4

as aaaaa

' w, ., ~aa's4FI+ '%401sttt1%ititt' «tntauwi

Poorly adapted physiologically todeal with the effects of loweredtemperatures, we are depemlent onshelter and clothing for protectionfrom the cold. When these are lack-ing or inadequate, even for shortperiods of time, cold traurrta mayresult.

Although most commonly seenin arctic and subarctic <.1imates,

54 Arnarroan Journal ol Nurarngr January 198'

Hy Tina Davis DeLspp local cold injuries can ot~r when-eVer a CatlS«tive COrnbinatit»Icold, wet, wind, and altitude exists.

The physiological response ofthe body to cold is Inost easilyunderstood by picturing the bod>as consisting of two In«jor parts; acore in which heat is produced and

rtlsA DAvts DKLApr, ala�M.s, is assistant prsr-fnssor of nursing, University of Alaska, rtn-chorage,

a shell in which heat is conserved ordissilrattd, tlcpending on the body'ineeds at the time. When core tem-perature is significantly reduced,hypothermia results. When shelltissues skin, subcutaneous fat, mus-ctrloskeletal components, vessels«Isd nerves! are subjected to lowtemperatures, local trauma may re-sult.

The physiological response ofshell tissues to cold is vasoconstric-

Chilblain

Immersion I'oot

tion. with a decreased blood flowand a proportionate decreiise in ox-ygen supply to the tissiies. Thevasoconstrii.tion is caused in partbv a direct effect of cold on theblood vessels and in part by a con-current sympathetic response. Thedegree of vasoconstriction dependson the duration and severity ofexposure and on the siisceptiliilityoi the indivfdiiai�!,

The effects of vas<rconstri«tionare many and varieif, 'I'he <lecresscdvoiiii»e of warming Iilood flowingthrough the part Further reducesthe temperature of the tissue. Thistemperature reduction produces acharacteristic inuscie weakness anda decrease in local sensation.

Direct damage to the vessel'wall from the cold resiilts in piasinaHuid leaking into the interstitialspaces. The resulting hemoconcen-tration, together with the narrowedlumen, promotes the developmentof small clots. These clots block thesmaller vessels. When the bloodHow f~ obstructed, either hy clots orby closure of the precapillarysphincters, the arteriovenoiis shuntsopen, allowing blood to bypass thepait. The cooled tissue thus be-comes essentially avascuiarf I!.

Skin is the Hrst tissue to be-corne cooled. Muscles, nerves, andvessels are also highly sus;eptible.Heiatively resiktant tissues includeconnective tissue, tendons, andbone, The parts most fmpientlysubject to cold trauma are thehands, feet, and facial skin, particu-larfy the ears, cheej«s, and nose l!.

Seen most commonly on thedorsal surfaces of the hands andfeet, chilblain resiilts from interrnit-tent exposure to teinperatures inthe range of 33 to 60'F., often in ahumid environment. Generally, theexposure is fairly short, although itmust be long enough to producethe physiological cold response.Cold response varies with the envi-ronInental temperature, the degreeof humidity, and the individual.

Shortly after vasoconstriction,a brief, intense vasodilatfon thatraises the temperature of the tissueabove that of unaffected ti<sues oc-cur>, Vasospasm produces typii;aledematous, reddish-bi«e patchesthat itch rind hiini. Th<-' itchy, f>rirn-

ing sensation becoines inore intensewith increased warmth�!. General-lv, the lesions siibside in a fewdays.

Repeated exposiire may resultin a chronic condition, In which thecharacteristic lesions develop ascold weather approaches. The con-dition goes into remission sponta-neoiisiy in the spring, when envi-ronrnental tern peratiires rise. Al-thoiigh the appearance of the Ie-siorrs vririe» with the room temper<i-tive arid the degree of depeiideii«eof the limb, they do not expand atthe border or spread to other partsof the body. This condition mayoccur perennially for several years.

Pathological specimens showintense edema of the papillary der-mis, which tends to separate inplaces from the epidermis. Endo-theiial proliferation is evident inthe small dermal vessels, with thedeeper vessels demonstrating amild vasculitis and perivasculi-tis�!.

Treatment consists of raisinglimb temperature, Rewarming canbe accoinplished by placing thelimb in «dependent position in awarm water bath, not to exceedI08 F. Because temperature sensa-tion is decreased in the aflectedlimb, the water temperature inustbe measured. The warin water islikely to increase the intensity oFpruritus and burning, so analgesicsmay be necessary. In general, thefaster the rewarining, the inore se-vere the pain. Vasodilators havebeen used as a treatment in bathaciite and chronic cases but withminimal success�!,

A second type of nonfreezinginjury is immersion foot, a condi-tion producM by prolonged expo-sure of the extremities usually thefeet! to cold and wetness at temper-atures below 50'F. Developmentof symptoms is associated with im-mobility and dependency of thelower extremities and with expo-sure times exceeding 10 to 12hours.

A variation of iinmersion footis trench foot, a condition seen inshipwreck survivors and in soldiersexposed to wet but not freezingcold for long periods, such as intrenches. Tropical immersion foot

SUSCEPTKBKLETVFACTORS

Local rnturres caused by co/d expo-sure are almost totally piwventable,partrcuiarly u the numenous factorsthat p~isp<~ the inc'<vidual tothese inturies are attended to.

~ Wind markedly increases therate of heat loss from expose<f skin. Ifliteraify blows away the thin. insuiai.ing layer oi boun<fary air thai ordi.<Mrrfy surrounds Ihe body. Boundaryair aiso is absent when the air is stillbut the body is moving "apidiy, asduring skung or when tr<rvefrng bysnow machine. The absence of theinsulating layer of bouna iry air hasthe effect of lowering the tempera.ture fa which the skin is exposed.

~ Moisture increases heat Iossvia conduction. When protectiveclothing becomes wet fr om rain,snow, or perspiration. the enclosedparts jose heal ai a faster rate than dobody parts covered by several layersof warm, dry clothing, Afro, wet skinincreases the cooling an<3 freexrnqrate.

~ Using <ifcohoi or ni<=otine in acold environrr<ent increases the hkeii-hood of cold injury by oppositemechanisms. nicotine use results rnperrpheraf vaivoconstrfctron, decreas-inq the ffow of warminq bjood to thepen phery.

Alcohol, on the other hand,causes peripheraj vasodrfatron, whichincreases the rate of heat loss fromthe skin. Individuals usir,g alcoholmay feel quite warm and:afl to pro-tect themselves adequatefr<, thus in-creasing the danger.

~ Disease conditions such asperipheral vascular disease, that slowthe rate of bicvod flow to .he penph-ery predispose the individual to caidinjuries. Severe generals' dehy-dration also slows blood flow byincreasing the viscosity of the biood.Arteriolar vasoconstriction occurs athigh altitudes, even at ncrmaI tem-perature. High altitude is <ijso a pre-disposing factor because the loweredoxygen tension of the au causes anincreased resforratory rate and thuspromotes increased flui fess.

~ Excessive washing and shav-ing increase the possibility of injury tosuperficraf faciai tissue by cornpro-rnising the skin integrity. After-shave!oiion further dries the skin and re-inoves oils thiit partially protect thetissue from coid injury.

A<i«<<tean J<r«rr<at o! Nu<v««r/taro«<y t~ 57

Frostbite

occurs in individuals whose extrem-ities are immeixed in warm waterfor long periods. These victims ex-hibit similar symptoms and patho-physiology and are treated in amanner similar to cold water im-mersion vfctfals�!,

HOOF TO FRRVECOLD IN JURT

~ Piafl &ctlvlt es c&refuUy 'to Itime of exposure,

~ Always let someone knowyou are and when to expectback.

~ When passible. use a burem when our in the ~s~kf.

~ Dress for the weather. Promore imporlant than fashi<

~ Avoid vigorous washing oiand shaving the beard uthe day's outing.

~ Apply protective cream taprior to exposure.

~ Wear several layers of lao<clothing rather than a sinelayer!.

~ Use hand protection. Miigenerally more effectigloves.

~ Carry extra socks. Keep b<dry and male sure wet <thoroughly dry before usir

~ Avoid alcohol and cigaret~ Avoid becoming wet wit

rain, or perspiration,~ Pcice yourself to avoid b

unduly fatigued.~ Pay attention to the messa

body sends. If yau note sand color changes in the sshelter.

~ if freezing does occur, aveing the part until refreezin<inated as a threat.

~ Do nor use snow, ice, color excessive hear to thaw fi

e Seek medical attention aspassible when freezing vours.

Cold water immersion injirrydevelops in three phases. In theflrst, the prehyperemic or ischemic,vasospastic phase, the extremitiesare cold, swollen, white ar blue,and pulseless. Tactile serisitfvity isdecreased or absent.

This is followed by the hyper-emic warming! phase, character-ized by extremities that are hot,dry, and red with baundi:ng pulsesand severe pain. The time it takes

for hyperemia to develop dependson the severity af the insult and theindividual's susceptibility. Thishase may last from 4 to 10 days

in severe cases may result inmuscle weakness, atrophy and ul-ceration, or gangrene of superficialdistal areas.

In the last phase, the posthy-peremic, or recovery phase, colorand pulse gradually return ta nor-mal. In severe injuries, some depig-mentation may occur, especially ifthe individual is dark skinned. Hy-persensitivity to cold or pain onweight bearing may develop andlast for several years.

Although the pathophysiologyof iminers/on foot is fxxirlv urxfer-stood, it is clear that the vasocon-strictive response to cold results intissue anoxia and subsequent dam-age to the vessel wall and nerve.Capillary permeability is thus in-creased, resulting in edema. Hyper-emia may occur as an exaggeratedresponse by compromised neuro-vascular mechanisms.

After careful rewarming of theaflected extremities, treatment isprimarily supportive. The indfvidu-al is kept in bed with the affectedfeet moderately elevated, and theaffected part is kept clean, Phen-oxybenzarnine hydrochloride Di-benzyl inc!, an alpha-adrenergicblocking agent, may be used todecrease spasm.

During the hyperemic phase,judicious cooling af the part may benecessary to decrease pain and talower oxygen requirements of thetissue to prevent gangrene. If gan-grene does develop, amputationmay be necessary, although this isusually delayed until the full extentof tissue loss is cle&5!.

Obviously the best approachta cold injuries is prevention.Nurses working in schools, irxiiis-try, and private clinics are in a frosi-tion to provide potential victimswith information regarding the dair-ger of immersion arid nonfreezingcold.

Frostbite, a freezing caid inju-ry, occurs when tissues are cooledto the point that ice crystals form insuperficial or deep structures. De-pending on the severity and dura-tion of the freezing and on the efli-

ciency of treatment, varying de-grees of tissue loss and functionmay occur with frostbite injury 8!.

In this condition, ice crystalsform in the extracellular spaces,causing the extracellular fluid tobecome hypertonic in relation tointracelluiar fluid. This results in

Ruid being pulled from the cell.When approximately one third ofthe cellular fluid is lost, injury tothe cell from dehydration and dis-ruption of enzymatic processes oc-curs�!.

The clinical manifestations of

frostbite injury vary. dependingupon the severity of the injury. Ifsuperficial � involving only the skinarxf siibciitaneoiis fat--sharp. iich-ing pain h common. The part iswhite or blanched, and frozen onthe surface, but when gentlypressed feels soft. After thawing,the part becomes flushrxI and some-times deep purple in color.

When frostbite injury involvesdeeper structures, the part appearswhite and feels solidly frozen onpalpation After thawing, it may beblue, purple, ar black in color. Theseverity of the inju> cannot beassessed prior to thawing.

Large blisters filled with se-rous Ruid generally form within thefirst 24 to 48 hours after rewarm-

ing, These blebs are frequentlylarge enough ta restrict motion ofthe part, If bleb formation does notoccur, this usually indicates thatadequate circulation is lacking, Tis-sue loss often results.

The bleb fluid begins to bereabsorbed within 5 ta 10 days,often followed by the tormation ofa hard black eschar layer that alsocan interfere with inability. Theeschar layer is insensit,ive and mayoccur over areas where blebs don' tfarm.

Within a few weeks, a firx. ofdemarcation «ppears. This linemarks the point [below which tissiiei» riot viable and makes it possibleta «stirnate the extent a probabietissue loss. Abave the line of dernar-

cation, the eschar layer separates,revealing the new underlying skin,The shiny, babyiike skin is oftenabnormally tender and sensitive totemperature; «i>narmai sweatingmay occur for a time. Within twoto three months, however, the ap-pearance becomes normal.

The eschar does not separate

58 Amenam Jautmd ot rr«r««g/ja<<u«<y l983

Rocov erin' trosza Frosthito

l. White or blanched frosen partsare rewarzned in s whiz'lpool bath.

4. In third week, hardeningeschar must be slit to free joints,

ix'low the liile of loni;in", t ioii.Rather, deeply injured tissiies re-main hard, black, and insensitiveand eventually undergo autoampil-tation without surgical interveii-ti oil 8j.

The clinical course and prog-nosis of frostbite injury varv consid-erably with clinical management.Experiences over the past 20 year~have led to the developmerit of atreatment method that minimizestissue loss and dysfunction.

Prior to 1955 in Alaska. frost-bite was initially treated withvariety of methods, including rub-bing with snow, thawing in «n iceor snow bath, gradual, spontaneousthawing indoors, and rarely, immer-sion in warm fluid. This was fol-lowed bv all tvpes of rnanagelnent,ranging from near total neglect toearly surgery, which often resultedin linwarranted tiSSue IOsS�'. Tre:lt-III 'III t XI iy iz s :ul ll l IIX ' i uil i I c

Suits in a Inure iaVOrill>lc oiiti<ink.In mediate first «id begi is with

2. Biebs develop within 48 hoursunless circulation is iznpaired.

5. Debridement occurs naturallyond because of treatments.

thc rem<lval of the <'lient to a shcl-tererl area lO prevclit refreeZiug Oltraulnatized tissiie. His or her tem-perature is taken immediately toassess the presence of hvpothermia.If the temperature is below 94'F.,the treatment of hvpotherrnia re-ceives priority because of its life-threatening effects.

Once there is no chance ofrefreezing and hypothermia hasbeen treated, the frozen part isrewarmed by immersing it in well-agitated water at 100' to 108'F. Awhirlpool bath is ideal for this pur-pose. For injuries involving the faceor ears, warm moist soaks change<ifrequently to maintain the desiredtemperature! are applied 8k Therewarming is continued until thepart is colnpletely flushed.

Rewarming is usually a painfulprocess that requires sedatives andanalgesics. Fiirther, because the cli- 'll II 'I! ls 'llllhsl:ui� w 't, g 'Ilcr,ilrewall Ill lllg Illeasilfc;s ill<.' ludlcal .'ckThese include provi fii dry «lath-

3. Within 10 days, Buid reabsorbsand hard eschar layer forms.

6. Appearance at 6 weeks; grossanatozny, function are preserved.

ing, adjiisting the environmentalteinperature accordingly, and en-couraging the client to dri.nk warmliquids.

Some authorities support thejudicioiis use of a small ar iount ofan alcoholic beverage, which actsas a mild sedative and encouragesperipheral vasodilation l!. The useof alcohol, however, should be re-stricted to clients who are beingmonitored by medical personnel.Alcohol as a treatment without pro-fessional assistance may prove haz-ardousus.

Once the Iewarrning process iscomplete, the client is hospita/izedand placed in protective isolation.The affected parts are placed onsterile sheets, A bed cradle protectsthe tissues from the presstire andfriction af top overs. No dressingsare used, although sterile cottonpledgets may be placed betweenIII<.I -sw III I»fig its Ir> mini »izr.I'ricthin a«d thils <lccrease the likeli-hood of bleb mpture. If protective

Amenran journal *t Nura ng/ianuar I' u<i $0

References

isolation is not possible, some phv-sicians apply an «»I i-infectivecream to the part and wrap it loose-ly in a Kerlix dressing, again usingcotton pledgets to separate the dig-its.

Rupture of the blebs is careful-ly avoided. Infection i< preventedby cleansing the part daily in awarm whirlpool bath between 90'and 98'F. to which «rniiid disinfec-tant soap has been added. Thewhirlpool with its gentle debridingaction stimulates circ cd ation andencourages active motion of thepart.

If the eschar that forms is sostiff that it prevents niovement ofthe part, it may be gently split onthe sides or on the dori»rn of thedigit. No additional debridernent iscarried out; this is left to naturalprogress and to the gentle action ofthe whirlpool. When the eschar be-gins to slough, protective isolationis discontinued, although the dailywhirlpool baths ond active exercisein the bath are conti>rued.

Where tissue loii is inevitable,no debridement is done urrtil sporr-taneous sloughing of the soft tissueiS virtually COrnplete, Any rernoiii-ing mummified portion may thenbe surgically removed. 'I'his delay,often as long as three to fourmonths, markedly decreases thedanger of retraction «nd infectionand reduces the need for later skingrafting and st»nip revision�!,

Increasingly, arteriography isbeing used to assess the extent a»dSeverity Of VaSOsp«sni i» frostbittentissues. If arteriograms demonstratesignificant v «sos pasm, «vasodilat-ing agent, such as reserpine, may beinjected into the artery. This cre-ates a local medical syrnpathecto-my that avoids the pernianent sys-temic side effects of surgical sym-pathectomy. Although studies eval-uating this treatrnerrt are limited inmope «»d nirrr!l>er, those p»hlishedhave demonstr«ted n>;Irkc l relieffrO»I v«SOSpasru;»I i «<<<<ocr«te<lsvrnptom< QI.

Anticoog» larlt therapy h«ibeen attempted in «Ir eHort to pre-vent sliidging in the rni:rocircula-tiO», l»!t With littl ' d<!»1»rrstr«l!tteRect. At Ie«St Orle i»I tlIOrrtv Slrg-gets that anticoagulant therapy.combined wr'th platelet «nti«dhe-sive drugs, might be irrcceisf»l inpreventi»g damage frorri i»trilv«i-

Cular COagrrlatioir if institrrted e�i-rl� IOj.

Basically, fewarr» ing withwant! water hath, followed by pro-tective isolat i»JI, l«il v whirl pooli,and avoidance of early surgic«.l in-terVentiOn remain the cOrrierstO»e

Of rnanageme»t, jn e therC iS Jr<>threat Of refreezirrg the part, i»itialrewarming sho»id riever l>c del«yeduntil the clie»t is transferred to «special treatment center. Bather,therapy should be institirted priortO the tranSfer, with nie«Sures beingtaken to protect the injured partand to prevent rcfreezi»g duringtransport.

NrrrSing care d»ri»g the re-Warming phase is corrcer»ed pri-»1«rily with pl<»>I<>ri» < co»>l<>rt;l<1 lwith observing the client's res po>isetO the thawing prOCedr re a»d tOcomfort measures.

During the tinie that the l lieutis in protective isoiatio» the» irse«ttenrptS ta prevent cOmpli .;It iOilsfrom immobility arid sensory depri-v«tiOn. Nursi»g history i»l'Or»I«tior>shor>id be iro <!rl!<>r;Itc l i>It ! th .plan Of Care, «»d «i »1 icl> I»dupe»-dence as thc client's physical andemOtiO»al state peru!its shor>id beencouraged.

Diversi»»al «ctivitiei, irr< lud-ing frequent contacts with friends,family, and mrrsing st«8 assumespecial importance during iiol«-tion. Explaining th» reasons for iso-lation and demonstrating the cor-rect procedure for gowning andhandWaxhing Ofterr r»;Irk di V i»-Cre«Se the COrrrfOrt of visitors. Ac-tivities such as needlework, pliz-zles, and model building can becontinued in the isot«tion ri»it.When the hands are «ffected,adaptive devices r»ay be use i toincrease independence.

During isolation, the client isWaiting fnr the eXte»l Oi tiiirre lOs»to become clc«r. 'I » d ail with piv-chologl .'ol pt' >t>il'tria l Ir>Ilg thiitime, Open 'Or»»r»1>i ",It i !» f<>I tl>celle»t to xl!I 'si lc 'llllgs, Ir» I'I'rill >-ties, i»id ft'. lri Ji eii .'Irtl«I. PI 'I'l'<llli-srte to open c JI>lr»I»l>cat>»» Is theestablish»re>it <>f nrst betwee» theellen't arid at le«it one Of two I'rle»1-I» rs Of th<r»»riirrg it, H'. 'I'hii I»;iyhc Crllirirrl'C l l>V llr»lt>rig t IIC »I»1-her of staR rrre»!her<< assigned to thccare of the clier>t «»d l!v m«i»t«i»-i»g conti»uitv»t c;rre.

If there h; i l> .ei> ii <1>ifi ai>t

tisiue loss, the hospital nurse en-s»rei that,lppropriat<: referr«IX I'arfch«bilitat ror1;Ifc I' lade, I»clad rigphysical <>r occ»pational therapy,Referral to,r public health riurseand possibly to vocational rehabili-tation services may be necessary.

Thc pn!g»osis i» frostbite inju-rv ii highlv variable, everr if o»lvrniirimal I iss lie loss occrirs. Late

results include hypersensitivity toeven uiildly cold we; ther «rid hu-midity, increased susceptibility torepeat frostl!ite inju.ry on subse-quent exposure, and pain and pares-thesias in the injured area. PhantomIir»b pair m«y fOlluw amputa-tion l I!. :hildren may sufferepiphyseai <I;lrrrage that later re-'rritx iri defOrrr Jiti«S; tl1ix is cape ial-lv corn »OI! i» the frn>Jers l2!.

It is likely that a old «cclirna-tization mechairism does exist. Thisis defined a» «n i»crea; ed metabolicheat prO h>CtIO» in reepOnze tO eX-tended periods of intermitterit ex-p»a»re t» I trigid envirOnment l I!.I'or sonic people, the combiried .II<! I Of ir>cre:lxcd he:it prO l»CtiOn«rrd hetter knowledge a»d use ofproteCtive nreaSureS increaSe abili-ty to withstand cold temperatures.StarvatiOn aii i fatigu ; m«y '»egatethe cold a ciir»atizotion mecha-niSm by lirrriting the abilitv tOincreaSe heat produC iOII�!.

r. Ward, M. I r > II><te BxM « J. I:88.8 >, Jan. 12,I 97 .D Xm><r««,<, a I .«I<1 < <>< r«-< e«c« ' <le -'d<J< .< w< <t<-'r r<w« t <'«« '..0315, Bar<, septIr>77.

3. rnn>r. I'. .: J«tr<rai«>, v«m.lr < e <3.I 5",!Vov. 10, I >

4. I~9 >nve, a S I >~i «< f ><>< in <'<Ill<><yw<<ri<er>. p.a / r 31, Spring S7<

S. P :te > rorf. Ir. F DIEI<!rt«> ><>> >f hest regula- I«<>. I> H«rns<<n'.< pn< r>r < <Ir <>venal Medi-

7th edir<<>n <>da«<r b! M. 4I. vi >rrobeand <>I>re >. sr~ York, Sr< !raw-rr>rr Soak C <�Isr4, p.sa.

II. �11< W t F x. I< < x 4«<'< ~io<> ~ <I theJ r«><le arur * r< v< '< «>1 l«Ala<I. <'< P< ri '< ee.l&«< <> M«' I I 1 2S XI. < J>17'3

7. 1!« :P, M,< t««:<«<I «�< n «'vi<~ <«< <r '< hvo< m in<I I«'< .<1<I<Ii<-«<i~< r<J <'" »m<r i<'«< err< I'! S » I« <. I'I",S'i<-ii«<ni, I J ., ~« I «th r I 'r<J' <t< l» <JI the< x . L~ry <J-'« < <<i« ll-�2 ..s< X. I >7 r.

9 P«ner, I. M ..<'«I « > err I< rs-arteriai <!mp> t><'.ti<' I<I > 'k«ae <n the tre'>rment «I Jr <>rt<ite,I «.IS«<X, I .825, N<>v I�a

10. 'h<>r>a<>, I. < ~ >d <> I< '<>. Bl >od ms >la ><>>>~»d J >mu «r <pi<-'«J <'h«nrr s as J<-'uted w hIr«irh<t ' a h< ;S ar <l«a<:. r««~! <4««<'>e«<rla 152, No" I'>7S.

Ir. I~«<- 'Il Sr ;<<Id i <j >res: r< ><lb< r and hypo-IIM'r « a. J,. < < r'«ll Hear<h:J«a<><. 23.2<X!-20I,I'er> 19 5.

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M/inter trauma

Acci lental hypotherniia, a condi-tion associated with a core tem-perature of 34.4'C 94"I } or lower,results when an individual losesmore heat to the environment

than he produces. Heat loss mayoccur rapidly, as from immersionin cold water, or slaw1y, as fromprolonged exposure to wet, coldweather. Drugs, disease, or fail-ure of the temperature-regulat-ing mechanism may be underly-ing factors.

Although you will rarely en-counter hypothermia, it's some-thing you would not want ta miss.!f you' re presented with a coma-tose or sernicomatose patient, whohas a history of exposure to coldor wet, rule out hypothermia ~itha low-reading thermometer. Arectal reading is a much more ac-curate representation of coretemperature than oral or axillaryreading. If the temperature is34.4'C 94'F! or lower, you' refaced tvith an emergency situa-tion requiring immediate inter-vention. The patient may be vol-urne-depleted and in metabolicacidosis; he niay develop seriousarrhythmias, including atrial andventricular fibrillation.

You do have one thing going foryou, however, par ticularly if thehypothermia is due to prolongedrather than acute heat loss: Thepatient is literally in a metabolicicebox, which gives you time to

Prepared in Consultation with.'.ay out a plan of action. f rnce youbegin rewarming the victim,clranges will occur fast, rt quiringquick and sure actions.

In the following article, youwill find pointers on the diagno-sis and management of hypo-tllerrnia, a discussion of its physi-ologic changes, and tips for help-ing outdoor enthusiasts avoid hy-pothermia.

Cameron C. Sangs, MDinternisl. Oregon City; clinical ins ruclor ofmedicine, Unrversity of Oregon MedicalSchool. Portland

. Murray P. Hamlet. DVMdirector, exqerimentat pathology division,U.S Army Research tnstitute ofEnvironmental Medicine. Natick, lvlass,

william J, Mills, Jr., MDorthopedic surgeon, Anchorage, Alaska

Staff editor: Rebecca Skinner

� ex peess sTop

ft1afting the diagnosis: The peoplemost susceptible to hypothermiainclude drug abusers, trauma vic-tims, those with debilitating dis-eases, and unprepared or injuredhikers, hunters, and mountaineers.The person with hypothermia fnaypresent as withdrawn, depressed,and uncoordinaled, with slurredspeech; he may be in a state easiiymistaken for death. Anyone with al-tered consciousness after coldand/or wetness exposure shouldhave his temperature takeri with alow-reading recta! thermometer,

Anything that modifies thebody's ability to regulate temper-ature can contribute to tht. devel-

opment of hypothermia in thepatient exposed to cold � not nec-essarrly freezing � temperaturesand/or wetness. Some of the morecotnmon contributing factors are:» Drugs Same drugs, such as al-coliol, may render the person whoabuses them u»able or unwillingto seek she1ter. Barbiturates,

r~iitir in r.w.nr rara vs~ i ~ is ixrr,

li tBIP fOl" 'tkB VlCtlN Gl 5JP3".ii iBiYt liB

pemlureala~us,

Hypothermia

SXPRKSS STOP

morphine, and phenothiazinesniay actually decrease body tem-perature.» Disc<tse A debilitating dis-ease � particularly di Tuse- skindiseases and metabolic disor<lei ssuch as myxedema � will make anindividual more prone to develophypothermia,» Tt'<l1<11<g An iildividua] who

suEers a head injury, fracture, crblood loss in a situation where

rescue is delayed may become hy-potherinic. If an accident while

,ting or skin <living in cold ~va-ter docsn t result in drowtiing,it's almost sure to res~it in hypo-thermia unless the victim is re-

moved from the water in min-

utes.

» Extrentes of age In prematurebirths, hypothermia is a seriousproblem. In the very old, arterio-sclerosis or central nervous sys-tem disease may impair the tem-perature-regulating mechanism.

Other people at risk are thosewhose occupation, avocation, orlife situation exposes them tocold and jor wet. More hvpo-thermia. occurs in cities aniongderelicts and older people than inthe wilderness among healthypeople see the patient,-educe.tie naid, "Hypothermia: Rare butdan---".ous," at left!.

~pelunkers and speleoiol:is tsare at risk. The camper, hiker,mountaineer, or hunter who is

pe7l~TC.LAC r Fr< W~1S, rp77

unprepared for ivcather condi-tions or wlio gets injured or lost issusceptible. The big killers aremoisture and wind; fatigue, dehy-dration, improper clotl.ing, andignorance about buillling sheltersor fires are accomplices.

How the patient with hypo-thermia presents dellends on howcold he is. Unless tlie patient isunconscious due to head injury or<lrunkenness, marked shivering,witlidr;iwal, apatliy, «nd depres-sion occur l'irst. Provided no fur-

ther cooling occurs, a patient.Ivith these syniptoms is»ot in se-rious trouble; his temperature isproba.bly over 34.4eC 94 F!.* At,about 34.4'C 94'F!, the victim

will become indecisive, irritable,and uncoordinated. Shiveringmay stop. With a teniperature of31. 1 � 32.2 C 88-90'I'!, a personmay either be lethar ic or comba-tive. He may have hallucinationsor be delirious. Under 311'C

88'F!, the patient will becomeprogressively delirious and un-coordinated, eventual 1 y corna.-

tose..

The severely hypotliermic pa-tient is often mistal<e» for dead.He may be in a state oi rigor in aflexed or huddled position. He' llbe cyanotic and pale, aiid his pu-pils may be fixed. You lnay fi 1d noaudible heart sounds, palpableThe <t'mpern<uree pfeeiden err penerel jruplrllrleli,

Secre peeple ere eereeteee ~ < '33..'I C !i' I'>; ethera ereeeeee>oue e< 3IYC I8G'F3.

pulses, or visible respiratory ex-cursions.

Rescuers sometimes find thesemicomatose or corn' tose pa-l.ient in a state of un<iress, The

victim of hypothermia often at-l,enipts to remove clothing, whichni;iy lea<l police o suspect sexual<assault.

IIypothcrinin is inore commont,han realized. Suspect it ~vhenev-er;i p;iticnt ln csents with an al-tere<l coiisciousness fol.'. !wing ex-posure to col,l «n<l/or ivetness.Think of it iii an older personfound uiiconscious in a poorlyheated «partinent, The diagnosisIs made by taking the patient' s:empet ature, A los-reading ther-mom'eter is essential, and a, rectal

! eading is preferable. A tentpera-ture of 34.4 C 94*1"! or below is

hypothermic.In general, tne healtliy person

has a good chance of re.overy. Ifalcohol or drug abuse is involved,his chances al.e lowered. The in-

dividual with severe disease who

develops hypothermia. has a verypoor chance of recovery.

initial steps in care: Handle the pa-tient gently. Ensure a patent air-way; intubate only it necessary.Evaluate and plan your approach.Vionitor temperature, ECG, and uri-nary output. Gct a CBC,-s.rum elec-trolyte determination, blood gases,and serum glucose determination.

Hypothermia

� EXPRESS STOP

Check for other diseases or inju-ries. 8egin correcting voiume de-pletion in ail patients except thosewith acute hypothermia.

FIospitalize the patient ~vith hy-pothermia as soon as possible. Asyou treat tlie patient, keep inmind two ger>eral principles:>> Excessive manipulation of thepatient can cause ventricularfibrillation, so handle him veryen tl y,

» Most problems ivill resolvecutaneously wi th rewar mi ng;

be conservative and do not over-

tre at.

Establish a patent airway. Ifendotracheal intubation is neces-

sary, use extreme caution toavoid fibrillation. Anesthetizetopically. If the patient requiresoxygen, consider administering100 percent humidified oxygen,heated to 46.2'C �15'I'!, usingpositive pressure respiration. Donot overventilate; to do so in-

creases the chance of ventricular

fibrillation. Some physician.;have observed that many pa-tients with hypothermia exhibit athick mucus that requires aspira-tion for adequate respira,tion.

Tkororr 01tlrJ er;acuate the pa-tietrt. Look for predisposing fac-t~s such as drunkenness or con-

,itant injuries that may aKectrewarnling methods or requireadditional care. If pottttibie, find.

ygT>mT*I st. "iYi&'IICXR tC, >Drt

out, how cooling occurreil. Exceptitl rlcal-dr'owning vrctnns, raprdcoolirig results in fewer nietabolicalterations than slow cooling.

Pfo.n ryon.r rr!!proa<:h. Your nla-jor corlce ms, beyond t. eturrilngthe tcruperature to normal, willbe correction of volume rnid aci-

dosis and avoidin serious car-

diac problems. Once rewarmingbegins, complications can arisequicklv. Tlie first 20 minutes oftreatment are the most critical,

Bc J<l n nutitorinJ< tetn perature,ZCG, a»d ttri>rary or<tpt<t. As soonas possible, start an IV; a cut-down may be necessary. Try toobtain enough blood for a CBC,serum electrolytes, arterial bloodgases, and serum glucose, At-tempt a CVP reading, br<t do notinsert tlute catheter tip into t!reheart. That can cause fibrillation,

Remember to have the lab cor-

rect the results of blood "ases for

temperature. Insert a urinarycatheter.

Unless sudden immersion in

very cold wa.ter caused the pa-tient's hypotnermia, suspect vol-ume depletiori. rXot only does heatloss increase diuresis, but usuallythe patient's intal e is reduced.Begin volume expansion prompt-lv, exerting caution if tlie fluidcontains potassium. !Var m thefluid in a blood warmer to 36.7-43.3'C 98-110'I'!, so tliat it runs

in at about normal body tempera-

ttrie. Try to hold the central ve-rrous pressure at 5-10 cm FI~O.An otherwise healthy patientmay require up to one liter off!uid in the f rst hour, IIyper-glyceniia blood sugars up to 400mg/rll! is not uriusu rl because in-sulin is relative ly inactive at lowtemperatures. 13o not administerinsulin. IEypol..lycemia has alsobeen reported in liypothermiavictinis; treat l>ypoglycemic pa-tients ivith dextrose.

Rewarming: With a patient with hy-pothermia due to rapid heat loss orwith a core temperature above32.2-33.3"C 90-92'F!, rewarm ext-ernaily in a warm water bath. Forother' patients, internal rewarmingmay prevent a dangerous afterdropin tempera-ture. But with carefulmonitoring, external rewarrning hasbeen successful even in patientswith very tow temperatures. For in-ternal rewarming, heated peritonealdialysis with potassium-free dialy-sate fluid is used most often.

lilith careful moriitoring; of thepatient, rewarming can b begun.Although the rrethod of ~ ewarm-ing is a matter of controversy, allauthorities agr'ee tllat a !iy pa-tient whose temperature is over3r.2-33.3'C �0-9'I"! carr be re-

warnied externally ivi tli littlerisk of complica.t,ions attr;butableto the reivarming procr.ss. Thepatient with a, lower tern perature

j&11lw s nvm,

&~VZi~I<

R -':='u "GU:- P" '!:-N, tS hYPC ~ K=;is'.~C Decision points in heavy outline!

;;;lining.r.i. dialysis

nietiiod.po tassIUm-

liul d lo,' hi I I rl g

ood- wa rm-rsed in ar at 54,4'C

I ITI!ng; Thenod 15 im-the torso intrrn watert3 -106'F!!,arms andwater via a

to avoidov0 le rniC

ming tech-I Ilia r to yotfted to thepatient.

YES

it's tem-per 32.2-

NO

=an be re.la'�y with lit-ip li CationS.

osl olio, cons iciery in warm water.

COPyrlght C' 1977 by Milter end Fink CprPOraticn VO Pnrt Ot lhiS FIOWChnrt may be reprnd COO Or OXtraoted in any fOrm wiihOV'I ihe Written permiSSIOn OiFlowchart service, Box 1245, parton, CT 068?Il. which prepares Flowcharis ior Pef enr care and reserves all republication r ghts 4 collect on ol morethan 200 Ftowcherts and en tlpdating service are available from ihe pubhsher.

I'ATI rrr I&he / rrr r. r. f $ rt 14, Irryr

Hypolhejmia

lure, ECG. blood Pres-sure, blood gases, and se-

BAVIN:NT '.ARl I CK CTWN A 1%, 'IP77

Hypothermia

Quiz A.nswers

Questions on page 13

1. neonatal tOtal bloOd exChange

2, d! t,000

3. d! 20

4. c! dextran

5. d! hypersplenism

6. b! false, 'Or every unit of lost blood replaced by packed red cell, on y 3percent ol the body albumin is removed,

7. d! t2-l4

8. stop the clotling ccnsumplicn by administration Of heparin: decrease theclotting depiction by adrninistraiicn ol fresh frozen plasma ana platoiet:9. d! factor-IX concentrate prothrontbin complex!

10. e! all of the above

11,34 4 C 94 F!

12, immersion iri cold water.

13. within fiv days

14. peritonea! dialysis.

15. b! false; asthma is not a psychologcai illness; its physiologic factors,usually built on a chronicity from immunologic and other levels, evoive aSthe patient sets up pathways through which he can expreSS anxiety. No par-tiCular type Of perSOnality StampS a perSOn aS aSthma prOne.

'le. b! false: refer patient and family for psychological evaluation as soonas you suspect that no medicat management will work.

17. the Jacobson progressive relaxation procedures; breathing exercisesmay also help.

1e. c! s-e

19. Palpation of the muscle posteriOr tO the upper last molar will produce ex-quisite pain if spasm is present.

20. a! true

21. elicit a positive jump response at the pOint of max~mum deep hy-pe ra Igesia.

22. a! dull and constant.

23. c! ice packs

24. restore affected muscles to noirr al length.

sslei Ied ituizres tro n past issues oi PH igniieri, write'psiienl Caie Quir Biioi., $61riornd,

due to cold ~vater immersion can

a!so be re~varmed extcrr. stiiy ivitbsafety.

Some authorities maintain that

external methods sucli as immer-

SiOn ln vertu Water may be harm-ful to some patients. The contro-versy involves the rem am'.in@ of

Hy p oci ioi mIQ

ne t ave � ~s .een oneCG change is Ine

iam J. willa.Jr,. MO

a. patient with a core tempera-ture under 32.2-33.3'C 90-92'F,'1,whose condition is due to pro-longed exposure. Many physi-cians prefer internal rewarming,for the following reasons:» ln the individual whose boilylras cooled over a long period oLtime, acid and potassium have ac-cumulated in the periphery of thebody, which is also the coldestarea sec "Thc physlolol'y of hy-po th cI m i a, page Lii!.» 1"xtcl'nal rcwarming results in

iphcral vasodilation so thatl..eod frOm the cOre moveS tO the

periphery, and cold, acidoticblood moves to the core. Tl>is maycause a drop in pH and in coretemperature afterdrop of O.ci-.1.7'C �,3'F! and a. rise in sei'um

potassium. A type of hypovolemicshock rewarIning shock! may de-velop, and the patient's alreadylife-threatening condition mayworsen.

A consultant for this articlewith considerable experience intreating cold injuries in Alaska'reports using external rewarm-ing successfully for patients withtemperatures as low as 23.99C�5'F!, p articu1 arly those wh osuft'er both hypothermia andfrostbite."" Rewarming in a tubof warm water �2.2 � 4.1'C t90-

See "'IVheri your iraaieat aul7era fraatbite." Cat~catCare, February i. i977, page 199.

Pt Ii%7 near eee! i,'nf ll ip 92'i77

10ti F]! treats both prob lelYls atonce. Prior correction oi the vol-

ume depletion with warm Iluidsand of acidosis with bicarbonateforestalls afterdrop in tempera-ture, he says, and constant moni-toring of the very rapid chan< escaused by thawing in a tub ofwarm water enables qilicl. correc-tive action «s necessary.

The preferred nietho i Of exter-nal rewarming is partial irnmer-

sion in warm water �2."-41,J. C[90-106'F]!. Immersing just thetorso � rigging up a sling systemto keep the hea:l, legs, and armsout of the wat r � may preventsome after<lrop in temperatureby warlning only the parts closestto the col'c. Ilc wcvcr, y 3u 131ay,vant to immerse the whcle bodywhen frostbite af feet or llands isa con|plication, A I cvi'arnlingblanket set at 4l!.0-43.390 L04-

Hypothermia

1 rtlt rirt hypothis t>y tirit ltottonic hit;il trt tho sIta 1, wl1OrO il it lii dialysalo Iod lo nIDOUt 'l:l hy ri>nninrg;1rt-warrninrt coilrrtod in a but:r!er twO titerS Oi in and then srtia.oiy withdraw

KxpREss srof

110'F! is less effectiv therapy.For lnfortlal rclvat iriliig, many

mefliods h:ive been eniployc<l suc-cessfully, buf, heated peritonealdialysis is used most often, 'Lieutregular potassiuin-free dialysa'.ef't iid to 43.3 C �10'F! by runnirigit, through a blood->varying coilimmersed in a bucket of ivatei at54.4'C �30'I"!. Add hot ivater tothe pail as needed to keep the wa-ter at the pt oper temperature. {Iftime permits, the quid may beheated in a ~vatcr batli,!

Run in twc liters of Quid as rap-idly as possible � in about 10 in:ln-utes � and then inimediately re-move it via the same trocar.Pepeat the exchange as nec s-sary. Usually six exchanges l,'12liters of Quid! are sufhcient, kiutone patient required 18 liters ofheated Quid to bring the coretemperature from 26,7'C 80'It'! to%.6 C 96'I"!.

Because you need to dialyzethe patient for only about twohours, the risk of infection is low-er than for longer or repeated di-alysis. But culture the first, fi:,'th,and tenth exchanges,

Other effective techniques forinternal reivarming are of limI tedusefulness because they requirean expertise not readily availablein many community hospitals.Examples are cardiopulmortarybypass and femoral A-V shunt;.

Internal rewarming techniques

PA, iIi<1 OIA ,' PCCC1>rirA 15. I ti77

that have proved ineffectivewhen used alone include warmedIV fluids, hot enemas, and heatedinspired air. These techniquesare good adjuncts to other re-v arming methods.

During and after rewarming: Con-tinue respiratory support, correc-tion of volume, and monitoring tem-perature, ECG, blood gases, and

serum elcctrolytes. Ob:ain any oth-er tests that you feel are necessary.Correct aciclosis cautiously. Vostcardiac problems re.,olve spon-taneously, but lidocaine HCI maybe indicatecl for ventricular prema-ture contr" clions. Dofibrillationonly worlds on warm heart . Ensureadequate renal perfusion, u" ingmannitol if necessary. Complica-tions such as pneumonia or renalfailure will occur by the fifth day.

Hypothermia

The physiology of hypothermiaWhat happens as the body losesheat? The cutaneous sensors lor

hot and cold send their messagesto the hypothalamus, which servesas a "compuler" for lemperatureregulation; the information is inte-grated, and impulSeS are transrrlit-ted to the various effector organs tocorrect for heat loss or gain. Whenthe body comes in contact with acold environment. the somatic andautonomic nervous systems andthe endocrine systems are all in-volved with counteracting the cool-ing process, If these responses failand the body continues to cool be-low 34,4'C 94'F!, the metabolicrate slows, oxygen consumptiondecreases, and heart rate slows.

Twa Of the defenSe mecrlaniSmSagainst the cold � vasoconstrictionand shivering � are of particularconcern clinically because of theirroles in the development of altera-tions in pH, electrolytes, and vol-ume. Vasoconstriction causes fluid

to move from the periphery of thebody, where heat is easily trans-ferred to the environmerit, to the

During rewarming, continue res-piratory support, correction ofvolume, and monitoring of tem-perature, ECG, blood pressure,

d gases, and serum elec...ytes. A determination i se-

rum or urine osmolality will, helpyou monitor volume. Other Itelp-

core, thereby preventing heat loss.The body interprets this shift asoverhydration and shuts off theproduction of antidiuretic hormone,The resulting diuresis producesvolume depletion. In most cases,the individual does not replace thelost fluid.

Shivering, an involuntary musclecontraction that is sometimes vio-lent, produces a considerableamount of heat. Shivering may ele-vate the basal metabolic rate five

ful tests to follow include CPC,platelet count, prothrombin, fib-rinogenn, BUiV, and serum glu-cose, amylase, calcium, and cre-ati ni ne determinations.

After rewarming the patient,obtain chest X-rays to check forpneumonia and skull X-rays to

times increasing the musclesneed for oxygen and glucose. I ac-tic acid and other metabolites ac-cumulate.

When the body cools enough forthe metabolic rale to slow down,oxygen supply is depressed, con-tributing to met- bolic acidosis.Cardiac irritability occurs, ir partdue to electrolyte imbalanc= andthe Slowed heart rate. At this saint.the incfividual exhibits the symp-toms of a slowed metabolic rate�altered consciousriess and incoor-

cfiration, eventually coma.TIIie longer the body is cold, the

more severe the metabolic altera-

tions. The patient whose heal iossis acute due to cold water irnrner-

siort exhibits only the effects of aslowed metabo!ism. On the otherhand, the patient with slow heatloss from exposure exhibits severedisturbances of pH and elec-trolytes as well as cf volume. iheseabnormalities are often aggravatedby an underlying condition sut=h asdiabetic ketoacidosis or alcohol in-tax ICatian.

riile out any hea.d injury.Most victinis of hypothermia

are in metabolic acidosis. A cau-tion: Patients «.ho have under-

gorie considerable stress may[ref'ely] exhibit a .urlini: s ulcerapd alkalosis.! 'El lood gas and elec-trolyte measu r en>ents change

kypothermia

!G: hfou iaa u Coifner, 19'70 freyr

r Goiak SprfurrIIIran Wet,urra Ir.k' Hyporkerauiea York, Grurae f

I"nearonauouiul iy Park Preaa, ISe>a rare-Phy air I

Eurirnururulniraiiy Park Preaf SeIcllee-Phpa

rapi<lly as rewarming pl ogresses;get, repeat readings at 15-20 rnin-ute intervals for an hour, tlien;isoften as you feel is necessary. Re-mind the lab to correct. blood gasfireadings for temperature. Cor"rect the acidosis with sodium bi-

en;bonate, but move cautiously.Do not try for normal measure.ments; as the patient rewarmsahe will revert to normal spon-taneously. Too vigorous correc-tion niay result. in alkalosis.

Avoid cardiac complications bynot, inserting the CVP or Sivan-

Ganz catheter tip into the heart�bv correcting volume and pH, andby carefut rewarming. Cardiacstimulants are rarely indicated,

Atrial arrhythmia or fibrilla-tion is a conimon complication ofhypothermia. Sometimes theECG exhibits a positive deflectionin the ST segment � a J-wave orOsborne wave. The Q-T durationis usually prolonged. These ab-normalities will make you feelyou should be doing somethingabout them, but in hypothermia,do liothillg. Antiarrhythmicdrugs are ineftective and poten-tially toxic; atrial arrhythmiasand ECG abnorma,lities will re-

solve with rewarming.Ventricular arrhythrnias and

fibrillation also may occur. Thetreatment of choice for ventricu-

lar premature contractions is lid-ocaine HC1 Xylocaine!. The heart

will not respond to defil» illationwilen the patient is cnhl, lf fibril-lat,ion occurs, use closed chestcolnpression during internal re-warming or put the patient on aheart-lung machine. 0»ce thetemperature reaches 32.2'C 90'I !, defibrillation may work.

Ensure adequate renal perfu-sion, using mannitol Osinitrol! if1'lee e ssa l'y,

Pneumonia is the inost common

Sequela Of hypothernlia. It isprobably a result of bronchor-rhea. Manage it or any other in-fection that develops with appro-priate antibiotics.

A concomitant injury resultingin hemorrhage may require theadministration of blood. GI bleed-

ing may be a consequence of hy-pothermia.

For several days � maybe evenweeks � after resuscitation, thepatient's temperature-regulatingmechanism will function poorly,and he should avoid temperatureextremes, His temperature mayfluctuate 2-3'. A few patients whorecover from severe hypothermiacomplain of temperature-regulat-ing problems for years.

Renal failure rarely occurs ifrenal perfusion is maintainedand hypovolemia is corrected.Hypertension is a warning sign.Very rare complications includepancreatitis, disseminated in-travascular coagulation, episod es

of hp potension, perit,oneal infec-tioi, 'fron> di;dy -.is, ileus, psychia-tric disorders, and myocardial in-farction.

I ly poth crmia alone d oes notcause brain damage � even in pa-tients wlio were comatose.

Kith niild h,.potherm Ia � over33.3'C 9"'F! � you can silnply re-wai'm the patient. and si.'nd himhome, unless he has other inju-rieS requiring ti.eat,nient. The pa-tient ivhose temperature is below33.3'C D2'F! sliould be monitored

very ClOSely fOr 24 hOulS. i!IOStshould remain hospitalized for3-5 days after rewarming. Com-plications, if tliey occur, usuallydo so by the fiftl i day.

As a general rule, see the pa-tient again about a week afterthe injury. Further fbi!low-upvaries, depending on other inju-ries, such as frostbite or frac-

tures, or underlying factors suchas diabetes or alcoholism.

PATIEtfT GAAE I DEGEI <rrcfl 15. ffiyy

Winter problems

When your patient suffers frostbitePrepared in consuitation with:

Cameron C. Bangs, MDinteri.ist, Oregon Ci!y; cknical instructor ofmedicine, University of Oregon MedicalSChOOI, POrtland

John A. Boswick, Jr., MDchief, l-,and surgical ser;ice, University ofColorado School of Medic,ne, Denver

Murray P. Hamlet, OVMdirector, experimental pathology divisionU.S Army Research Institute ofBnvironmentai MediCine, NatiCk, MasS.

David S. Sumner. MDprofessor of surgery, Southern I!IinoisUniversity School of Medicine. Spnngfield

R.C.A, Weatherfey-White, MOassistant clinical prcfessor of surgery,

rsity of Colorado School ofine, Denver

Rev'ewed prior to publication by:

William J, Mills, Jr.. MDorthopedic surgeon, Anchorage Alaska

Hazards of frostbite extend beyond winter anc subtemoerate zones,;his oatier.t was lockedlor 24 hours in a railroad refrigerator car with a:emperature of � 20' I '-2B9' C',. His lectwere most severely affected because boots const«cted the circulation

Staff W for: Rebecca Skinner

PATIEkr CAAE i FEBRuwBY 1. '!977

'With winter resorts drawingweekend ers from thousands ofmiles away, you don't need to bein an area where temperatures dipbelow freezing to see patients whohave suffered partial or totalfreezing of tissues, Anyone ex-posed to subfreezing tempera-tures without adequate protectionis a candidate for frostbite. Espe-cially at risk are sports enthusi-asts � hikers, skiers, hunters, andskimobilers. Also at high risk arethose individuals whose sensorium

is disturbed by alcohol or otherdrugs.

In the following article, author-ities in the care of the victims offrostbite provide a review of the

fundamentals of prevention andtherapy. They also discuss newmodes of therap'> now be.tng in-vestigated and current thinkingon controversial procedures pur-ported to minimize tissue lossfrom frostbite.

Other highlighrs of the articleinclude a patient educati.n aid,"How to avoid frostbite," on page136, which you may reproduce foryour patients; "Rapid thaw forfrostbitten extremities," on page140, describing this tissue-sarontechnique; and, on page 141, aconcise discussioft of hypothermia,the life-threatening condition thatin some instances accompaniesfrostbite.

� EXPAESS STO

Basic treatment: Hospitalize thepatient. Treatment of hypothermia indicated by rectal temperature!has precedence over frostbite ther-apy. For frostbite, begin rapidrewarming in 100'-110'F �7,8'-433 C! water; continue rewarminguntil the tips of the part flush. Pre-scribe an analgesic for pain. Themainstay of postrewarming therapyis whirlpool baths, with an antisep-tic solution added, for 20-30 min-utes, 2-3 times per day. Activephysical therapy helps preventcontracture. Avoid dressings.

While still frozen, even severelyfrostbitten tissue may appear al-most normal. Frozen tissue usu-ally looks pale and feels firm to thetouch. Sometimes a slight ptuylishdiscoloration and insensitivity tolight touch are the only utliicationsthat a part is frostbitten. As arule, the patient describes the aj'-fected part as bulky or "clublike,"implying numbness, He may alsoreport ths,t the part was verypainful before it became numb,Often, however, the frostbittenarea vdl have thawed before yousee the patient. In that case, hwill tell you that as the areawarmed he felt throbbing, burn-ing pain, and a "pins and needles'sensation. Blisters may not ap-pear for a day or two after injury.

Patients with frostbite oftensuffer from hypothermia, thetreatment of which see page 141!

takes precedence over � andsometimes conflicts with � frost-bite therapy. Also examine thepatient for other injuries such asfractures or dislocations.

You will not be able to judge theextent of injury when you first seethe patient. To get some idea,however, take a car eful history ofthe kind and length of exposure;ask about protection fr om clothingand verify the temperature and>~md velocity at the time of expo-sure from the local weather sta-tion. Also flnd out about hispreinjury physical condition, par-ticularly relating to the vascularand peripheral nervous systems.

Hospitalize every frostbite vic-tim. The first step m emergencycare is rapid rewarming in waterat 100'-110 F �7.8'-43.8'C!; use athermometer and keep the watertemperature within this range see page 140!. Slower rewarm-ing � starting with cold water andslowly adding warmer water�contributes to tissue loss. Re-warming at temperatureshigher than 112'F �4.4 C! mayadd burn injury to the frostbite.An ear or nose may be thawed bypouring warm water over thepart, Continue the rewarmingprocess until the tips of the partflush, which may require 45 min-utes or longer.

During rewarming, aspirin pro-vides sm%cient analgesia for some

patients; others require as muchas 100 mg of meperidine HCl De-merol! or 15 mg of morphine sul-fate in order to tolerate the treat-ment, Remember, howe rer, thathypothermia may prolong opiatemetabolism.

After rapid rewarming, themainstay of therapy is vigorouswhirlpool baths in a solution towhich an antiseptic such as poxi-done-iodine Betadine! or hexa-chlorophene has been added.Repeated for 20-,'<0 minutes, 2-3times a day, whirlpool therapydebrides the injury safely, allevi-ates pain, and helps control iMec-tion. While the patient is in thewhirlpool, active, continuous,complete range-of-motion physicaltherapy should be done to preventflexion contracture dur:ing thehealing process.

Keep the patient hospitalized atleast until you can estirrIate theseverity of injurI:. Home care issatisfactorv for most superficialinjuries that are limited to ears,nose, and knees. >fore severe in-juries and most i1njuries to handsand feet may require pe«hapsseveral months ~f hospita...ization.

A fairly accurate estimate ofextent of injury can be made bypalpating the pul=es, ordering aDoppler scan or I echnetium-99mmstudies, and noting evidence oftissue demarcatI.on and necrosis.Researchers are investigating the

PATIENT CAAE / PEBAU*AY 1. 1977

Frostbite

in healingJ Mari ed eoema and:ister ',ormation deni.-ate deep

fros;b;te. The blisters are reddish and no! t anslucent

2 Two cays later. the a ea has been debriaed. and '.he '.is ueunderneath is red and sensitive locking.

3 . en days after frostbite areas of thick black crusts appear,

4 Twc Aeeks postfrost'cite, it is obvious that ",c tissue csson Ine ear will ensue. This patient, however. ost allfinge.s cn both hands as a result cf his xpcsure to co.'d

PATIENT CARE / PesRLJARY 1, 1977

use of infrared thermography tohelp determine the severity of in-jury, make early decisions on sur-gery, and assess the progress oftherapy,

If the feet are invOlve, pre-scribe bed rest and a cradle tokeep bedclothes off the injury.Elevate frostbitten hands on pil-lows or with a sling. Separate fro-zen digits with small wedges ofcotton. Avoid dressings, butloosely wrapped sterile towe'..s arepermissible to help protect theextremity. Make sure sterilesheets are used on the bed.

Forbid smoking for the patient

recovering fr om 'rostbite; vaso-constriction caused by nicotinemay aggravate the inju v.

Authorities disagre~ onwhether removing blisters ~r

medica! folk belief ever given youan insight that helped patient care7If you have an amusing cr ir terest-

s alSO inStruCtive,

e Bc i ter, Patier.f

C;role, P.O. Box

06820 If we pub-

cu $25.

leaving then. intact best preventsinfection. All agree that punctur--ing the skin and allowing the blis-ter to collapse without debridinginvite infection, The patient may'oe more co&ortabie tvith largeblister= ro.;!r.ved. 4Vhen blistersdo break spontaneou.ly, be sureto debride them to avoid over-hanging edges.

Tetanus prophylaxis* is indi-cated for patients with frostbite,but prophylactic antibiotics arenot. If signs of infec"ion de:cloparound the injury,� do a Gram's

«See nte who, «hat, and when of tetanus pt«sphy-laais." Pausai Ca;~. August 1, 'i!ITS page l44,

Instructions for your patient

How to avoid frostbite

Wind chill factor chart

Actual thetmorneter readingEstimatedwind speed

ln mphj!'F 'C! 'F i 'C!0 <-17.8! -10 -23.3!

'F <'C!50 <10!

'F 'C!40 �.4!

'F 'C!20 <-6.?!

1F ~ C!10 -1 2. 2!

'F 'C!30 -1.1!

EQUIVALENT TEMPERATURE

50 �0> � 4! i 0 -12.2!30 - I 1! 0 -'I si20 -6,7! -1: i � 233!calm

,'37 �.g!

28 -2.2!

6 i-144!

-9 -22.8>

-5 -20.5>

-24 -.,1.! I

27 -2.7!

16 -8.9!

15 -e 9!

4 -15.6!

48 89>

40 � cl

- l5 - 5 I!

-33 � 36,1!10

'- -'32 -'-S,o!36 �.2! :: -45 -42.8!

-53 -c/ 2!

15 � 18 t-27 8>

-25 -31.7! '-

9 � 12.7!

4 -15,6>

� 5 I � 20.6>

� 10 � 23 3!

22 -5,6!

'8 -7 8!32 �> � 39 -39.4! '

-59 -50.6!

-63 � 52.8!

30 - I 1!

28 -2.2!

-44 -42.2!

-48 -44. 4!

� 29 -33 9!

-33 <-36.1!

0 -17 8>

-2 -18.9>

16 � 8,9!

".3 � 10.6!

� 15 l � 26. 1!

--18 -27.8!

-67 � 55!

-6!9 -56. 1!

-35 -37.2!

-37 <-38,3!

27 -2.7!

26 -44!

-51 -46.1>

-53 � 47.2!

'i1 � 11.7!

0 -12,2>

� 4 i � 20!

-6 -21 1!

-20 -2I3 9>

--21 -29 4!

Wind speeds greaterthan 40 mph have littleadditional effect >

INCREASING DANGERDanger from freezing of exp. sed tlesh.

LITTLE DANGER for properly clothed person!.Maximum dangei of false sense of secutity.

ffote ftypothermia. trencnfoot, and immerardn tOOt may occttr Kt any point on thiS chart

This patient educaiion ard may be reproduced oy office copier for distribution by physicians to their oaeents. Yyritte~ permission is required ioi snr otiter use

PATIENT CARP r f EjrnuARY 1. 19TT

To avoid frostbite when you are ex-posed to subfreezing temperature,you must protect yourself against notjust cold but also the conditions Ihatincrease body heat loss: moisture andwind, Because moisture conducts

heat, it is of utmost importance to re-main dry. Wetness, whether from rain,snow, or perspiration, speeds I eatconduction away from your body,

Wind has a marked effect on heat

toss. If the thermometer reads 20'F

� 6.7'C! and the wind speed is 20mph, the exposure is comparable to-10 F � 23.3 C!. This is called thewind chill factor, A rough measure ofwind velocity is: If you feel the wind onyour face, the velocity is about �mph; if small branches move or dustor snow is raised, 20 mph; if largebranches are moving. 30 mph; and ifa whole tree bends, about 40 mph. To

obtain an idea of the relative degreesof danger according to combinationsof wind speed and thermometer read-ing, study the wind chill factor chart.

Proper clothing for winter weatherprovides insulation from cold, ventila-tion so that perspiration can evapo-rate, and protection against wind, rain,or snow. Rather than one bulky,heavy, or constricting garment, wearseveral layers of light, loose clothingthat will trap air, a very effective in-sulator, and provide adequate ventila-tion. Wool and polyester downsubstitutes retain some protectivevalue when wet; cotto~ and goose orduck down do not.

For ideal protection, wear under-clothing made of cotton or cotton-lined!; it will absorb perspiration.Wear layers of wool or synthetic downbetween underwear and the outer

layer of a water-iepellent a-d wind-proof coverng. Waterproof clcthingis not recommended since i'. holds in

the moisture produced by your body.!Protect your head and neet; with ascarf and a hat or hood and your lacewith a mask Wear two pairs «f socks� both wool or one cotton and the

other wool � and well-fittir,g bootshigh enOugh ta prateCt your ankleS.

Your hands are better protected bymittens than gloves, but keep n mindthat since mittens limit what you cando with your finge s, you may need toremove them frequently. By wearinglightweight gloves under mitiens,you will still have protection againstheat IOSS if you remave the;TiittenS.

Be sure that your clothing is nottight. Heat in your extremitie is sup-plied by your blood and anything thathampers blood flow will increase the

Frostbite

~PRESS STOP

'F 'C!-ao -34.4!

F' C!-20 -28.9!

risk of frostb te For this same iea.ondo not remain in a sitting or kneeingposition for long periods of time.

Many people suffer frostbite wt entheir cars break down in freezingweather, Be sure to keep protectiveclothing in your car if there's any r skof breakclown in an isolatecl area.When working on a car in the cold,a' oid getting gasoline on your hands.Wl ile it doesn't freeze, it takes on thetemperature of the surrounding areaand cools skin by evaporation Avoidbare skin contact with metal; don't tryto make repairs without gloves.

Don't walk through the snow in loshoes, If you lack proper protectivclothing, stay in the car, As a rule,

� rescue team is more likely to find yo.f you remain close to your vehicle.

For whatever reason you' re straned in the colcl, if possible use the al

PATiENT CARE / PESRUARY t,1QTT

heater with a window open slightly toguard against caro-�- monoxidepoisoriing or' build a fir=- protect your-self from the wind as n-i ch as possi-ble; if there is no she.'I=r, make onewith tree boughs and/or snow. Butdon't work so fast that you gel wetfrom perspiration or over'.ired, both ofwhich make you more susceptible tocold in!ury. Insulate,.=.self from theground with tree boughs.

Don't drink alcoho,'ic Leverages "tokeep warm." Alcohol makes yourface red ancf gives you a warm feel-ing, but the warmth is deceptive, By

stain and cujture and prescribeantibiotics accordingly. Staphylo-cocci, streptococci, and P~ct do-moTt, as are the most common in-

fecting organisms. If an e~the-matous response typical of strep-tococcal infection appears, it ispermissible to start penicillin oralternative therapy itr.mediatelyand modify the regimeri as cultureresults ind>cate,

Some authorities feel a patientwho has undergone rapidrewarming and has no tissue lossmay be discharged as soon as es-chars are dn if treatments can becontmued at home with a portablewhirlpool,

New or controuersia! therapy: Med-ical sympathectomy with intra-ar-terial reserpine is showing promisein initial investigations. F asciotomyis being reintroduced as therapy forfrostbitten extremities that sweilenough to occlude circulation. Lesssupport can be found for the useof low-molecular-weight dextran,surgical sympathectomy, heparin,or hyperbaric oxygen.

Tissue 1oss from frosti ite is re-lated both to thrombosis of themicrovascular nutritive vesselsand to direct cellular in.ury fromdehydration. enzymatic action,and the mechanical effect of

crystals. Frequently, the vasculardamage is the cieciding factor,since damaged cells are oftencapable of survival if they aregiven an adeauate blood supply.Years of research have r.ot yet

F rOStbite

to the hospital and l epeated every'-3 days over the;:~'st tveek. Gen-erallv, reserpine has no systemiceffect, but some ~ a odllatton mayoccur in other extl emities.

Phenoxybenzar.,ine HC1 Diben-zyline! also appears to be effectivein achieving me<",.cal sympathec-tomy. The sug ested regimen ls10 mg/day, incre..sed gradually to20-60 mg!day if:.ceded,

F'asciotomy, «r. old treatmentfor frostbite. is iow being rem-Mills WJ: Summand of in a ment of the caid injured

panent, +ountain Medica. c.tnpoaiuta. Seatcaber 9-12 1976.

Recognizing and treating hy, ctherrniaAny pa'.ient with a history of exposure should hav:his temperature taken, prefe ably with a Iow-readin"rectal thermometer If his temperature is 94'F�4.4cC!, or below, he is hypothermic, and aggres-sive treatment should be Instituted immediately,

Find out the type ancl length of exaosure. Acu'.ehypothermia from rapid heat loss, such as occursir. coid water immersion, may be treated wtti- aaicexternal reittarming; in chronic hypothermia, ha';ever, rapid external rewarming may be fatal. Chror. =hypothermia results fram a series of small hea.losses. In attemptir g to conserve heat, blood vesselsconstrict and warm blood is shut ted inward: theperiphery af the body � 40-50 percent of the bodyby we'gl t � becomes volume-depleted, The perion-ery is also:he ccldest area and is the area wne eacid and potassium accumulate. To further compli-cate the situation. most victims of chronic hypothet-rnta are dehydrated.

External rewarming causes a per aheral vat 'otion. Blood from the core moves to the periphand cold, ac:datic bloocl moves to lh care resuin a drop in core temperature and pH As bl:oshunted to the periphery, a type or hypavoleshock rewarming shock! may deveicp; the er dsuits may be cardiac arrhythmia ard death.

Specialists in hypothermia mancgement recmend a two-foid .'reatment consisting of volumepat sian and rewarming fron. the core aut. Anyof volun;e expander may be used t'methods ufor rewarming include heateci peritoneal dialadministering warm fluids IV. heated extracorpocirculation taking t;lood out, I;eating t, and ouit back in!, or hea'.ir.g:nspired air. 'v",hen rewarmfrcm the care out s not feasiLle, au:,,arities re=met d warming only,he trunk and nor the extrer-

ihe patient recovering 'rom hypothermia stbe monitored for cardiac arrhythn-iias. theca se of death 'n hypothermia. Blood gase-, stpotassium. and serum glucose also should bElowed closely.

The cat en', actn nycctnet- a r eed -ct have -een eapcsea;c s 'ctteez'«tentaera:U eS 1 inC bitt ae' C: ne.ttiCiert CtCtt tng, Cr tattgue Can Cree Cirate nyCctherrn a at teniCte-e',utes .vet at ore «eezing

PATIENT CARR. f FEBRUARY t, t977

wielded a sure way of improvingthe microcirculation folio ~~ngfreezing,

Specialists in frostbite manage-ment have begun using intra-ar-terial reserpine to provide tempo-rary medical sympathectomv.' Itis said to achieve vasodilationxiithout the complications of sur-gical sympathectomy. In one regi-men, 0.5 mg of reserpine is in-jected intra-arterially proximal tothe frostbitten limb on admission'Porter JM. et al. intra-arteriai svtnpathetlc btocitadein trcattnent of c~rcat frostbite. Am J curtt 1:-2:625-36. 19i6.

traduced,* It is performed whensch elling in a t'rostbitten extremityoccludes circulation. The proce-dure increases blood flow into theextremity, a benefit that out-iveighs the adrled risk of superfi-cial inf ection.

Low-molecular-weight dextran Dextran 40, L.4I.D., Rheoma-crodex, etc.! is thought by somephysicians to be of value in pro-moting microcirculation. Immedi-ately after rewarming., they start

ills WJ Frostbite: A. discussion of the prabtetn anda rcxzea. of an Afaakan etperieni e Aiocka .'Ited15:2T-59. 19ia.

Frostbite

Instructions ior your patient

How to tell if it's frostbite carried will delay your getting to a medical facilityIf you' re caught out in severe cold without adequate by several hours, it is better to walk cn it.protection. you may end up with frostbite. You can If you must thaw the part yourself remember, dotell if part of your body is frostbitten by the way it so only if there is no chance of its refreezing!, followfeels. If t feels numb � what many people describe this procedure to minimize tissue damage: immerseas "clubiike" or bulky � freezing of tissue has proba- the p"rt in water at 100'-110'F �7.8'-43.3'C!; il ably occurred. Some people report the part was thermometer is not available, keep tl.e water al apaintul at first. then became riumb; however, don't temperature that teels comfortably I ot to nor ~aithink that because you feel rio pain, you are not tissue; continue the rewarrning until the tips of yourgetting frostbitten. toes or fingers flush; a foot takes 20-45 minute; to

thaw There may be pain as the part gets warm.What to do about it Oo nor immerse tne injured part in cold water aidGet'to a physician or hospital as soon as possible. add warmer water gradually.Only if you can't get medica' help should you attempt Oo not put the affected part in a warm oven, closeto thaw f~ozen tissue yourself. and even then only to a heat source, or in water hotter than normal tis: uewhen you have reached shelter where there wfi/ be can stand over 112'F or 44.4'C!. Frozen;issue loi esno chance of the parr being refrozen Having a part its abi ity to feel; you can add a burn to the frostbiteof your body frozen solid for severai hours poses Injury without feeling it.much less risk of severe injury titan improper thawing If bl;sters form quickly after thawing, co not try toor refreezing after thawing. break them. Also, do not put bandages, salves, or

Protect the frozen part. Oon't rub it to restore ointments on the part. Separate thawed fingers aidcirculation, and especially do not rub it with snow,;oes with wedges of cotton or small pieces of cleanwhich only adds to the damage. Massage increases cloth. And, if necessary, while traveling to a medicalthe injury to frozen tissue. If you suspect your foot ',acility, protect the part from refreezing with towelsis frostbitten, avoid walking on it However, if being or blankets.

ThiS Patient eCtuCaticrt aic may Ce reorOCtuoed Ciy OtfiCe COPier far diSlribtitiOtt Oy OhySioi>riS tO the» Pasenta Written PermiSSiOn iS requiem rpr arty OtrtSr Oee

low-molecular-weight dextran,giving 1.5 gm/kg IV on the firstday followed by 0.75 gm/kg IVdaily for five days. The rationalefor the use of low-molecular-

weight dextran is that it maystimulate flow in the damagedcapillaries and venules if begunwithm hours of the thaw. Someauthorities � because they feelthere is insuflicient clinical evi-

PATIENT CARE r FEBRIJARY I. 1977

Emergency treatment for fros<bIte

dence supporting efficacy, and be-cause dextran infusion is notwithout risk � recommend dex-tran for only those patients inwhom tissue loss is likely.

Surgical sympathectomy as anearly measure �4-48 hours afterinjury! is supported bv only a fewexperts in frostbite treatment.Advocates of early sympathec-tomy contend that the procedure

relieves vasospasm and results inmore rapid resolution of edemaand earlier distal demarcation.

Opponents counter that possibleadverse effects of sympathectomysuch as impotency are too g.eata penalty for the possible benefits.

Administration of an antico-

agulant such as heparin may behelpful, but its use is corttrctver-sial. Diathermy, in the experience

Frostbite

of some physicians, only increasestissue loss, and the use of hyper-baric oxygen has not been estab-lished as efIicacious.

� EttPRESS STOP

Prognosis: The course of recoverydepends on the extent of irljury.Permanent tissue loss is unlikelywith superficial or partial-thicknessskin loss injury. Deeper injuriesmay require grafting or amputation.Most victims of frostbite experi-ence sequelae; the treatment of thispostfrostbite syndrome is largelysymptomatic and supportive�al-though medical sympathectomyshows promise.

Ta provide vasodilation. eserpine may t:e ir.lectect in tne lemor-i artery or a patient with afroslbitten foot, leSSening vain anti parestl,esia. Administer E mmeC;ately after:he part ttiaws.

PATIENT CARE .' FEBRUARY i, 't977

In a sUperficial injuryt swe,.lingand tenderness subside over a pe-riod from several days to severalweeks. Fingertips or toe tips mayheal in a few days to a week, butif the entire foot is involved, thepatient may require bed rest forthree weeks or more. Skin peelingmay occur,

With partial-thickness skin loss,blisters form anywhere from min-utes to hours after the injury andenlarge for severa1 days. After~-1G days, if they have not beenpunctured, they become soft andrupture; infection is likely to occurat this point. Thick black crustsmay develop and separate, leavingeddish, sometimes sensitive skin.

Joints usually stifFen.In a deep injury mth full-

thickness skin loss, blisters, ifpresent, are small and dark col-

ored and situated proximallv.They do not extend to the tips ofthe digits. Lack of blisters isusually a poor prnmostic sign.!The skin becomes black and de-

velops a tough eschar, which mayrequire incision to prevent con-striction. When the eschar sepa-rates, a layer of granulation tissuewill be left. If there is a large areaof involvement, it may necessitategrafting, and, possibly, amputa-tion.

When the injury extends intothe muscle and bone, there are noblisters and no edema. The partremains cold and bloodless; it issenseless, and the patient is un-

able to move it. The skin becomesdark and loses . olume. ln time thepart will amputate itself; how-ever, most patients prefer sur-gery to auto imputation. Surgicalintervention ' oo early tnay resultin more tissue loss than is neces-sary. Do not consider:.mputationfor at least six weeks after frost-bite injury unless there is infec-tion present or there is a clear lineof demarcation of destroyed tis-sue.

Regardless of the de,gee of in-jury, any patient ivith frostbitemay develop paresthesia, coldsensitivity, excess sweating, cau-salgia, and svmptoms similar toRaynaud's sv»drome, In deeperinjury, bone and joint <.hanges

TREATlNG FROSTBITEttDecisfon points in heavy outtinej

Copyright 41977 by Mtffer and Fink Corporation. Dsnen, Conn.Aif rights reserved. No pari of this Flowchart msy be reprodticed or extracted in any form withoUt wrnten permission oi the cooyr gnt owner.

~ATIEN7 cAF E FEBRUARY i, 1977

may occur, including small,punched-out areas in the bone.Loss of subcutaneous tissue,which may also occur, @rill resultin a reduction of sensitivity in theaffected part.

Treatment of frostbite sequelaeis largely supportive and sympto-matic, but researchers are inves-tigating the use of intra-arterialreserpine in tl;e postfrostbitesyndrome. Initial re ports showgratifying results, with most pa-tients obtaining instant, lastingrelief.

%hen frostbite involves the,

epiphyses in a child, you can ex-pect growth impairment. In blackpatients loss of pigmentation isnot uncommon; in milder cases,this sadl be temporary, but inmore severe cases, it may bepermanent.

t I A retdevr oftheortes and thev apoticatjon to '=eaConn 5fed 39:8-10, 1975.Gage AA, fshtkatva I, '4'inter PM:mental frostbite and htTterbarie oxygsSargevtt 55:1044-50. 1&i9.

3. Gralino BJ, Porter Jhf Roach J; AnghI in the diagnOSia and theranv Of frOStb

diofoffy 119:301m, 1975.Holm PC, Vanggaard L.t Frostbite, P

19 is,xperienoss in the r

A study of 1:ttl.man RM: Seveth survtval afts53 506-10, 19Tivoid. Ktaertrrai 76.: Treatment ol.'

tetra-erterhtiSa rttery 77; 557-5

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