Cold Injury and its Management
What is cold injury?
Cold injury is a tissue trauma produced by exposure to freezing temperatures and even brief exposure to a severely cold and windy environment.
Cold Injuries
Generalised
Hypothermia
Localised
Non-freezing
Chilblains Trench Foot
Freezing
Frostnip Frostbite
Incidence Of Cold Injuries Indian Army(2003)
Cold Injury Frostbite Chilblains Hypothermia Trench foot
-
Admission Rate 0.21% 0.11% nil nil
(Based on Western Himalayan HA region troops data)
Hypothermia
Mild(cold stress)
Moderate Severe
37-35C
35-33 C
Pallor,Shivering,Complex motor function loss
Irrational behaviour,Intense shivering,Fine motor coord loss
>33 C
No shivering,uncooperative,skin pale/ice cold,Decrease HR/RR,arrhythmias
Hypothermia- Treatment
Mild/moderate- Re-warming, conserving/
replenishing body heat Severe- Prevention of ventricular fibrillation Prevention-Multiple loose layer,dry clothes,avoid direct exposure to wind/snow, exercise, warm calorific food & drink
Chilblains
Non-freezing injury,abnormal reaction to cold
Pallor, erythema, pressure sites Importance - prone to frostbite
Treatment -Reassurance, Re-warming &
drying
Frostbite
Symptoms and clinical features of Frostbite.
1. 2. 3. 4. 5. 6. Initial tingling and burning Limb feels heavy and numb Increase in pain and swelling Possible blistering Progressive reduction in sensation Gangrene, with increase in severity
FACTORS AFFECTING OCCURRENCE OF COLD INJURY
1. Environmental factors: a) Severity of exposure to cold b) Duration of exposure c) Wind velocity d) Moisture e) Hypoxia (Lack of Oxygen) 2. Host factors: a) Lack of Acclimatisation b) Stagnation of circulation c) Physical Inactivity d) Nutrition e) Dehydration f) Local conditions eg. Injury, Infection, etc. g) Alcohol consumption
COMMONLY AFFECTED AREAS
1. 2. 3. 4. 5. 6. 7. Fingers Toes Ear lobes Nose Cheeks Chin Soles, heel
8.
9.
Dorsal surface of foot
Male genitalia
10. Buttocks
Patho Physiology
Phase of cooling Freezing of extracellular fluid Movement of fluid (intra to extracellular) Vasoconstriction Endothelial damage Sludging of RBC, platelets Freezing intracellular fluid Tissue damage & cell death
Patho Physiology
Phase of Re-warming
Dilatation leads to leakage of fluid & proteins
from damaged capillaries Edema Free radical generation leads to continued endothelial damage Microcirculatory failure due to microthrombi Prostaglandin & thromboxane (Inflammatory mediators)
CLINICAL CLASSIFICATION
Superficial- First Degree
Erythema
Edema Itching
No blisters/necrosis
Recovers completely
Superficial-Second Degree
Vesicles With
Clear Fluid
Second Degree(contd.)
Eschar formation
2-3 weeks
Deep-Third Degree
Violaceous haemorrhagic blisters
CLINICAL CLASSIFICATION
Superficial- First Degree
Erythema
Edema Itching
No blisters/necrosis
Recovers completely
Superficial-Second Degree
Vesicles With
Clear Fluid
Deep-Third Degree
Violaceous haemorrhagic blisters
Third Degree (Contd)
Skin Necrosis
Blue grey discolouration
Deep- Fourth Degree
Minimal oedema Initially mottled,deep
red/cyanotic
Fourth Degree (Contd)
Eventually dry black
mummified Loss of tissue
Site Of Lesion (Our Experience) N=80
Site Upper Limb Lower Limb Both Face (Ear&nose) No. Of Cases 56 18 07 05 Percent 71% 23% 8% 6%
Treatment
Pre-hospital
Prevent further cold injury Prevent mechanical trauma Avoid rubbing Restore general body warmth Analgesics Tetanus toxoid
Treatment
Re-warming
37 410 c for about 30 mins/ till flushed Danger of burn injury Avoid freeze-thaw-freeze cycle Analgesics/sedatives
Sterile loose dressings Prophylactic antibiotics Physiotherapy
Treatment -Contd
Surgery
Excision, escharotomy, Skin graft Amputation Reconstruction procedures
Treatment Contd.
Therapy
Vasodilators (ketanserin, buflomedil) Haemodilution (lomodex) Platelet aggregation inhibitiors (Aspirin) Prostacycline analogues (iloprost) Fibrinolytics ( strepto / urokinase, r-tpa) Heparin Hyperbaric oxygen Aloe vera
Treatment in field situation
1. Treat systemic hypothermia, if any. 2. Rehydrate with warm fluids 3. High calories and protein diet. 4. Avoid further trauma 5. Avoid freezing-thaw-freeze 6. Avoid consequent frostbite 7. Reduce dislocation if any immediately 8. Treat fractures if any 9. Rewarm only if no chance of refreezing 10. Keep clean to prevent infection 11. Administer anti tetanus toxoid 12. Prohibit smoking. 13. Offer assurance and support. 14. No rubbing and dry heating. No thawing in the field. After thawing prevent freezing
Primary Prevention
Health promotion
Hygiene Nutrition Exercise Smoking
Specific protection
Shelter Clothing, boots & socks Foot hygiene Venous congestion
Secondary Prevention
-Early Diagnosis -First Aid -Prompt treatment : The following action should be taken as soon as a cold injury case is seen: -Stretcher case -Sheltered place -Oxygen should be given through BLB mask -All constricting clothing should be loosened and boots removed -The affected part should be kept at absolute rest -Gently cleaned and wrapped in sterile dressing -A booster dose of 0.5ml of tetanus toxoid.
Prevention - Contd.
Buddy system
Cold adaptation Rapid evacuation
Limit tissue injury
Re - exposure
Precautionary measures to prevent Cold Injury
1. 2. 3. Physical well being and adequate nutritious food. Limit the period of cold exposure. Take every effort to retain body warm with proper insulative clothing (multi-layers).
4.
5. 6.
To maintain hydration by taking hot tea, coffee etc.
Heavy socks with well fitting boots and insulative gloves should be worn. Keep the body parts, especially the extremities dry and free from abrasions.
7.
8. 9.
Wet garments, socks, boots, gloves, etc., should be changed immediately and dried.
Never touch metallic objects with bare hands in severe cold. Do not wet hands with kerosene or petrol.
10. Boots and socks to be changed regularly. Feet to be washed often.
11. Avoid use of alcohol and smoking. Early recognition of cold injury and instant administration of firstaid can avoid permanent tissue damage
Dos and Donts on Recognition of Cold Injury
Dos
1. Remove tight shoes, socks etc. 2. Warm the injured parts.(Not by direct heat) 3. Cover the body with blankets. 4. Provide hot drinks and rest. 5. Cover blisters with dry dressing. 6. Treat as a stretcher patients.
Donts 1. Dont massage or rub the parts. 2. Dont smoke or drink.
