Cold injuries include frostbite and frostnip. Frostbite is the term for damage to skin and other tissues caused by freezing. Frostnip is a milder form of cold injury.
In North America, frostbite is largely confined to Alaska, Canada, and the northern states. However, it can occur whenever people are exposed to sustained cold temperatures without proper protection. Recent years have witnessed a substantial decline in the number of cold injury cases, probably for several reasons, including better winter clothing and footwear and greater public understanding of how to avoid cold-weather dangers. At the same time, the nature of the at-risk population has changed. Increased numbers of homeless people have made frostbite an urban as well as a rural public health concern. The growing popularity of outdoor winter activities has also expanded the at-risk population.
Causes and symptoms
Skin exposed to temperatures slightly below the freezing mark can take hours to freeze, but very cold temperatures can freeze skin in minutes or seconds. Air temperature, wind speed, and moisture all affect how rapidly skin becomes cold. A strong wind can lower skin temperature considerably by dispersing the thin protective layer of warm air that surrounds human bodies. Wet clothing read- ily draws heat away from skin because water is a potent conductor of heat. The evaporation of moisture from the surface of skin also produces cooling. For these reasons, wet skin or clothing on a windy day can lead to frostbite even if the air temperature is above the freezing mark.
The extent of any permanent injury, however, is determined not by how cold skin and underlying tissues become but by how long they remain frozen. Consequently, homeless people and others whose self- preservation instincts may be clouded by alcohol or psychiatric illness face a greater risk of frostbite-related health effects because they are more likely to stay out in the cold when prudence dictates seeking shelter or medical attention. Alcohol and smoking also affect blood circulation in the extremities in a way that can increase the severity of injury. A review of 125 Saskatchewan frostbite cases found a tie to alcohol in 46% and to psychiatric illness in 17%. Other risk factors identified by researchers include inadequate clothing, previous cold injury, fatigue, wound infection , atherosclerosis, and diabetes. Driving in poor weather can also be dangerous. Vehicular failure was a predisposing factor in 15% of the Saskatchewan cases.
Three nearly simultaneous physiological processes underlie frostbite injury: tissue freezing, tissue hypoxia, and the release of inflammatory mediators. Tissue freezing causes the formation of ice crystals and other changes that damage and eventually kill cells. Much of this harm occurs because the ice produces pressure changes that cause water (crucial for cell survival) to flow out of cells. Tissue hypoxia (oxygen deficiency) occurs when blood vessels in the hands, feet, and other extremities narrow in response to cold. Among its many tasks, blood transfers body heat to skin, which then dissipates the heat into the environment. Blood vessel narrowing is the body's way of protecting vital internal organs at the expense of the extremities by reducing heat flow away from the core or center portions of the body. However, blood also carries life-sustaining oxygen to skin and other tissues, and narrowed vessels result in oxygen starvation. Narrowing also causes acidosis (an increase in tissue acidity) and increases blood viscosity (thickness). Ultimately, blood stops flowing through capillaries (tiny blood vessels that connect arteries and veins), and blood clots form in the arterioles and venules (the smallest arteries and veins). Damage also occurs to endothelial cells that line blood vessels. Hypoxia, blood clots, and endothelial damage lead, in turn, to the release of inflammatory mediators (substances that act as links in the inflammatory process), which promote further endothelial damage, hypoxia, and cell destruction.
Frostbite is classified by degree of injury (first, second, third, or fourth), or simply divided into two types, superficial (corresponding to first- or second-degree injury) and deep (corresponding to third- or fourth- degree injury). Most frostbite injuries affect the feet or hands. The remaining 10% of cases typically involve ears, nose, cheeks, or penis. Once frostbite sets in, an affected part begins to feel cold and usually becomes numb. This is followed by a feeling of clumsiness. Skin turns a white or yellowish color. Many individuals experience severe pain in the affected part during rewarming treatment. This is often followed by an intense throbbing pain that arises two or three days later and can last for days or weeks. As skin begins to thaw during treatment, edema (excess tissue fluid) often accumulates, causing swelling. In second- and higher-degree frostbite, blisters appear. Third-degree frostbite cases produce deep, blood- filled blisters and, during the second week, a hard black eschar (scab). Fourth-degree frostbite penetrates below the skin to the muscles, tendons, nerves, and bones. In severe cases of frostbite the dead tissue can mummify and drop off. Infection is also a possibility.
Like frostbite, frostnip is associated with ice crystal formation in tissues, but no tissue destruction occurs and any crystals dissolve as soon as the skin is warmed. Frostnip affects areas such as the earlobes, cheeks, nose, fingers, and toes. The skin turns pale and one experiences numbness or tingling in the affected part until warming begins.
Frostbite diagnosis relies on a physical examination and may also include conventional radiography (x rays), angiography (x-ray examination of the blood vessels using an injected dye to provide contrast), thermography (use of a heat-sensitive device for measuring blood flow), and other techniques for predicting the course of injury and identifying tissue that requires surgical removal. During the initial treatment period, however, a physician cannot judge how a case will progress. Diagnostic tests only become useful between three and five days after rewarming, once the blood vessels have stabilized.
Emergency medical help should always be summoned whenever frostbite is suspected. While waiting for help to arrive, one should, if possible, remove wet or tight clothing and put on dry, loose clothing or wraps. A splint and padding are used to protect an injured area. Rubbing an injured area with snow or anything else is dangerous. The key to prehospital treatment is to avoid partial thawing and refreezing, which releases more
inflammatory mediators and makes an injury substantially worse. For this reason, the affected part must be kept away from heat sources such as campfires and car heaters. Experts advise rewarming in the field only when emergency help will take more than two hours to arrive and refreezing can be prevented.
Because the outcome of a frostbite injury cannot be initially predicted, all hospital treatment follows the same protocol. Treatment begins by rewarming the affected part for 15–30 minutes in water at a temperature of 104–108°F (40–42.2°C). This rapid rewarming halts ice crystal formation and dilates narrowed blood vessels. Aloe vera (which acts against inflammatory mediators) is applied to the affected part, which is then splinted, elevated, and wrapped in a dressing. Depending on the extent of injury, blisters may be debrided (cleaned by removing foreign material) or simply covered with aloe vera. A tetanus shot and possibly penicillin are used to prevent infection, and the injured person is given ibuprofen to combat inflammation. Narcotics are needed in most cases to reduce the excruciating pain that occurs as sensation returns during rewarming. Except when injury is minimal, treatment generally requires a hospital stay of several days, during which hydrotherapy and physical therapy are used to restore health to the affected body parts. Experts recommend a cautious approach to tissue removal, and advise that 22–45 days must pass before a decision on amputation can safely be made.
Alternative practitioners suggest several kinds of treatment to speed recovery from frostbite after leaving a hospital. Bathing the affected part in warm water or using contrast hydrotherapy may help enhance circulation. Contrast hydrotherapy involves a series of hot and cold water applications. A hot compress (as hot as the patient can stand) is applied to the affected area for three minutes followed by an ice cold compress for 30 seconds. These applications are repeated three times each, ending with the cold compress. Nutritional therapy to promote tissue growth in damaged areas may also be helpful. Homeopathic and botanical therapies may also assist recovery from frostbite. Homeopathic Hypericum (Hypericum perforatum) is recommended when nerve endings are affected (especially in the fingers and toes) and Arnica (Arnica montana) is prescribed for shock . Cayenne pepper (Capsicum frutescens) can enhance circulation and relieve pain. Drinking hot ginger (Zingiber officinale) tea also aids circulation. Other possible approaches include acupuncture to avoid permanent nerve damage and oxygen therapy .
Frostnipped fingers are helped by blowing warm air on them or holding them under one's armpits. Other frostnipped areas can be covered with warm hands. The injured areas should never be rubbed.
The rapid rewarming approach to frostbite treatment, pioneered in the 1980s, has proved to be much more effective than older methods in preventing tissue loss and amputation. A study of 56 first-, second-, and third- degree frostbite patients treated with rapid rewarming in 1982–85 found that 68% recovered without tissue loss, 25% experienced some tissue loss, and only 7% needed amputation. In a comparison group of 98 patients, treatment using older methods resulted in a tissue loss rate of 35% and an amputation rate of nearly 33%. Although the comparison group included a higher proportion of second- and third-degree cases, the difference in treatment results was determined to be statistically significant.
The extreme throbbing pain that many frostbite sufferers endure for days or weeks after rewarming is not the only prolonged symptom of frostbite. During the first weeks or months after a cold injury, people often experience tingling, a burning sensation, or a sensation resembling shocks from an electric current. Other possible consequences of frostbite include skin-color changes, nail deformation or loss, joint stiffness and pain, hyperhidrosis (excessive sweating), and heightened sensitivity to cold. For everyone, a degree of sensory loss lasting at least four years—and sometimes a lifetime—is inevitable.
Health care team roles
The head of most health care teams is a physician. A physician determines a plan for treatment, provides guidance, assigns tasks for other members of the team, and monitors progress. Paramedics or other persons renderingfirst aid are also members of the team by providing immediate or early assistance to persons with frostbite or frostnip. Nurses may provide treatment alongside physicians. Physical therapists may become involved with rehabilitation of serious cases of frostbite. Occasionally, surgeons are called upon to amputate (remove) portions of bodies that have become too severely damaged to recover from frostbite.
With appropriate knowledge and precautions, frostbite can be prevented even in the coldest and most challenging environments. Appropriate clothing and footwear are essential. To prevent heat loss and keep blood circulating properly, clothing should be worn loosely and in layers. Covering the hands, feet, and head is also crucial for preventing heat loss. Outer garments need to be wind and water resistant, and wet clothing and footwear must be removed and replaced as quickly as possible. Alcohol and drugs should be avoided because of their harmful effects on judgment and reasoning. Experts also warn against alcohol use and smoking in the cold because of the circulatory changes they produce. Paying close attention to weather reports before venturing outdoors and avoiding unnecessary risks such as driving in isolated areas during a blizzard are also important.
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L. Fleming Fallon, Jr., MD, PhD, DrPH