COLD INJURIESCOLD INJURIES

Epidemiology

• Caused by the inability to physiologically compensate for cold that produces injury.

• Duration of exposure, humidity, wind, altitude, clothing, medical conditions, behavior, and clothing, medical conditions, behavior, and individual variability are contributing factors.

• Inadequate clothing is the most preventable cause of cold related injuries with exposed head and neck accounting for 80% of heat loss.

Epidemiology

• Disease states as atherosclerosis, arteritis, hypovolemia, diabetes, vascular injury may predispose to cold-related injury.

• Dark-skinned people and those from • Dark-skinned people and those from warmer climates are more susceptible to frostbite

Local cold injuries result from Local cold injuries result from

decreased blood flow to, or freezing decreased blood flow to, or freezing

of, a body part.of, a body part.

These injuries are often called

frostbite or frostnip.

Local cold injury after thawing.Local cold injury after thawing.

FrostbiteFrostbite

FrostbiteFrostbite

�Symptoms

– initially redness in light skin or grayish in

dark skindark skin

– tingling, stinging sensation

– turns numb, yellowish, waxy or gray color

– feels cold, stiff, woody

– blisters may develop

Clinical features

• Classification of frostbite

• first degree is characterized by partial skin freezing, erythema, mild edema, lack of blisters, and occasional skin desquamation, has excellent and occasional skin desquamation, has excellent prognosis.

Clinical features

• second degree is characterized by full-thickness

skin freezing, formation of substantial edema over

3 to 4 h, and formation of clear blisters that

desquamate to form black eschars and has good desquamate to form black eschars and has good

prognosis.

Clinical Features

• third degree injury is characterized by damage that extends into the subdermal plexus and leads to formation of hemorrhagic blisters, skin necrosis and a blue-gray discoloration of skin, has poor and a blue-gray discoloration of skin, has poor prognosis

Clinical Features

• fourth degree injury is characterized by extension into subcutaneous tissues, muscle, bone, and tendon, there is little edema, nonblanching cyanosis, bloody blebs, has extrememly poor prognosis

Treatment in the field

• Remove wet and

constrictive clothing.

• Elevate and wrap in dry

sterile gauze the involved

• There is controversy with

regards to debridement of

clear blisters on the field

• Pain management should sterile gauze the involved

extremities.

• Rapid rewarming if rapid

access to hospital

• 400 to 420 C clean water

should be used

• Pain management should

start with NSAIDS to

counteract the arachidonic

acid cascade, in addition

to opioids

• Smoking should be

discouraged

Treatment in the ED

• Injured extremity should be placed in circulating water at a temperature of 400 to 420 C for approximately 10-30 min

• Hemorrhagic blisters should not be debrided

• Alo vera cream should be applied to the blisters

approximately 10-30 min until the distal extremity is pliable and erythematous

• Pain should be treated with parenteral antibiotics

• Clear blisters should be debrided or aspirated

• Role of antibiotics is unclear.

• Staph aureus, Staph epi, beta-hemolytic Strep, Pseudomonas, and Enterococus are important pathogens.

Treatment in ED

• Infection prophylaxis

using topical

bacitracin is as good

as IV penicillin.

• Early surgical

intervention is not

indicated in treatment

of frostbiteas IV penicillin.

• Tetanus immunization

status should be

assessed.

• Ibuprofen

of frostbite

• Amputation if needed

within 3 weeks

ChilblainsChilblains

� Nonfreezing cold injury

� Cold, wet conditions (between 32-60oF, high

humidity)

� Repeated, prolonged exposure of bare skin

� Can develop in only a few hours

� Ears, nose, cheeks, fingers, and toes

ChilblainsChilblains

�Symptoms:

– initially pale and colorless

– worsens to achy, prickly sensation then – worsens to achy, prickly sensation then

numbness

– red, swollen, hot, itchy, tender skin upon

rewarming

– blistering in severe cases

ChilblainsChilblains

�Treatment

– prevent further exposure

– wash, dry gently– wash, dry gently

– rewarm (apply body heat)

– don’t massage or rub

– dry sterile dressing

– seek medical aid

Trench/Immersion Foot Trench/Immersion Foot

�Potentially crippling, nonfreezing injury (temps from 50oF-32oF)

�Prolonged exposure of skin to moisture �Prolonged exposure of skin to moisture (12 or more hours, days)

�High risk during wet weather, in wet areas, or sweat accumulated in boots or gloves

Trench/Immersion FootTrench/Immersion Foot

� Symptoms

– initially appears wet, soggy, white, shriveled

– sensations of pins and needles, tingling,

numbness, and then painnumbness, and then pain

– skin discoloration-red, bluish, or black

– becomes cold, swollen, and waxy appearance

– may develop blisters, open weeping or bleeding

– in extreme cases, flesh dies

Trench/Immersion FootTrench/Immersion Foot

Trench/Immersion FootTrench/Immersion Foot

� Treatment

– prevent further exposure

– dry carefully

– DO NOT break blisters, apply lotions, massage, – DO NOT break blisters, apply lotions, massage,

expose to heat, or allow to walk on injury

– rewarm with body heat

– clean and wrap loosely

– elevate feet to reduce swelling

– evacuate for medical treatment

Trench/Immersion FootTrench/Immersion Foot

� Prevention

– keep feet dry

– change socks at least every 8 hours or – change socks at least every 8 hours or

whenever wet and apply foot powder

– bring extra boots to field

– no blousing bands

Care for Local Cold Injuries Care for Local Cold Injuries

�� Remove patient from cold environmentRemove patient from cold environment

�� Protect the cold extremity from injuryProtect the cold extremity from injury

�� Administer oxygenAdminister oxygen�� Administer oxygenAdminister oxygen

�� Remove wet or restrictive clothing and all jewelryRemove wet or restrictive clothing and all jewelry

�� Splint if extremity involved, and cover with dry, Splint if extremity involved, and cover with dry,

sterile dressingsterile dressing

Place dressings Place dressings

between those between those

fingers affected by fingers affected by

local cold injury.local cold injury.