients and the association of these scar thickness with laser Doppler imaging (LDI) determined burn depth. A total of 60 ultrasound scar assessments were conducted on 33 scars from 21 paediatric burn patients at 3, 6 and 9 months after-burn. The mean of peak scar thickness was 0.39 ± 0.032 cm, with the thickest at 6 months (0.40 ± 0.036 cm). There were 17 scald burn scars (0.34 ± 0.045 cm), 4 contact burn scars (0.61 ± 0.092 cm), and 10 flame burn scars (0.42 ± 0.058 cm). Each group of scars followed normal distributions. Twenty-three scars had original burns successfully scanned by LDI and various depths of burns were presented by different colours according to blood perfusion units (PU), with dark blue <125, light blue 125–250, and green 250–440 PU. The thickness of these scars was significantly different between the predominant colours of burns, with the thinnest scars for green coloured burns and the thickest for dark blue coloured burns. Within light blue burns, grafted burns healed with significantly thinner scars than non-grafted burns. This study indicates that LDI can be used for predicting the risk of hypertrophic scarring and for guiding burn care. To our knowledge, this is the first study to correlate the thickness of burns scars by ultrasound scan with burn depth determined by LDI.     

The use of AlloDerm on major burn patients: AlloDerm prevents post-burn joint contracture

In efforts to prevent and reduce joint contracture and scar formation after burn, we used the acellular human dermis (AlloDerm^®) as a dermal replacement in the acute stage. A total of 64 patients received AlloDerm^® graft selectively on joint areas during the study period from March, 2005 to July, 2007. From January to March, 2008, a total of 31 patients returned to our burn center to examine the functional results by measuring range of motion of joints. Additionally, the quality of grafted skin condition criteria of skin elasticity, scar thickness, trans-epidermal water loss, melanin and erythema level was measured in a total of 11 patients among them. By analyzing the limitation level of 55 joints excluding hand areas, we found that 24 joints (43.6%) showed no limitations, 12 joints (21.8%) showed limitations below 10%, 16 joints (29.1%) showed limitations between 10 and 19% and 3 joints (5.5%) showed limitations over 20%. The scar thickness of non-AlloDerm applied areas was 2.5 ± 0.9 mm and AlloDerm applied areas was 1.8 ± 0.7 mm (p = 0.396). Trans-epidermal water loss for non-AlloDerm applied areas was 20.9 ± 7.7 g/h/m² and AlloDerm applied areas was 10.8 ± 3.4 g/h/m² (p < 0.001). Erythema value for non-AlloDerm applied areas was 436.1 ± 65.8, whereas AlloDerm applied area was 394.4 ± 61.2 (p < 0.001). Acellular dermal matrix is a good option for treating major burns to prevent scar formation after burn and loss of joint function.     

Evaluation of the spontaneous breathing trial in burn intensive care patients

Background

The extubation failure rate in our burn patients is 30%.

Objective

To evaluate the influence of the 30 min spontaneous breathing trial on extubation outcome in burn patients.

Methods

A prospective, observational study in a burn intensive care unit. All adult patients requiring mechanical ventilation for >24 h and meeting the inclusion criteria underwent a 30 min spontaneous breathing trial (SBT). Extubation was undertaken after a successful SBT.

Results

Of 49 planned extubations, 9 failed (18%), much lower than the 30% extubation failure rate identified prior to the implementation of the SBT. The duration of ventilation was significantly shorter (p = 0.04) in the patients who passed a SBT and those who failed extubation were significantly older (p = 0.003). The logistic regression analysis identified that age independently predicted extubation outcome. Patients who failed extubation, after a successful SBT, had a significantly longer duration of ventilation (p = 0.0001) and ITU length of stay (p = 0.001).

Conclusions

The incidence of extubation failure was much lower and the duration of ventilation significantly shorter in patients who were extubated after a successful SBT. These findings support the use of the SBT in burn patients. Age independently predicts extubation outcome in burn patients who have passed a SBT.     

Determinants of burn first aid knowledge: Cross-sectional study

Introduction

This study investigated demographic factors, experience of burn/care and first aid course attendance as factors influencing burn first aid knowledge.

Methods

A cross-sectional study was undertaken using convenience sampling of members of sporting and recreation clubs. The main outcome measure was the proportion of correct responses to multiple-choice questions relating to four burn scenarios: (1) scald, (2) contact burn, (3) ignited clothing, and (4) chemical burn.

Results

A total of 2602 responses were obtained. Large gaps (30–50% incorrect answers) were identified in burn first aid knowledge across all scenarios. 15% more individuals gave correct answers if they had attended a first aid course compared to those who had not (p < 0.0001); this proportion increased if the course was undertaken within the previous five years (p < 0.0001) or contained a burns-specific component (p < 0.0001). Males and younger (≤25 years) and older (≥65 years) age-groups had relatively lower levels of burn first aid knowledge. Gender and age were significant predictors of first aid course attendance, with males and younger (≤25 years) and older (≥65 years) age-groups less likely to have attended a first aid course.

Conclusion

In this sample, first aid training undertaken within the last 5 years with a specific burns component was associated with enhanced burn first aid knowledge.     

Changes in cutaneous innervation in patients with chronic pain after burns

Background

Chronic pain is a common occurrence for burn patients and has significant impact on quality of life. However, the etiology is not well understood. Understanding the mechanisms underlying the restoration of sensory function and the development of chronic pain after burn is critical to improving long-term outcomes.

Objective

To determine whether cutaneous innervation in burn patients with chronic pain is altered when compared to patients without chronic pain.

Methods

Twelve patients with unilateral injury and who reported chronic pain were recruited. Each patient underwent sensory function testing and both scar and matched site uninjured skin biopsy. Biopsies were analyzed for total nerve density and nociceptive C-fiber density using immunohistochemistry. Results were compared to a control group of 33 patients with unilateral injury and no reported long-term pain.

Results

Sensory function was significantly diminished in scar compared to uninjured tissue in both study groups, but chronic pain patients did not have significantly diminished function when compared to control. Total nerve density was not significantly different between scar and uninjured sites in either group, or between groups. However, the density of nociceptive nerve fibers was significantly elevated in both uninjured (p = 0.0193) and scar sites (p = 0.0316) of the patients with chronic pain when compared to the control group.

Conclusions

This data suggests that differences in cutaneous innervation may contribute to chronic pain after burn. There also appears to be a systemic difference in cutaneous innervation extending to distal uninjured sites. Therefore efforts to affect cutaneous reinnervation after burn may lead to less patients experiencing chronic pain.     

235. Die Kaltwasserbehandlung frischer Verbrennungen

Zusammenfassung Die Mehrzahl der schweren Verbrennungen ist primär zweitgradig und wird erst innerhalb der folgenden Minuten durch Nachbrennen drittgradig. 5 min nach einer Verbrühung mit siedendem Wasser beträgt die Temperatur der verbrannten Haut immer noch über 50° C. Das sofortige Eintauchen in kühleres Wasser bewirkt neben einer deutlichen Schmerzlinderung eine Begrenzung von Ausdehnung und Tiefe der Verbrennung, sowie eine Senkung des Stoffwechsels mit verminderter Freisetzung von autolytischen Enzymen und Toxinen. Das Schockstadium wird verkürzt, die Ödembildung verringert und das Allgemeinbefinden gebessert. Im Tierexperiment konnte die Mortalität bei Ratten nach drittgradiger Verbrühung durch sofortiges Eintauchen in 20° C kaltes Wasser von 65% auf 2,5% gesenkt und die Dauer des Schockstadiums von 24 auf 6 Std verkürzt werden, wie Messungen der Phagocytose-Aktivität mit Hilfe des CarbonClearance-Testes ergaben. Die Dauer der Epithelisierung war von 9,3 auf 1,8 Wochen verkürzt und frühes Haarwachstum war der Beweis, daß eine drittgradige Verbrennung verhindert worden war. Da die richtige Therapie in den ersten Minuten über die Tiefe der Verbrennung entscheidet, sollte die Kaltwasserbehandlung vor allem in Erste-Hilfe-Kursen, Mütterberatungen und entsprechenden Betrieben nachhaltig bekannt gemacht werden.

---

Cold water treatment of fresh burns

Summary The majority of severe burns are primarily of 2nd degree and become 3rd degree only within the following minutes through further-burning. 5 min after scalding with boiling water the temperature of the burned skin is still above 50° C. Immediate immersion in cooler water causes, besides a definite relief of pain, a limitation of the extent and depth of the burn as well as a reduction of the metabolism with reduced liberation of autolytic enzymes and toxins. The stage of shock is shortened, there is less oedema and the general condition improved. In animal experiments the mortality of rats after 3rd degree scalds was lowered from 65% to 2.5% by immediate immersion in cold water of 20° C and the duration of the stage of shock shortened from 24 h to 6 h as shown by estimation of phagoeytic activity with the carbon clearance test. The period of epithelialisation was shortened from 9.3 to 1.8 weeks and early growth of hair proved that 3rd degree burn had been prevented. Since correct treatment in the first few minutes determines the depth of the burn, cold water treatment should be thoroughly publicised in first aid courses, mother advice centres and working places.