4-15 COLD EXPOSURE INJURIES

LEARNING OBJECTIVE:

When the body is subjected to extremely cold temperatures, blood vessels constrict, and body heat is gradually lost. As the body temperature drops, tissues are easily damaged or destroyed.

The cold injuries resulting from inadequate response to the cold in military situations have spelled disaster for many armiesthose of Napoleon and Hitler in their Russian campaigns, for example. The weather (i.e., temperature, humidity, precipitation, and wind) is the predominant influence in the development of cold injuries. Falling temperature interacting with high humidity, a wet environment, and rising wind accelerates the loss of body heat.

Other factors that influence the development of cold injuries are the individual's level of dehydration, the presence of other injuries (especially those causing a reduction in circulatory flow), and a previous cold injury (which increases susceptibility by lowering resistance). In addition, the use of any drug (including alcohol) that modifies autonomic nervous system response or alters judgment ability can drastically reduce an individual’s chance for survival in a cold environment.

Like heat exposure injuries, cold exposure injuries are preventable. Acclimatization, the availability of warm, layered clothing, and maintenance of good discipline and training standards are important factors. These are commandnot medicalresponsibilities, but the medical technician plays a crucial role as a monitor of nutritional intake and personal hygiene (with emphasis on foot care) and as an advisor to the commanding officer. A medical technician is also responsible for acquainting the troops with the dangers of cold exposure and with preventive measures.

Two major points must be stressed in the management of all cold injuries: Rapid rewarming is of primary importance, and all unnecessary manipula­tions of affected areas must be avoided. More will be said about these points later.

In military operations the treatment of cold injuries is influenced by the tactical situation, the facilities available for the evacuation of casualties, and the fact that most cold injuries are encountered in large numbers during periods of intense combat when many other wounded casualties appear. Highly individualized treatment under these circumstances may be impossible because examination and treatment of more life-endangering wounds must be given priority. In a high-casualty situation, shelter cold-injury victims, and try to protect them from further injury until there is sufficient time to treat them.

All cold injuries are similar, varying only in the degree of tissue damage. Although the effects of cold can, in general, be divided into two types — general cooling of the entire body and local cooling of parts of the bodycold injuries are seldom strictly of one type or the other; rather, these injuries tend to be a combination of both types. Each type of cooling, however, will be discussed separately in the sections that follow.

General Cooling (Hypothermia)

General cooling of the whole body is caused by continued exposure to low or rapidly falling temperatures, cold moisture, snow, or ice. Those exposed to low temperatures for extended periods may suffer ill effects, even if they are well protected by clothing, because cold affects the body systems slowly, almost without notice. As the body cools, there are several stages of progressive discomfort and disability. The first symptom is shivering, which is an attempt to generate heat by repeated contractions of surface muscles. This is followed by a feeling of listlessness, indifference, and drowsiness. Unconsciousness can follow quickly. Shock becomes evident as the victim’s eyes assume a glassy stare, respiration becomes slow and shallow, and the pulse is weak or absent. As the body temperature drops even lower, peripheral circulation decreases and the extremities become susceptible to freezing. Finally, death results as the core temperature of the body approaches 80° F.

The steps for treatment of hypothermia are as follows:

As soon as possible, transfer the victim to a definitive care facility. Be alert for the signs of respiratory and cardiac arrest during transfer, and keep the victim warm.

Local Cooling

Local cooling injuries, affecting individual parts of the body, fall into two categories: freezing and nonfreezing injuries. In the order of increasing seriousness, they include chilblain, immersion foot, superficial frostbite, and deep frostbite. The areas most commonly affected are the face and extremities.

CHILBLAIN.—Chilblain is a mild cold injury caused by prolonged and repeated exposure for several hours to air temperatures from above freezing 32°F (0°C) to as high as 60°F (16°C). Chilblain is characterized by redness, swelling, tingling, and pain to the affected skin area. Injuries of this nature require no specific treatment except warming of the affected part (if possible use a water bath of 90°F to 105°F), keeping it dry, and preventing further exposure.

IMMERSION FOOT.—Immersion foot, which also may occur in the hands, results from prolonged exposure to wet cold at temperatures ranging from just above freezing to 50°F (10°C). Immersion foot is usually seen in connection with limited motion of the extremities and water-soaked protective clothing.

Signs and symptoms of immersion foot are tingling and numbness of the affected areas; swelling of the legs, feet, or hands; bluish discoloration of the skin; and painful blisters. Gangrene may occur. General treatment for immersion foot is as follows:

  1. Get the victim off his feet as soon as possible.
  2. Remove wet shoes, socks, and gloves to improve circulation.
  3. Expose the affected area to warm, dry air.
  4. Keep the victim warm.
  5. Do not rupture blisters or apply salves and ointments.
  6. If the skin is not broken or loose, the injured part may be left exposed; however, if it is necessary to transport the victim, cover the injured area with loosely wrapped fluff bandages of sterile gauze.
  7. If the skin is broken, place a sterile sheet under the extremity and gently wrap it to protect the sensitive tissue from pressure and additional injury.
  8. Transport the victim as soon as possible to a medical treatment facility as a litter patient.

FROSTBITE.—Frostbite occurs when ice crystals form in the skin or deeper tissues after exposure to a temperature of 32°F (0°C) or lower. Depending upon the temperature, altitude, and wind speed, the exposure time necessary to produce frostbite varies from a few minutes to several hours.

The areas most commonly affected are the face and extremities.

The symptoms of frostbite are progressive. Victims generally incur this injury without being acutely aware of it. Initially, the affected skin reddens and there is an uncomfortable coldness. With continued heat loss, there is a numbness of the affected area due to reduced circulation. As ice crystals form, the frozen extremity appears white, yellow-white, or mottled blue-white, and is cold, hard, and insensitive to touch or pressure. Frostbite is classified as superficial or deep, depending on the extent of tissue involvement.

Superficial Frostbite.—In superficial frostbite the surface of the skin will feel hard, but the underlying tissue will be soft, allowing it to move over bony ridges. This is evidence that only the skin and the region just below it are involved. General treatment for superficial frostbite is as follows:

  1. Take the victim indoors.
  2. Rewarm hands by placing them under the armpits, against the abdomen, or between the legs.
  3. Rewarm feet by placing them in the armpit or against the abdomen of the buddy.
  4. Gradually rewarm the affected area by warm water immersion, skin-to-skin contact, or hot water bottles.
  5. Never rub a frostbite area.

Deep Frostbite.—In deep frostbite, the freezing reaches into the deep tissue layers. There are ice crystals in the entire thickness of the extremity. The skin will not move over bony ridges and will feel hard and solid.

The objectives of treatment are to protect the frozen areas from further injury, to rapidly thaw the affected area, and to be prepared to respond to circulatory or respiratory difficulties.

  1. Carefully assess and treat any other injuries first. Constantly monitor the victim’s pulse and breathing since respiratory and heart problems can develop rapidly. Be prepared to administer CPR if necessary.
  2. Do not attempt to thaw the frostbitten area if there is a possibility of refreezing. It is better to leave the part frozen until the victim arrives at a medical treatment facility equipped for long-term care. Refreezing of a thawed extremity causes severe and disabling damage.
  3. Treat all victims with injuries to the feet or legs as litter patients. When this is not possible, the victim may walk on the frozen limb, since it has been proven that walking will not lessen the chances of successful treatment as long as the limb has not thawed out.
  4. When adequate protection from further cold exposure is available, prepare the victim for rewarming by removing all constricting clothing such as gloves, boots, and socks. Boots and clothing frozen on the body should be thawed by warm-water immersion before removal.
  5. Rapidly rewarm frozen areas by immersion in water at 100°F to 105°F (38°C to 41°C). Keep the water warm by adding fresh hot water, but do not pour the water directly on the injured area. Ensure that the frozen area is completely surrounded by water; do not let it rest on the side or bottom of the tub.
  6. After rewarming has been completed, pat the area dry with a soft towel. Later it will swell, sting, and burn. Blisters may develop. These should be protected from breaking. Avoid pressure, rubbing, or constriction of the injured area. Keep the skin dry with sterile dressings and place cotton between the toes and fingers to prevent their sticking together.
  7. Protect the tissue from additional injury and keep it as clean as possible (use sterile dressings and linen).
  8. Try to improve the general morale and comfort of the victim by giving hot, stimulating fluids such as tea or coffee. Do not allow the victim to smoke or use alcoholic beverages while being treated.
  9. Transfer to a medical treatment facility as soon as possible. During transportation, slightly elevate the frostbitten area and keep the victim and the injured area warm. Do not allow the injured area to be exposed to the cold.

Later Management of Cold Injuries

When the patient reaches a hospital or a facility for definitive care, the following treatment should be employed:

  1. Maintain continued vigilance to avoid further damage to the injured tissue. In general, this is accomplished by keeping the patient at bed rest with the injured part elevated (on surgically clean sheets) and with sterile pieces of cotton separating the toes or fingers. Expose all lesions to the air at normal room temperature. Weight bearing on injured tissue must be avoided.
  2. Whirlpool baths, twice daily at 98.6°F (37°C) with surgical soap added, assist in superficial debridement, reduce superficial bacterial contamination, and make range of motion exercises more tolerable.
  3. Analgesics may be required in the early post-thaw days but will soon become unnecessary in uncomplicated cases.
  4. Encourage the patient to take a nutritious diet with adequate fluid intake to maintain hydration.
  5. Perform superficial debridement of ruptured blebs, and remove suppurative scabs and partially detached nails.