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Nurses need to know how to provide emergency care to victims of wintertime injuries and illnesses--and how to survive such circumstances themselves. In this article, the author, a ski patrol member, describes cold-weather strategies and how to respond to hypothermia, frostbite, winter sports injuries, and avalanches.
Medical difficulties related to otolaryngology that occurred during the Lewis & Clark Expedition (1803-1806) are highlighted. These difficulties included ear and face frostbite, upper respiratory infections, temporal vessel laceration from an air gun accident, neck scrofula, and a pediatric neck mass. The custom of Clatsop Indian head flattening is also described. These descriptions also aim to illustrate the state of otolaryngology during the early 19th century in America.
Exposure to cold can produce a variety of injuries that occur as a result of man's inability to adapt to cold. These injuries can be divided into localized injury to a body part, systemic hypothermia, or a combination of both. Body temperature may fall as a result of heat loss by radiation, evaporation, conduction, and convection. Hypothermia or systemic cold injury occurs when the core body temperature has decreased to 35 degrees C (95 degrees F) or less. The causes of hypothermia are either primary or secondary. Primary, or accidental, hypothermia occurs in healthy individuals inadequately clothed and exposed to severe cooling. In secondary hypothermia, another illness predisposes the individual to accidental hypothermia. Hypothermia affects multiple organs with symptoms of hypothermia that vary according to the severity of cold injury. The diagnosis of hypothermia is easy if the patient is a mountaineer who is stranded in cold weather. However, it may be more difficult in an elderly patient who has been exposed to a cold environment. In either case, the rectal temperature should be checked with a low-reading thermometer. The general principals of prehospital management are to (1) prevent further heat loss, (2) rewarm the body core temperature in advance of the shell, and (3) avoid precipitating ventricular fibrillation. There are two general techniques of rewarming--passive and active. The mechanisms of peripheral cold injury can be divided into phenomena that affect cells and extracellular fluids (direct effects) and those that disrupt the function of the organized tissue and the integrity of the circulation (indirect effects). Generally, no serious damage is seen until tissue freezing occurs. The mildest form of peripheral cold injury is frostnip. Chilblains represent a more severe form of cold injury than frostnip and occur after exposure to nonfreezing temperatures and damp conditions. Immersion (trench) foot, a disease of the sympathetic nerves and blood vessels in the feet, is observed in shipwreck survivors or in soldiers whose feet have been wet, but not freezing, for long periods. Patients with frostbite frequently present with multisystem injuries (e.g., systemic hypothermia, blunt trauma, substance abuse). The freezing of the corneas has been reported to occur in individuals who keep their eyes open in high wind-chill situations without protective goggles (e.g., snowmobilers, cross-country skiers).
The necropsy files of the National Zoological Park and Baltimore Zoological Society were reviewed for cases of distal extremity necrosis (DEN) in birds. Nineteen cases of DEN occurred following either trauma or frostbite. Six birds developed an apparently primary type of DEN in which no predisposing factors were obvious clinically. The toes and feet were most commonly involved, and in several cases the beak was also affected. Some pathologic evidence is provided that certain cardiovascular lesions may predispose birds to DEN by compromising circulation of the extremities.
Winter climate is prone to induce cutaneous and systemic alterations mediated by cold. Xerosis due to the impairment of the desquamation process is not rare on the limbs. Chilbain results from reversible alterations of the dermal vasculature. Cold panniculitis is the consequence of lipid crystallization within adipocytes. More dramatic issues occur when cold exposure extends beyond skin. They are represented by frostbite and body hypothermia. Intensity and duration of cold exposure combined with wind speed, altitude and environmental hygrometric value govern the potential type of low temperature-dependent pathology. Ultraviolet irradiation can also induce cutaneous lesions during winter time.
This report considers how thermal balance of soldiers wearing nuclear, biological and chemical (NBC) protective clothing in combination with the Extreme Cold Weather Clothing System (ECWCS) is affected during work in cold weather. A review of published reports concerning physiological consequences of wearing NBC protective clothing during cold exposure was completed. The findings reported in the experimental literature were too limited to adequately forecast the effects of adding NBC clothing to ECWCS. To remedy the information gap, simulation modeling was employed to predict body temperature changes during alternating bouts of exercise and rest throughout 8 h of exposure to three different severely cold conditions. Published findings indicate that NBC protective clothing may inadequately protect against hand and finger cooling, especially during rest following strenuous activity. No evidence substantiates suggestions that wearing NBC protective masks increases susceptibility to facial frostbite. Collectively, the limited experimental work and the results of simulation modeling argue against any increased risk of hypothermia associated with wearing NBC protective clothing while working in the cold. However, wearing NBC protective clothing during strenuous activity in cold weather may increase the risk of hyperthermia, and cause sweat accumulation in clothing which may compromise insulation and increase the risk of hypothermia during subsequent periods of inactivity.
INTRODUCTION: Cold weather has been recognized in the Israel Defense Forces (IDF) as a potential medical and operational threat to the soldier. Although regulations have been issued to cope with this situation, every year about 20 cases of hypothermia (T(core) < 35 degrees C) and peripheral cold injuries are reported. METHODS: This study was aimed at following cold weather injuries (CI) in the IDF in the period 1994-2001. 136 cases were reported to our institute during this period. All patients were from the general population of young (20 +/- 2 yr), male soldiers in the IDF. All were classified a priori as healthy, active subjects. RESULTS: Of these patients, 51% were diagnosed with mild hypothermia and 49% with peripheral CI. Among those soldiers who suffered from peripheral CI, less than 5% were diagnosed with frostbite. Most of the cases (76%) occurred in the winter months; however, 10% occurred in the spring, 13% in autumn, and 2 cases (1%) were reported in the summer. The majority of all CI cases occurred during routine scheduled training (51%), and 15% occurred during routine duties. Of the cases, 34% occurred during combat operations (mainly ambushing and surveillance). DISCUSSION: The present study provides data on CI cases in an army where the awareness of the hazards involved in hostile environments is extensive, and in which detailed regulations aimed to prevent these injuries are common practice. The Israeli experience indicates that CI is preventable in most instances by following a few simple regulations and providing proper education to the soldiers and their commanding officers.
BACKGROUND: Cold weather injuries (CWI) are of great military concern due to their wide-ranging impact on military readiness. Previous short-term studies have identified CWI to be more prevalent in African-Americans, infantrymen, and lower-ranking soldiers. The purpose of this cross-sectional study was to determine the occurrence of CWI hospitalizations in the U.S. Army from 1980 to 1999, and to identify possible trends, high-risk groups and/or activities. METHODS: The U.S. Army Research Institute of Environmental Medicine Total Army Injury and Health Outcomes Database was searched for hospitalizations with ICD-9-CM codes for frostbite, hypothermia, immersion foot, chilblains, and other. Information concerning each soldier included: gender, age, ethnicity, rank, occupation, type of injury, home of record, duty station, principle diagnosis, trauma code, and cause of injury. Data was available on the demographic composition of the Army, by year, and was used as the denominator when calculating the frequency of occurrence. RESULTS: During the study period there were 2143 hospitalizations due to CWI. African-American men and women were injured approximately 4 times and 2.2 times as often as their Caucasian counterparts, respectively. Trauma and cause of injury codes indicate that about 80% of all CWI hospitalizations result on-duty and during organized training. The yearly rate of CWI hospitalization has declined from 38.2/100,000 in 1985 to 0.2/100,000 in 1999. CONCLUSIONS: Our data are consistent with previous research concerning the increased rate of CWI among African-Americans though further investigation appears warranted. The occurrence of most CWI during on-duty training suggests preventability. The decline in the overall rate of CWI hospitalizations is multifactorial.
We report a case of auricular calcification in an elderly man with a history of frostbite and normal serum calcium levels. The causes of calcification of the cartilage of the external ear are discussed.
The environment can have a profound impact on human performance. Over the past decade there has been considerable interest in the scientific study of the human ability of to protect oneself against heat and cold. This new knowledge has led to a better understanding of physiology and resulted in better prevention, recognition, and treatment of hyperthermia, hypothermia, and frostbite. This article reviews the pathophysiology of extreme environmental exposure and discusses current strategies for prevention and treatment.
At elevations above 1500 m, even a healthy person undergoes acclimatization. To avoid problems such as acute mountain sickness (AMS), high altitude cerebral edema (HACE) or high altitude pulmonary edema (HAPE), the speed of ascent and the daily sleeping elevation are of primary importance. Mild symptoms and peripheral swelling are usually harmless. However, when the severity of altitude sickness progresses, rapid therapy and immediate transport to lower elevations can be life-saving under certain conditions. A sojourn in the mountains requires effective preparation and prophylaxis against oxygen deficiency, increased UV radiation, as well as against the possibility of hypothermia and frostbite.
The pathogenesis of freezing cold injuries (FCI) is not yet entirely understood. Two possible hypothesis emerge: 1) Injury is a direct result of cryogenic insult to the cells. 2) Injury is secondary to vascular stasis which leads to anoxia. In clinical congelatio ice crystallization takes place in the EC-space. When water is transformed into ice, the osmolality in this compartment will increase leading to a passive diffusion of water from the IC-space. Cell dehydration modifies protein structure, alters membrane lipids and cellular pH leading to destructions incompatible with cell survival. Cold induces vasoconstriction of both arterioles and venules, which enhances peripheral filtration and raises plasma viscosity. The stability of red corpuscle aggregates increases and showers of emboli course microvessels. Finally progressive thrombosis will end up in anoxia. The indirect vascular effect has earlier been interpreted similar to that found in non-freezing injuries. Recent studies have, however, shown, that endothelial cells are very sensitive to freezing. The rheologic part of the pathogenesis therefore also seems to depend on a direct injury to cells. The development of FCI does not always depend on ambient temperature and duration of exposure but more to the heat loss subjected to exposed skin. Wind chill, humidity and wetness are all of significance in this matter. From a clinical point of view FCI are best subdivided into superficial and deep injuries. The superficial frostbite is limited to the skin and nearest subcutaneous tissue. A stringing, pinching pain is often the first symptom. The affected area becomes pale or waxy-white and numb.(ABSTRACT TRUNCATED AT 250 WORDS)
Findings from the recent Canadian/Soviet transpolar skitrek are reviewed. Comparison of field heart rate measurements with laboratory data suggests a high rate of energy expenditure over the trek; the 13 participants covered some 20 km/day at a speed of about 3.5 km/h, while carrying 37-45 kg packs. Strength increased and body fat decreased over the journey, but aerobic power data showed an anomalous decline, possibly related in part to intensive pre-trip training and an increase of skiing efficiency during the trek. Two of the 13 participants suffered sufficient local cold exposure to develop significant frostbite, and all had sufficient cold exposure to show some general cold acclimatization. Eight of the 13 also suffered from excessive ultraviolet exposure. The main psychological problems were related to inter-personal conflicts and difficulties of communication between the two teams. Hormonal changes were extensive, but generally in line with expectations for a combination of vigorous exercise, cold exposure and psychological stress. Nutritional responses reflect a high rate of fat usage, with a significant increase of HDL-cholesterol levels. It is concluded that well-trained young and middle-aged adults from an urban environment can participate in a well-planned and prolonged arctic winter traverse without serious adverse effects on either physiological or psychological systems.
The authors treated 603 sufferers with acute cold damage. The principal reversibility of tissue damage in local cold traumas at the prereactive period is shown. The difference of therapeutical tactics in freezing, primary cryonecrosis, local cold trauma at the prereactive period, frostbite is noted. The necessity of individual immunotherapy of the sufferers is stressed. Criteria for estimation of the effectiveness of aid to such patients are suggested.
A variety of cold exposure injuries were discussed, including frostnip, chilblains, trench foot, frostbite, and hypothermia. The usual precipitating factors for each were discussed along with the clinical course, the pathophysiology, and management from the perspective of one being in the field or backcountry. Prevention is the key to all cold-related problems as adequate treatment is often not possible out of the hospital setting. Detailed recommendations were made for all conditions, relative to treatment and prevention, with special emphasis on hypothermia.
The method of accelerated plasty with an inguinal flap was used for treatment of 13 patients with electric burns and frostbites of the IV degree. The 2nd step of the non-free skin plasty was performed 5 days (120 hours) after the first operation which was possible following a special training--a periodical, with increasing duration of the compression of the flap feeding pedicle which was started next day after the first step of the plasty.
Serratia liquefaciens mastitis was detected and investigated in a 41-cow Holstein herd. Twenty cows were treated for mastitis over a 3-month period. Serratia liquefaciens was isolated from milk samples obtained from 8 of 12 cows tested during the epizootic. Results of an epidemiologic investigation suggested that extensive frostbite of the teats decreased the udder defense. Poor milking technique and hygiene were responsible for increased exposure of the damaged teats to potential udder pathogens. Treatment of each cow resulted in initial clinical improvement, but exacerbations occurred in 75% of the cows with documented S liquefaciens infections.
Chilblain is a frostbite, it belongs to the vascular acrosyndromes by the mere fact of symmetrical lesions and to the dystrophic group by its organic obstructive and thrombotic microangiopathy, especially of venules. Chilblain is conditional on a dysesthesia for cold, diagnosis is easy if in the know, prognosis as usual good and treatment must be more preventive than curative.