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Cold Injuries
Frostbite and immersion foot are cold injuries caused by prolonged exposure to wet and cold conditions. Frostbite results from actual freezing of tissue and causes numbness, pain, blistering and tissue death. Treatment involves rapid rewarming in warm water followed by pain medication and wound care. Immersion foot occurs in wet, non-freezing environments and causes swelling, blistering and nerve damage. Prevention of both injuries focuses on keeping skin dry and body insulated through proper clothing, activity, hydration and avoiding nicotine use.
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Cold Injuries
- 1. Freezing and NearFreezing Tissue Injuries
- 2. TLO • Given asimulated casualty, treat cold injuries, in accordance with the references.
- 3. ELO’s • From agiven list select the correct definition of frostbite. • From a given list select the correct two mechanisms of injury for frostbite. • From a given list select the correct signs and symptoms of frostbite. • From a given list select the correct favorable post thaw signs of a frostbite injury.
- 4. ELO’s • From agiven list select the correct unfavorable post thaw signs of a frostbite injury. • From a given list select the correct field treatment for frostbite. • From a given list select the correct primary field treatment consideration when treating frostbite in the field.
- 5. ELO’s • From agiven list select the correct methods to reduce the chance of becoming a frostbite casualty. • From a given list select the correct definition of immersion foot. • From a given list select the correct mechanism of injury for immersion foot.
- 6. ELO’s • Given alist of categories and characteristics match the category of immersion foot to its characteristics. • From a given list select the correct field treatment of immersion foot.
- 7.
- 8. Napoleon Retreats fromRussia • Entered Russia with an army of 250,000 • Retreated with only 20,000 soldiers (only 350 were combat effective) • Temperatures dropped to –38 degrees C
- 9. WWII • In Novemberand December 1942, the Germans performed 15,000 amputations for cold injuries.
- 10. FROSTBITE • Definition: Frostbite isthe actual freezing of tissue.
- 11. Mechanisms of Injury •Actual freezing of the tissues. – Ice crystals form extracellularly and grow by extracting water from the cells. – Cells are injured by dehydration and electrolyte disturbances. – Ice crystals that form intracellularly are much more damaging, but this requires much colder temperature and faster freezing time.
- 12. Mechanisms of injury •Obstruction of blood supply – Cells lining the capillaries and small veins are damaged, this allows serum to leak out into the tissues and activates coagulation cascade – Serum leakage increases viscosity and reduces blood flow. – The reduced fluid volume and activation of coagulation cascade causes obstruction. – This obstructs blood flow and circulation, this produces irreversible damage.
- 13. Frostbite Signs andSymptoms • Sensation – Numbness – Paresthesias – Pain – after extremity is rewarmed
- 14. Frostbite Signs andSymptoms Appearance: • Pale/White to yellowish white to gray • Bluish tinge/mottled blue • Erythematous ( after rewarming) • Blisters- clear to hemorrhagic • Black (days to weeks out)
- 20. Frostbite Signs andSymptoms • Sensation – Loss of pliability – Waxy – “frozen chicken” – “block of wood”
- 21. Late Frostbite Signsand Symptoms • Blisters/edema will occur approximately 6-24 hrs after injury • Black hard eschar appears within 4-10 days if severe frostbite
- 24. Frostbite Classification • Classificationmust be done retrospectively. • 1st- Erythema, edema, tingling, burning. • 2nd- CLEAR BLISTERS, edema, anesthesia or paresthesias. • 3rd- Entire thickness of skin and subcutaneous tissue. Hemorrhagic blisters. • 4th- Entire thickness of skin including bone.
- 25. Baron de Larrey •Chief of the Medical Corps for Napoleon’s Army • Organized the concept of the “flying ambulance” • Captured by the Prussians and sentenced to death
- 26. Baron de Larrey •Made observations about frostbite • Soldiers who thawed hands over bonfires and allowed them to refreeze did worse than those who did not rewarm them
- 27. Baron de Larrey •Made correct conclusion that frostbite victims should not rewarm the affected extremity and allow it to refreeze nor should they rewarm it over open flames
- 28. Baron de Larrey •However, his recommendation was to rub the frostbitten extremity with snow. • “when some external part of the body is caught by the cold…it is necessary to rub the affected part with substances containing very little calorick”
- 29. Primary Consideration • Donot rewarm the extremity if there is a chance of it refreezing. • This will greatly increase the amount of tissue damage.
- 30. Field Treatment (Frostbite) • Rapidrewarming produces the best results. • Immersion of the affected part in warm water. • Water temperature: 99-102 (F) until tissues of distal extremities are flush • This is extremely painful: NARCOTIC ANALGESIA.
- 32. Frostbite Treatment • Forcedhydration- IV fluid if necessary • Motrin 400mg BID before rewarming if possible • Aloe Vera 99% tid • Daily Betadine Soaks • Daily dressing/bandage changes • Denali Protocols:Toradol
- 33. Frostbite Treatment • Nonicotine
- 34. Blister Management • Donot aspirate hemorrhagic blisters • Leave intact • If blisters rupture apply topical antibiotic
- 35. Amputation • Keep orthopedicsurgeons away from patient • Amputate late
- 36. Experimental Treatments • Vasodilators •Heparin • Hyperbaric oxygen • Topical nitrates
- 37. Favorable Signs (Frostbite) • Warmthof tissue. • Normal tissue color. • Preservation of sensation. • Blisters extending all the way distally on the affected part. • Edema persisting more than 24 hours. • Good capillary refill.
- 38. Unfavorable Signs • Thesesigns indicate a poor prognosis with probable tissue loss. – Complete absence of edema. – Cyanotic tissue. – Continued loss of sensation. – Affected areas continue to stay cold.
- 39.
- 40.
- 41. Frostbite Risk Factors/Prevention • Vasoconstriction causedby hypothermia • Cold Induced Vasodilation (CIVD) - 59F
- 42. Frostbite Risk Factors/Prevention • Keepwhole body warm- “if feet are cold put on a hat” • Adequate clothing • Activity • Maintain nutrition status • Maintain hydration
- 43. Frostbite Risk Factors/Prevention • InadequateBlood Supply – Fractures – Dislocations – Shock – Dehydration
- 44. Frostbite Risk Factors/Prevention • InadequateBlood Supply – Tight boots/gloves – Tight harness/pack • Ensure fingers and toes can move freely
- 45. Frostbite Risk Factors/Prevention • InadequateBlood Supply – Nicotine – potent vasoconstrictor – Avoid nicotine- • Must have strong command interest
- 46. Frostbite Risk Factors/Prevention • IncreasedHeat Loss – Inadequate insulation – Wet gloves – Gloves versus mittens
- 47. Frostbite Risk Factors/Prevention • Keepclothing/gloves dry – Off the deck – Dry in the evenings – Secure straps – Fleece liners are not an outer layer • Wear mittens instead of gloves – trigger finger • Have dry gloves readily available
- 48. Frostbite Risk Factors/Prevention • Increasedconductive heat loss when in contact with metals and fuels • Do not touch metals and fuel with bare hands- always use contact gloves. • Avoid placing hands in “splash” zone • Insulation for ice axes
- 49. Rewarming Cold Hands •Set an acceptable time period for “cold hands” • Whole body warmth • Conduction- skin to skin – axilla, groin • Isometrics • Windmilling
- 50.
- 51. Frostbite Risk Factors/Prevention • Unwashedskin protective – minimizes insensible heat loss
- 52. Frostbite Risk Factors/Prevention • Peaktimes – Completion of movements – Night movements – Displacement- digging in – Inexperienced leadership
- 53.
- 54. Immersion Foot (Trenchfoot) •Original term from WWI trench warfare
- 55. Immersion Foot • 4500American soldiers suffered from trenchfoot from 1943- 1944 in WWII
- 56. Immersion Foot • FalklandsWar – Trenchfoot prevalent – 70%
- 57. Immersion Foot • VaporBarrier boots can cause immersion foot
- 58. IMMERSION FOOT • DEFINITION:Immersion foot is a non- freezing injury of the extremities in which the tissues are damaged.
- 59. Mechanism of Injury •Occurs in wet cold (nonfreezing) environment • Prolonged exposure • Cold induced vasoconstriction – Nerve Injury – Epidermal Damage – ? Reperfusion Injury
- 60. Timeline of Injury-Signs and Symptoms • Prehyperemic Phase – “cold and numb” – Pulses may be initially absent – Blanched, yellowish/white appearance – “walking on wooden limbs”
- 62. Timeline of Injury-Signs and Symptoms • Hyperemic Phase- after rewarming – Can last 6-10 weeks – Characterized as deep, burning, throbbing ache – Erythematous initially- may become diffusely blue/mottled/deep purple red – Increased warmth – Swelling – Blister/Intracutaneous Hemmorhage
- 63.
- 65. Category(Immersion Foot) • Minimal-reddening of skin, slight sensory changes. • Mild- Edema, sensory changes (reversible). • Moderate- Edema, redness, blisters, intracutaneous hemorrhage, irreversible nerve damage. • Severe- Severe edema, massive intracutaneous hemorrhage, necrosis, gangrene.
- 66. Field Treatment (Immersion Foot) •Pat drying of extremity. • Gentle rewarming- damage may occur secondary to reperfusion. • Elevation of affected extremity. • Bed rest. • Treatment after this is supportive. – debridement, resection. – tetanus booster. – no nicotine.
- 67. Treatment of ImmersionFoot • Significant Risk of Infection • Pain is difficult to control – Neurogenic pain • Wet gangrene- – Look for fever, increased CPK and leukocytosis. – Treatment is early surgical intervention and sequential amputations. Do not put these patients in water! – Severe chronic pain syndromes may develop.
- 68. Prevention • Change outsocks frequently • Dry out feet at night • Antiperspirants • Do not wear boots while in the sleeping bag!
- 69. Review • Frostbite Definition •Frostbite Diagnosis / Treatment • Frostbite Risk Factors / Prevention • Immersion Foot Definition • Immersion Foot Diagnosis / Treatment • Immersion Foot Risk Factors / Prevention
Editor's Notes
- #9 Only one major engagement between the Russians and French- the Russian peasants enacted a “scorched earth” policy – burning crops and killing livestock and throwing them into the wells- cutting off all logistical support for the French.
- #11 Debate- however the tissue is between 27-29 degrees F before it freezes
- #17 Barry Bishop, one of the first Americans to summit Everest- afterwards
- #18 Ken Kamler MD treating Makalu Gau- picking out bits of sock. For more details read “Doc on Everest” by Kamler or “Into Thin Air” by Jon Krakauer
- #19 Once again – Makalu Gau
- #21 Waxy- smooth and hard as if the fingers have been dipped in wax.
- #26 However he was freed when the Prussian battalion surgeon recognized him as a former attending when he was a med student and pleaded with his father (and the battalion commander) for his release
- #30 William Mills reports that this is by far the worst category of frostbite he has ever seen- 2nd worst was frostbitten tissue warmed over a flame
- #32 Beck Weathers and Ken Kamler- see “Into Thin Air” and “Doc on Everest” – Beck Weathers also wrote a book entitled “Left for Dead”
- #34 Potent vasocontrictor
- #37 None of these really work well
- #38 Need blood flow in order to form blisters
- #41 Failed 40 km ski march in central Norway- this is the turn around point.
- #42 CIVD – otherwise know as Hunter’s Reflex. This can be trained. More pronounced in Eskimos and Laplanders.
- #43 Hypothermia equals peripheral vasoconstriction making one vulnerable to frostbite.
- #45 Avoid tight mountaineering boots- be able to move toes freely.
- #47 When possible remove trigger finger and place with rest of mitten
- #49 Hackett had a good story where it was 20 below on Denali and he reached for a metal flask of booze outside of his tent- until he realized that the flask was stuck to his lips – he then took a swig to gather up the courage to rip off the flask and nearly got frostbite on his esophagus and the worst brain freeze imaginable.
- #50 Know when to stop training and get your hands warm. Windmilling for 1 minute provides 250mm Hg of blood pressure to distal extremities.
- #51 Daily.
- #53 Anything with movement (sweating) which leads to hypothermia/exhaustion poor judgement or digging (wet gloves) or movement at night (cold temps, longer exposure when adjusting bindings)
- #57 The Falklands are peat bogs are the Brits were constantly on the move – unable to change socks. There are still trenchfoot clinics in Britain for Falkland War vets.