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Cold Weather Injuries
Recognizing, Preventing and Treating
Outline
History
Cold Injury v Heat Injury
Definitions
Physiology/Effects on Organ Systems
Non-Freezing and Freezing cold injuries
Treatment
Field Management
Historical Perspective
French invasion of Russia in 1812. Baron
de Larrey, chief surgeon, noted mental
and physical hardships by Soldiers
exposed to the cold
Freeze-thaw-refreeze phenomenon.
Historical Perspective
WWII 200,000 Allied and German troops
suffer cold related injuries or deaths
Definitions
Accidental Hypothermia: the unintentional
drop in core body temperature to <35C
(95F)
Intentional Hypothermia:
controlled cooling of core
body temperature for
specific medical
indications (CVA, MI, TBI)
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Medicine Symposium
Definitions
Types of Heat Loss
Radiation: dispersal of heat energy from
uncovered skin to nearby objects
>50% of our heat loss
Definitions
Types of Heat Loss
Conduction: transfer of heat from one
object to another through physical contact
Conductivity of water is 23X that of air!!
Immersion injury reduces body temp more
rapidly than convective loss
Hypothermia
Stages/Classifications
ACCIDENTAL
MILD: 32C 35C
Shivering
90F - 95F
Hypothermia of TRAUMA
33-35(91-95), 31-32(88-90)
<31(<88)
SEVERE: <32C
<90F
Jurkovich GJ. Surg Clin N AM
87(2007) 247-267
Human Physiology
Range of 34-40.5C(95-105F) to retain
normal organ function
Thermoregulatory drive is so important
that it takes precedence over many other
homeostatic functions
Human body can compensate for
hyperthermia better than hypothermia
Heat Loss
Heat Gain
Physiology/Effects on Organ
Systems
Initial effects mimic those of sympathetic
stimulation
Tremor
Vasoconstriction
Increased O2 consumption
Increased Heart Rate
Increased Minute Ventilation
Physiology/Effects on Organ
Systems
Cardiovascular:
Initial tachycardia progresses to bradycardia
starting at 34C
CO initially increased despite a drop in BP
50% decrease in HR
Physiology/Effects on Organ
Systems
Cardiovascular:
Conduction system is VERY sensitive to
decrease temperatures.
PR interval, QRS and QT interval prolong as
temperature decreases or stays below normal
J or Osborn wave in 80% of hypothermic
patients
Bretylium is the only CV drug that works at
decreased temperatures
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Osborn or J wave
Physiology/Effects on Organ
Systems
Respiratory:
Initially increased but becomes depressed at
temperature <33C
Increased mucous production (bronchorrhea)
Left shift in oxyhemoglobin curve impairing
oxygen delivery
Physiology/Effects on Organ
Systems
GI:
Ileus, bowel wall edema, shallow gastric
ulcers (Wischnevskys Ulcers)
Decrease hepatic function drug metabolism
Hemorrhagic pancreatitis, elevated amylase
RENAL:
Initial vasoconstriction contributes to diuresis
Later loss of distal tubular water reabsorption
due to dec ADH sensitivity and inc electrolyte
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excretion
Medicine Symposium
Physiology/Effects on Organ
Systems
HEME:
Cold platelets DO NOT work
34C 40% decrease in coagulation enzyme
function
Hemoconcentration
1C drop in temp 2% increase in hematocrit
Normal hematocrit in moderate to severe
hypothermia: need to be concerned about blood
loss.
risk
Physiology/Effects on Organ
Systems
NEUROLOGICAL:
Decreased neural transmission
Incoordination and cognition, numbness
Hypothermia
Standard clinical thermometers and a
false sense of security
Only go down to 34C(94F) need low-reading
rectal thermometers (<32/90C/F)
Best accuracy thermometer in place for 3
minutes at a depth of 10 cm
Hypothermia Treatment
Rewarming Methods
External
blankets
hot water bottle
heater
another body
Immersion
Internal
Warm IV fluids
Warmed air
Exercise is BAD
Depletes glycogen,
reduces shivering
Increases heat loss
Hypothermia in Sport
High risk sports
Water sports
Running, cycling
Alpine & cold weather sports
Moderate Hypothermia
88-90 F
Passive rewarming
In field, no active rewarming until rectalT >93F
Severe Hypothermia
<88 T
Handle with care!
Gentle passive rewarming only
Transport immediately, ERICU
Trenchfoot
Prolonged exposure to temps
between 0-32C(32-60F) for hours
to 3-4 days
Dry
Chilblains or Pernio
Exposure to temps <32C(60F)
Dry
Late Sequelae:
Hyperhidrosis
Hyperesthesia/Anesthesia
of digits
Dec ROM and joint swelling
Edema
Fat pad loss, transient
muscle atrophy
Pain from injury to
peripheral nerves or small
vessels as a result of
ischemia
ACSM 2005
Hyperesthesia of distal
digits
Increased sensitivity to
heat and cold
Nail bed deformities
Hyperhidrosis,
hypohidrosis or anhidrosis
Decreased proprioception
Pain
Loss of fibrocartilage in ear
AVN, growth plate injuries
Hyperosmolarity disrupts
cell function
Rapid freezing leads to
intracellular crystals and
immediate cell death
Loss of pain sensation
Reperfusion Injury
RBC, WBC and platelet
aggregation leads to
patchy thrombosis in
microcirculation
Oxygen free radicals,
prostaglandins and
thromboxane worsen
vasoconstriction and
thrombosis
MAJORITY of damage
occurs during
REWARMING
ACSM 2005
Rewarming
PASSIVE: involves the use of blankets to
cover body and head to trap heat being
lost.
ACTIVE: the application of outside heat to
raise body temperature
External heat blanket/forced hot air system
Internal introduction of warm fluids into the
body
Warm IVF, body cavity lavage, extracorporeal
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Medicine Symposium
very painful!!!
16th Annual AMAA Sports Medicine
Symposium
Prevent Thrombosis
tPA a few studies demonstrate the benefit of tPA in
preventing/minimizing amputations or the amount of
amputated tissue
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Symposium
TREATMENT
Amputation should be
delayed 2-3 months
MRI/MRA
Technetium 99m methylene diphosphonate bone scan
(triple phase 1 minute, 2 hours and 7 hours) as early
as 48 hours after admission may help identify viable
(hibernating) tissue
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Medicine Symposium
Late Sequelae:
Hyperesthesia of distal
Hyperhidrosis
digits
Hyperesthesia/Anesthesia
Increased sensitivity to
of digits
heat and cold
Dec ROM and joint
Nail bed deformities
swelling
Hyperhidrosis,
Edema
hypohidrosis or
anhidrosis
Fat pad loss, transient
Decreased
muscle atrophy
proprioception
Pain from injury to
Pain
peripheral nerves or small
vessels as a result of
Loss of fibrocartilage in
ischemia
ear
AMPUTATION IS THE ULTIMATE LONG-TERM AVN, growth plate
injuries
SEQUELAE TO A FCI
16th Annual AMAA Sports
Medicine Symposium
FIELD PASSIVE
REWARMING EQPT
FIELD ACTIVE
REWARMING EQPT
Review
Questions