1. COLD INJURIES

2. Epidemiology Caused by the inability to physiologically compensate for cold that produces injury. Duration of exposure, humidity, wind, altitude, 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.

3. Epidemiology Disease states as atherosclerosis, arteritis, hypovolemia, diabetes, vascular injury may predispose to cold-related injury. Dark-skinned people and those from warmer climates are more susceptible to frostbite

5. Local cold injuries result from decreased blood flow to, or freezing of, a body part. These injuries are often called frostbite or frostnip.

6. Local cold injury after thawing. Frostbite

9. Frostbite Symptoms –initially redness in light skin or grayish in dark skin –tingling, stinging sensation –turns numb, yellowish, waxy or gray color –feels cold, stiff, woody –blisters may develop

10. 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 prognosis.

11. 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 prognosis.

12. 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 prognosis

13. 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

14. Treatment in the field Remove wet and constrictive clothing. Elevate and wrap in dry sterile gauze the involved extremities. Rapid rewarming if rapid access to hospital 40 0 to 42 0 C clean water should be used There is controversy with regards to debridement of clear blisters on the field Pain management should start with NSAIDS to counteract the arachidonic acid cascade, in addition to opioids Smoking should be discouraged

15. Treatment in the ED Injured extremity should be placed in circulating water at a temperature of 40 0 to 42 0 C for 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 Hemorrhagic blisters should not be debrided Alo vera cream should be applied to the blisters Role of antibiotics is unclear. Staph aureus, Staph epi, beta-hemolytic Strep, Pseudomonas, and Enterococus are important pathogens.

16. Treatment in ED Infection prophylaxis using topical bacitracin is as good as IV penicillin. Tetanus immunization status should be assessed. Ibuprofen Early surgical intervention is not indicated in treatment of frostbite Amputation if needed within 3 weeks

18. Chilblains Nonfreezing cold injury Cold, wet conditions (between 32-60 o F, high humidity) Repeated, prolonged exposure of bare skin Can develop in only a few hours Ears, nose, cheeks, fingers, and toes

19. Chilblains Symptoms: –initially pale and colorless –worsens to achy, prickly sensation then numbness –red, swollen, hot, itchy, tender skin upon rewarming –blistering in severe cases

20. Chilblains Treatment –prevent further exposure –wash, dry gently –rewarm (apply body heat) –don’t massage or rub –dry sterile dressing –seek medical aid

24. Trench/Immersion Foot Potentially crippling, nonfreezing injury (temps from 50 o F-32 o F) 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

25. Trench/Immersion Foot Symptoms –initially appears wet, soggy, white, shriveled –sensations of pins and needles, tingling, numbness, 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

26. Trench/Immersion Foot

27. Treatment –prevent further exposure –dry carefully –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

28. Trench/Immersion Foot Prevention –keep feet dry –change socks at least every 8 hours or whenever wet and apply foot powder –bring extra boots to field –no blousing bands

29. Care for Local Cold Injuries  Remove patient from cold environment  Protect the cold extremity from injury  Administer oxygen  Remove wet or restrictive clothing and all jewelry  Splint if extremity involved, and cover with dry, sterile dressing

30. Place dressings between those fingers affected by local cold injury.