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COLD INJURIES Treatment & Prevention Tips Our wilderness medical courses dedicate a significant amount of time to dealing with cold injuries including frostbite and hypothermia. We teach you how to be flexible, innovative and above all courageous in coping with medical care in the wilderness setting when the mercury drops. Participants learn preventative strategies, how to recognize and treat the symptoms of mild cold injuries so that they don’t progress to more severe conditions, and also how to treat severe frostbite or hypothermia FROSTBITE Frostbite comes in three different levels: frost nip, partial-thickness and full-thickness frostbite. The degree of severity determines the course of action that needs to be taken.

Assessment & Treatment When you envisage what frost does out in nature such as crumbling mountain ranges and heaving up roads, it is easy to see how it can cause so much damage when freezing occurs in your fingers and toes. At the superficial stage of frostbite, which is known as frost nip, the

patient may not yet be aware of the problem as their sensation to touch is still intact. The area will appear pink or white and soft to touch. The second stage (partial thickness frostbite) is characterized by a dulled sensation to touch as the skin cells begin to freeze. The skin appears white or blue and feels doughy and “thick” to the touch. Both of these levels can be treated immediately in the field by replacing any wet clothing (where possible), gently covering the area, warming the patient, and feeding and hydrating to stimulate the metabolism of heat and blood flow into the affected areas. Unlike the first two levels of frost bite that can be treated immediately out in the field, full-thickness frostbite is a very serious injury and the patient should be re-warmed under controlled conditions in a medical facility where evacuation is a possibility. The classification of full thickness frostbite injury is freezing from the skin into the underlying tissues and muscles. The skin is pale white and has a woody texture and feels completely numb to touch. Other symptoms include burning, throbbing and aching. Treating full thickness frostbite correctly is imperative. Just as much tissue damage can occur during the re-warming stage as during the initial freezing! Besides pain, the patient is also likely to suffer inflammation and infection.

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However, if the decision to treat in the field is made rapidly thaw the body part in warm (38-42℃) water. Accurate temperature is a must to prevent burning or thawing too slowly. After thawing the patient must absolutely be kept warm as refreezing is devastating and could lead to amputation. The decision to thaw in the field is very serious. It is possible that leaving the injury frozen until completely out of the field is the best action. Prevention of Frostbite: ▪ Stop and warm your feet or hands

if they start to feel numb; this is an early warning of frostbite.

▪ Throw an extra layer on your upper and/or lower body as this can warm cold feet and hands too

▪ Wear a warm, windproof hat as you lose more heat from the head than any other part of the body

▪ Avoid tight clothing or boots that can restrict blood flow

▪ Avoid alcohol, nicotine and caffeine which all restrict blood vessels and reduce blood supply to extremities

▪ Wear well insulated boots, gloves (mitts are even warmer) and even a face mask in extreme conditions

▪ A good breakfast will go a long way to keeping you warm

▪ Eat small, frequent, easily digestible snacks

▪ Stay hydrated! Sip frequently. HYPOTHERMIA A healthy body has a core temperature of approximately 37oC. However, a number of factors can interfere with the function of the thermoregulatory system and the body can become overwhelmed by

environmental extremes. If exposed to enough cold that the body’s internal mechanisms are unable to replenish the heat that is being lost, a drop in core temperature occurs. The drop in temperature can happen very gradually and characteristic symptoms to watch for include fumbling, grumbling, and mental confusion. Hypothermia can be divided into mild and severe classifications, although in hospital scenarios it is classified as mild, moderate and severe. However, for field treatment the technique for treatment is mostly based on whether the patient can cooperate or not. Even mild hypothermia (where body temperature drops to 32-35oC) is an urgent problem and requires immediate treatment in the field. If left to linger, it may easily lead to severe hypothermia, which is much more difficult to handle. Vigorous shivering (in a sheltered location) is one of the most efficient methods of re-warming, while feeding the patient with fluid and fuel. Adding external heat is generally a safe strategy but no attempt should be made to mobilise the patient until obvious improvement in their mental status. It may require 40 minutes of shivering, sugar, fluids and aggressive external rewarming before it becomes safe to allow the patient to exert themselves. As the core temperature of the patient drops below 32oC their mental status will become obviously compromised.

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As the patient continues to deteriorate, the shivering mechanism slows and eventually stops as the muscles are deactivated by the cooling of the core and lack of calories to burn. Vital signs will become difficult to detect. This is a true emergency. Ideally treatment for severe hypothermia is found in the hospital but if this is more than 24 hours away, immediate steps need to be taken in the field. Find shelter, set up a tent or build a snow cave as fast as possible. Get the patient into dry clothes and a sleeping bag, and give them a hot drink to sip continually. If the patient needs more warmth, get into the sleeping bag with them to add your body heat to the rewarming effort. Another method of rewarming is the administration of intravenous normal saline warmed to 40oC. This can restore fluid without contributing to any heat loss from the patient. Performing CPR on a hypothermic patient is very questionable and may actually be harmful. Chest compressions may cause a functioning but very slow cardiac rhythm to decay into ventricular fibrillation. For this reason, only perform chest compressions if evacuation is not an attainable goal in the next 24 hours. If transport to hospital is possible, take the time to properly package the patient and evacuate gently but as quickly as possible. The need for gentle handling is due to the fact that rough treatment can cause a cold heart to go into ventricular

fibrillation, an irregular heart beat that can lead to a heart attack. In summary, while severe frostbite and hypothermia can be difficult to treat, they are very easy to prevent. So when you head outside this winter, remember the “must dos” include maintaining an adequate amount of energy though sufficient fluid and food, dressing appropriately, and taking extra layers - even when your pack already filling up. It could easily make the world of difference. Early Recognition = Easy Cure!!