Hypothermia and Cold Weather Injuries

 

Am Fam Physician. 2019 Dec 1;100(11):680-686.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/hypothermia.

Author disclosure: No relevant financial affiliations.

Hypothermia, frostbite, and nonfreezing cold injuries predominantly affect older adults, homeless or intoxicated people, adventurers, and military personnel. Prevention begins with clothing that is clean, layered, and loose to promote circulation. Base layers made of moisture-wicking materials are favored over wool or cotton. Wool or fleece garments are ideal for middle layers, whereas outer layers should repel moisture. Hypothermia occurs when core body temperature drops below 95°F and can be staged by clinical symptoms when core temperature measurement is unavailable. Initial treatment includes external and internal rewarming. Warmed normal saline is favored over lactated Ringer solution. Frostbite is a freezing injury that usually affects the extremities. After rapid rewarming, prognosis is best determined with technetium 99mTc pyrophosphate scintigraphy or magnetic resonance angiography. Initial treatment includes protecting tissue from further trauma, preventing refreezing, and avoiding dry heat sources. Ideally, patients should be transported to facilities where rapid rewarming, imaging, and thrombolytic treatment are available. Tissue plasminogen activator significantly decreases amputation rates for severe injuries if started within 24 hours of rewarming. Immersion foot occurs during damp nonfreezing conditions. Rapid rewarming should be avoided, and amitriptyline should be considered for pain control.

Hypothermia, frostbite, and nonfreezing cold injuries predominantly affect older adults, homeless or intoxicated people, adventurers, and military personnel.1,2 Alcohol consumption is an important risk factor and was associated with 68% of accidental hypothermia cases in one retrospective study.35 From 2006 to 2010, there were 10,649 deaths in the United States attributed to natural weather causes; two-thirds of these were associated with excessive cold.5 Cold-related mortality was substantially higher in older adults and in rural or low-income areas.

WHAT'S NEW ON THIS TOPIC

Hypothermia

From 2006 to 2010, two-thirds of the 10,649 deaths in the United States attributed to natural weather causes were associated with excessive cold.

In one retrospective study, 68% of cases of accidental hypothermia were associated with alcohol consumption.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Rewarming frostbitten tissue should be avoided if there is a risk of refreezing.16

C

Consensus guidelines in the absence of clinical trials

Ibuprofen (12 mg per kg divided into two daily doses) should be given for frostbite until the wound heals or surgery is performed.16

C

Consensus guidelines in the absence of clinical trials

Tissue plasminogen activator decreases the risk of amputation if started within 24 hours of rewarming in patients with grade III/IV or deep frostbite.16,19,22,27

B

Limited clinical trials with outcomes of reducing amputation

Rapid rewarming of nonfreezing cold injuries (i.e., immersion foot) should be avoided.24,31

C

Consensus guidelines in the absence of clinical trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Rewarming frostbitten tissue should be avoided if there is a risk of refreezing.16

C

Consensus guidelines in the absence of clinical trials

Ibuprofen (12 mg per kg divided into two daily doses) should be given for frostbite until the wound heals or surgery is performed.16

C

Consensus guidelines in the absence of clinical trials

Tissue plasminogen activator decreases the risk of amputation if started within 24 hours of rewarming in patients with grade III/IV or deep frostbite.16,19,22,27

B

Limited clinical trials with outcomes of reducing amputation

Rapid rewarming of nonfreezing cold injuries (i.e., immersion foot) should be avoided.24,31

C

Consensus guidelines in the absence of clinical trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Optimal human thermoregulation requires a core temperature within 2 to 3 degrees of 98.6°F (37°C).6 The five mechanisms of heat loss are radiation, conduction, convection, evaporation, and respiration.7 The skin is the main mechanism of heat exchange and is responsible for approximately 90% of total heat loss,3 which can be exacerbated by vasodilation secondary to alcohol consumption or medication use.3,7,8 Conduction is the direct transfer of heat between objects. Frostbite can occur within seconds of bare-skin contact with a cold metal surface.9 Convection is the transfer of heat with the movement of fluids or gases; it is most evident with inadequate coverage in windy conditions.7,8

Prevention

Cold weather injuries are largely preventable through avoidance of prolonged exposure and use of protective equipment. Clothing and boots should be kept clean, layered, and loose to promote circulation.10 Shoe size should be increased if extra socks are needed.11 Base layers made of polypropylene or polyester are preferred over cotton or wool because of their moisture-wicking and heat-trapping properties. Wool or fleece garments are ideal for middle layers, and outer layers should repel moisture while allowing for ventilation.12 Socks should be changed daily or more frequently if they become wet. Adequate hydration and nutrition should be maintained, and nicotine and alcohol should be avoided. Exercise can increase core temperature, but exhaustion, sweating, and stress may exacerbate cold injuries.10,11  Certain medical conditions and medications may exacerbate or predispose patients to cold weather injuries (Table 1).6,12

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TABLE 1.

Medical Conditions and Medications That May Exacerbate or Increase the Risk of Cold Weather Injuries

ConditionRisk

Cardiovascular

Congestive heart failure

Decreased circulation at baseline; beta blockers delay vasoconstriction response to cold

Coronary artery disease

Cold increases mean arterial pressure, peripheral resistance, and myocardial oxygen demand

Peripheral vascular disease

Decreased circulation at baseline

Dermatologic

Raynaud phenomenon

Exaggerated vascular response to cold

Skin conditions (e.g., hyperhidrosis, psoriasis, sunburn)

Increased evaporative heat loss

Endocrine

Adrenal insufficiency

Impaired metabolic thermogenesis

Diabetes mellitus

Decreased circulation at baseline; hypoglycemia impairs protective response (e.g., shivering); increased risk of infection; peripheral neuropathy may delay recognition of cold

Hypothyroidism, hypopituitarism

Decreased metabolism and heat production

Medications

Antihypertensives, beta blockers, diuretics

Impaired vasoconstriction and/or decreased blood volume

Barbiturates, benzodiazepines, narcotics, tricyclic antidepressants

Impaired reaction time and judgment; behavioral modification

Clonidine

Impaired protective response (e.g., shivering)

Insulin

Decreased blood glucose; may impair protective response (e.g., shivering)

Nicotine

Vasoconstriction; increased risk of frostbite

Neurovascular

Multiple sclerosis, Parkinson disease, spinal cord injury, stroke, trauma

Impaired mobility and/or thermoregulation

Peripheral neuropathy

Impaired sensation

Psychiatric

Alcoholism

Behavioral modifications; vasodilatory effects; malnutrition/depleted glycogen stores

Anorexia nervosa

Malnutrition/depleted glycogen stores

Dementia, recreational drug use, schizophrenia

Impaired judgment

Pulmonary

Asthma

Increased risk of cold-induced bronchoconstriction

Chronic obstructive pulmonary disease

Increased morbidity and mortality in cold weather


Information from references 6 and 12.

TABLE 1.

Medical Conditions and Medications That May Exacerbate or Increase the Risk of Cold Weather Injuries

ConditionRisk

Cardiovascular

Congestive heart failure

Decreased circulation at baseline; beta blockers delay vasoconstriction response to cold

Coronary artery disease

Cold increases mean arterial pressure, peripheral resistance, and myocardial oxygen demand

Peripheral vascular disease

Decreased circulation at baseline

Dermatologic

Raynaud phenomenon

Exaggerated vascular response to cold

Skin conditions (e.g., hyperhidrosis, psoriasis, sunburn)

Increased evaporative heat loss

Endocrine

Adrenal insufficiency

Impaired metabolic thermogenesis

Diabetes mellitus

Decreased circulation at baseline; hypoglycemia impairs protective response (e.g., shivering); increased risk of infection; peripheral neuropathy may delay recognition of cold

Hypothyroidism, hypopituitarism

Decreased metabolism and heat production

Medications

Antihypertensives, beta blockers, diuretics

Impaired vasoconstriction and/or decreased blood volume

Barbiturates, benzodiazepines, narcotics, tricyclic antidepressants

Impaired reaction time and judgment; behavioral modification

Clonidine

Impaired protective response (e.g., shivering)

Insulin

Decreased blood glucose; may impair protective response (e.g., shivering)

Nicotine

Vasoconstriction; increased risk of frostbite

Neurovascular

Multiple sclerosis, Parkinson disease, spinal cord injury, stroke, trauma

Impaired mobility and/or thermoregulation

Peripheral neuropathy

Impaired sensation

Psychiatric

Alcoholism

Behavioral modifications; vasodilatory effects; malnutrition/depleted glycogen stores

Anorexia nervosa

Malnutrition/depleted glycogen stores

Dementia, recreational drug use, schizophrenia

Impaired judgment

Pulmonary

Asthma

Increased risk of cold-induced bronchoconstriction

Chronic obstructive pulmonary disease

Increased morbidity and mortality in cold weather


Information from references 6 and 12.

Hypothermia

Hypothermia occurs when the core body temperature drops below 95°F (35°C). It is commonly associated with freezing temperatures but can occur throughout the year—even in tropical climates—when proper protection from the environment is lacking.13 The classic definition classifies hypothermia as mild, moderate, or severe.8  Early recognition is key in facilitating recovery and promoting survival. As the core temperature drops to 89.6 to 95°F (32 to 35°C), the body's initial response is to generate heat via active movement and involuntary shivering. Moderate hypothermia occurs at 82.4 to 89.6°F (28 to 32°C), with pupil dilation and risk of cardiac arrhythmias. Below 89.6°F, the risk of cardiac arrest increases substantially and thermoregulation becomes significantly less effective; rewarming is possible only via exogenous heat. In severe hypothermia, the core temperature falls below 82.4°F, bradycardia and ventricular fibrillation are likely, and nearly all individuals are unconscious. If the core temperature cannot be measured, the Swiss Staging System can be used based on vital signs and clinical indicators (Table 2).13,14

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TABLE 2.

Swiss Staging System for Hypothermia

StageSymptomsSuspected core temperature

I

Conscious and shivering

89.6 to 95°F (32 to 35°C)

II

Altered mental status, not shivering

82.4 to 89.6°F (28 to 32°C)

III

Unconscious, not shivering, vital signs present

75.2 to 82.4°F (24 to 28°C)

IV

No vital signs

< 75.2°F (< 24°C)


Information from references 13 and 14.

TABLE 2.

Swiss Staging System for Hypothermia

StageSymptomsSuspected core temperature

I

Conscious and shivering

89.6 to 95°F (32 to 35°C)

II

Altered mental status, not shivering

82.4 to 89.6°F (28 to 32°C)

III

Unconscious, not shivering, vital signs present

75.2 to 82.4°F (24 to 28°C)

IV

No vital signs

< 75.2°F (< 24°C)


Information from references 13 and 14.

Initial treatment of hypothermia should be based on symptoms alone, with core temperature used to confirm staging and to aid management decisions. Thermometers capable of reading low temperatures are essential because many standard thermometers do not read below 94°F (34.4°C).7,14 The use of rectal thermometers may be inadvisable in the field because exposure can increase heat loss.13 When accurate measurement of core temperature is not practical, management decisions should be based on the Swiss Staging System.

Treatment begins in the prehospital setting with advanced cardiac life support and passive and active external rewarming (Figure 1).13,14 Detecting a pulse may be challenging; feeling for a carotid pulse for one minute may be helpful.13 Conscious, uninjured, shivering patients (stage I) may be treated in the field. For patients with impaired consciousness (stage II, III, or IV), full-body insulation and rewarming should be provided if it does not impede cardiopulmonary resuscitation or delay transport.13 Ideal modalities for field-based rewarming include chemical, electrical, or forced-air heating packs and blankets.8,14 The use of aluminum or aluminized space blankets is also permissible. First responders should place large heating pads or blankets over the chest and into the groin or axillary region. Small chemical heat pads (normally used for hands) can cause thermal burns and should be avoided. Patients should be thoroughly insulated before transport.13 Defibrillation and administration of medications to assist cardiac resuscitation should be withheld until the patient is rewarmed to at least 82.4°F.15 Patients should be horizontal during transport and should avoid physical exertion to decrease the risk of core temperature afterdrop that can result as blood returns to the core from cool extremities.13

FIGURE 1.

Algorithm for the management of hypothermia.

Information from references 13 and 14.


FIGURE 1.

Algorithm for the management of hypothermia.

Information from references 13 and 14.

When fluid resuscitation is warranted, normal saline is preferred over lactated Ringer solution because hypothermic patients cannot effectively metabolize lactate.13 Fluids should be warmed to 100.4 to 107.6°F (38 to 42°C). Passive heat transfer from warmed crystalloids allows for symmetric internal rewarming. Patients who have cardiac instability (e.g., systolic blood pressure less than 90 mm Hg, ventricular arrhythmias, core temperature less than 82.4°F) or who are in cardiac arrest should be transported to a center capable of providing cardiopulmonary bypass services.14 Survival without significant neurologic impairment may be possible for extended periods of time because of the decrease in total body metabolic demand and a concomitant decrease in cerebral oxygen requirements. In most circumstances, hypothermic patients should be rewarmed—ideally to a core temperature of 98.6°F—before pronouncing death. However, terminating or avoiding advanced cardiac life support without rewarming is advisable for hypothermic patients with lethal injury, a stiff chest, airway obstruction, snow burial for more than 35 minutes, or serum potassium level greater than 12.0 mEq per L (12.0 mmol per L).

Frostnip and Frostbite

Frostnip is a self-limiting process that presents similarly to frostbite, with hyperesthesia, paresthesia, and pallor.1,16 However, there is no tissue loss when the area is warmed, and symptoms resolve within 10 minutes.17 The extremities and face are most commonly affected. The time between frostnip and frostbite varies depending on the severity of environmental exposure, presence or lack of insulating clothing, and use of medications or recreational drugs.16 Frostnip should be addressed at the onset of symptoms.16,17

Frostbite is a freezing injury in which initial cooling causes vasoconstriction and localized ischemia. Continued exposure leads to ice crystal formation that causes cellular lysis, electrolyte abnormalities, and microvascular occlusion.16,18 Rewarming causes an inflammatory response, which increases the risk of thrombosis and reperfusion injuries. This process is worsened if tissue is allowed to refreeze.18

There are several frostbite classification systems.1,16,19  Traditionally, frostbite has been organized into four categories based on acute physical findings (Table 3).1,16,1820 However, these categories are difficult to assess before rewarming, and it may take several weeks to determine severity.16,19 Furthermore, frostbite severity may vary within an extremity.16 A two-tier system—superficial (first- and second-degree) or deep (third- and fourth-degree)—helps simplify the evaluation.16  Another classification approach uses physical findings immediately after rewarming (Table 4).19,20 Grade I injuries lack cyanosis and are unlikely to require amputation. Grade II to IV injuries have worsening cyanosis, which increases the risk of amputation.20 Angiography and technetium-99m pyrophosphate (99mTc) scintigraphy help predict perfusion and should be considered immediately after rewarming in patients who are candidates for tissue plasminogen activator (TPA).21,22 For patients with a delayed presentation, 99mTc scintigraphy should be considered within 48 hours to help with prognosis.23

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TABLE 3.

Traditional Frostbite Grading System

GradePresentation

First degree (superficial)

Edema, pallor, and erythema; slightly raised plaque; no blisters; absent to minimal tissue loss

Second degree (superficial)

Clear blisters with edema and erythema; absent to minimal tissue loss; blisters develop 6 to 24 hours after rewarming1

Third degree (deep)

Hemorrhagic blisters suggest subcutaneous or dermal involvement; black eschar develops over weeks; tissue loss

Fourth degree (deep)

Muscle and/or bone involvement; mummification and gangrene; full-thickness tissue loss; absence of blisters in deep frostbite is a poor prognostic factor1


Note: Frostbite severity may take several weeks to completely assess and is difficult to assess before rewarming.

Information from references 1, 16, and 1820.

TABLE 3.

Traditional Frostbite Grading System

GradePresentation

First degree (superficial)

Edema, pallor, and erythema; slightly raised plaque; no blisters; absent to minimal tissue loss

Second degree (superficial)

Clear blisters with edema and erythema; absent to minimal tissue loss; blisters develop 6 to 24 hours after rewarming1

Third degree (deep)

Hemorrhagic blisters suggest subcutaneous or dermal involvement; black eschar develops over weeks; tissue loss

Fourth degree (deep)

Muscle and/or bone involvement; mummification and gangrene; full-thickness tissue loss; absence of blisters in deep frostbite is a poor prognostic factor1


Note: Frostbite severity may take several weeks to completely assess and is difficult to assess before rewarming.

Information from references 1, 16, and 1820.

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TABLE 4.

Frostbite Grading System Immediately After Rewarming

GradePresentationPrognosis and management

I

Absence of cyanosis and blisters

99mTc scintigraphy not necessary Amputation unlikely

II

Cyanosis restricted to distal phalanx, clear blisters at 48 hours

99mTc scintigraphy at 48 hours: decreased uptake Risk of tissue loss; hypoxemia and injury at higher elevation (4,000 m [13,000 ft]) increase risk; consider treating as grade III or IV in these scenarios

III

Cyanosis on proximal phalanx, hemorrhagic blisters at 48 hours

99mTc scintigraphy at 48 hours: absence of radiotracer High risk of amputation

IV

Cyanosis on carpal/tarsal, hemorrhagic blisters at 48 hours

99mTc scintigraphy at 48 hours: absence of radiotracer 100% risk of amputation


99mTc = technetium-99m pyrophosphate.

Information from references 19 and 20.

TABLE 4.

Frostbite Grading System Immediately After Rewarming

GradePresentationPrognosis and management

I

Absence of cyanosis and blisters

99mTc scintigraphy not necessary Amputation unlikely

II

Cyanosis restricted to distal phalanx, clear blisters at 48 hours

99mTc scintigraphy at 48 hours: decreased uptake Risk of tissue loss; hypoxemia and injury at higher elevation (4,000 m [13,000 ft]) increase risk; consider treating as grade III or IV in these scenarios

III

Cyanosis on proximal phalanx, hemorrhagic blisters at 48 hours

99mTc scintigraphy at 48 hours: absence of radiotracer High risk of amputation

IV

Cyanosis on carpal/tarsal, hemorrhagic blisters at 48 hours

99mTc scintigraphy at 48 hours: absence of radiotracer 100% risk of amputation


99mTc = technetium-99m pyrophosphate.

Information from references 19 and 20.

An algorithm for the treatment of frostbite is shown in Figure 2.18,19,2125 Hypothermia management should take precedence over treating frostbite.17 Jewelry should be removed, wet clothing should be replaced, and friction should be avoided. Dry heat sources (e.g., stoves, fires, engines, heating pads) should not be used to treat frostbite because the temperature is difficult to regulate. The frostbitten extremity should not be used unless essential for evacuation, and rewarming should be avoided if refreezing is a risk.16,17 If rapid rewarming is not possible, body heat (axilla and/or groin) may be used for spontaneous thawing.19

FIGURE 2.

Algorithm for the treatment of frostbite. (99m Tc = technetium-99m pyrophosphate.)

Information from references 18, 19, and 2125.


FIGURE 2.

Algorithm for the treatment of frostbite. (99m Tc = technetium-99m pyrophosphate.)

Information from references 18, 19, and 2125.

Rapid rewarming should be done in a water bath maintained at 98.6 to 102.2°F (37 to 39°C). The extremity should be actively swirled, avoiding the bath edge, until the tissue appears red or purple and is soft to touch (30 to 60 minutes).16 To prevent reperfusion injuries, ibuprofen (12 mg per kg divided into two daily doses) should be given until the wound heals or surgery is performed.16 Oral or intravenous opioids may also be required for pain relief. The extremity should be allowed to air dry after removal from the water bath; it should not be rubbed.16,17 Hypovolemia should be corrected with warm oral or intravenous fluids.16 Empiric antibiotics are not recommended unless there is an open or dirty wound.24 Tetanus prophylaxis is recommended per routine guidelines.16

Although there is conflicting evidence on the debridement of blisters, clear blisters are usually drained, whereas hemorrhagic blisters are left intact.16 TPA can significantly decrease amputation rates.2428 If the patient has severe injuries (grade III/IV or deep frostbite) and no contraindications, intravenous or intra-arterial TPA should be considered within 24 hours of rewarming.16,19,22,24,27 Contraindications include hypersensitivity, trauma, coagulopathy, anticoagulant use, stroke in the past three months, or blood pressure greater than 180 mm Hg systolic or 110 mm Hg diastolic.19 TPA has been used successfully in remote areas outside the hospital setting.19 Heparin or low-molecular-weight heparin may be considered for adjunctive therapy.16,24,27 Iloprost (Ventavis), a vasodilator that prevents clot formation, has been beneficial in severe cases up to 48 hours after rewarming. 29 Peripheral nerve blocks and/or hyperbaric oxygen therapy may also be beneficial.19,30 Early amputation should be avoided; complete injury demarcation may take one to three months.16 Magnetic resonance angiography and 99mTc scintigraphy can help predict surgical margins.16,23 Ideally, frostbite should be managed at facilities where rapid rewarming, imaging, and further thrombolytic treatment can be performed.

Nonfreezing Cold Injuries

IMMERSION FOOT

Immersion foot (also called trench foot) is a nonfreezing injury that occurs with prolonged exposure (typically two to three days) to wet conditions above 32°F (0°C).24 Symptoms typically present in four phases. Patients initially have numbness and a feeling of “walking on wood blocks” with pale or white skin from vasoconstriction. Once cold exposure is removed, the skin may become blue and mottled, with continued numbness followed by intense pain and erythematous or edematous skin.31 The posthyperemic phase ranges from several weeks to years and is associated with sensorimotor and autonomic deficits.

Treatment begins with moving the patient to a warm, dry environment and preventing or treating hypothermia. Pressure, including walking, on the affected limb should be avoided. The extremity should be elevated above the heart and allowed to air dry at room temperature; rapid rewarming may lead to further injury.24,31 Controlled studies on pain management are limited. Amitriptyline, beginning with 10 mg at night and titrated to 75 mg, is more effective for pain control than nonsteroidal anti-inflammatory drugs or opioids.24,32 Immersion foot can be prevented with frequent changing of wet footwear and remaining active to maintain circulation in the extremities.12

PERNIO

Pernio (also called chilblains) is a nonfreezing injury characterized by localized inflammatory lesions that most commonly affect the hands or feet within 24 hours of exposure to damp environments (Figure 3). Young women, people with a body mass index less than 25 kg per m2, and people with systemic lupus erythematosus are at higher risk.33,34 The pathophysiology is not well understood.34 Lesions typically present as purple or erythematous papules that may become edematous.33 Associated symptoms include paresthesia, pruritus, and pain.34 Prevention and treatment involve smoking cessation and adequate protection from cold.33 Lesions may persist for weeks to months before resolving spontaneously. Tissue loss is uncommon, but scarring may occur.34 Nifedipine, vasodilators, and topical corticosteroids may reduce pain, prevent new lesions, and promote healing, but controlled studies are limited.33

FIGURE 3.

Pernio (chilblains).

Image used with permission from VisualDx.


FIGURE 3.

Pernio (chilblains).

Image used with permission from VisualDx.

This article updates a previous article on this topic by McCullough and Arora.7

Data Sources: A PubMed search for evaluation and treatment of hypothermia, frostbite, immersion foot, and nonfreezing cold injury was performed. The search was limited to English-only human studies published since 2008. We also used references from articles identified by the search. Last search date: July 2019.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army Medical Department or the U.S. Army Service at large.

The Authors

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NICHOLAS A. RATHJEN, DO, is a family physician at William Beaumont Army Medical Center, Fort Bliss, Tex....

S. DAVID SHAHBODAGHI, MD, MPH, is medical director of the Soldier and Family Medical Clinic and a family physician at William Beaumont Army Medical Center.

JENNIFER A. BROWN, MD, is the brigade surgeon for the 4th Security Force Assistance Brigade at Evans Army Community Hospital, Fort Carson, Colo.

Address correspondence to Nicholas A. Rathjen, DO, William Beaumont Army Medical Center, 5005 N. Piedras St., Fort Bliss, TX 79920 (email: nicholas.a.rathjen@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Mohr WJ, Jenabzadeh K, Ahrenholz DH. Cold injury. Hand Clin. 2009;25(4):481–496....

2. Paton BC. Cold, casualties, and conquests: the effects of cold on warfare. In: Pandolf KB, Burr RE, eds. Medical Aspects of Harsh Environments. Office of the Surgeon General; 2001:313–349.

3. Kempainen RR, Brunette DD. The evaluation and management of accidental hypothermia. Respir Care. 2004;49(2):192–205.

4. Kosiński S, Darocha T, Gałązkowski R, et al. Accidental hypothermia in Poland – estimation of prevalence, diagnostic methods and treatment. Scand J Trauma Resusc Emerg Med. 2015;23:13.

5. Berko J, Ingram DD, Saha S, et al. Deaths attributed to heat, cold, and other weather events in the United States, 2006–2010. Natl Health Stat Report. 2014;30(76):1–15.

6. Cheshire WP Jr. Thermoregulatory disorders and illness related to heat and cold stress. Auton Neurosci. 2016;196:91–104.

7. McCullough L, Arora S. Diagnosis and treatment of hypothermia. Am Fam Physician. 2004;70(12):2325–2332. Accessed July 25, 2019. https://www.aafp.org/afp/2004/1215/p2325.html

8. Petrone P, Asensio JA, Marini CP. Management of accidental hypothermia and cold injury. Curr Probl Surg. 2014;51(10):417–431.

9. Geng Q, Holmér I, Hartog DE, et al. Temperature limit values for touching cold surfaces with the fingertip. Ann Occup Hyg. 2006;50(8):851–862.

10. Roberts DE, Hamlet MP. Prevention of cold injuries. In: Pandolf KB, Burr KB, eds. Medical Aspects of Harsh Environments. Office of the Surgeon General; 2001:411.

11. Fudge J. Preventing and managing hypothermia and frostbite injury. Sports Health. 2016;8(2):133–139.

12. Fudge JR, Bennett BL, Simanis JP, et al. Medical evaluation for exposure extremes: cold. Wilderness Environ Med. 2015;26(4 suppl):S63–S68.

13. Brown DJ, Brugger H, Boyd J, et al. Accidental hypothermia [correction in N Engl J Med. 2013;368(4):394]. N Engl J Med. 2012;367(20):1930–1938.

14. Zafren K, Giesbrecht GG, Danzl DF, et al. Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2014 update. Wilderness Environ Med. 2014;25(4 suppl):S66–S85.

15. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council guidelines for resuscitation 2010 section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation. 2010;81(10):1400–1433.

16. McIntosh SE, Freer L, Grissom CK, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2019 update [published online ahead of print July 17, 2019]. Wilderness Environ Med. 2019. Accessed August 6, 2019. https://www.sciencedirect.com/science/article/pii/S1080603219300973?via%3Dihub

17. Handford C, Buxton P, Russell K, et al. Frostbite: a practical approach to hospital management. Extrem Physiol Med. 2014;3:7.

18. Hutchison RL. Frostbite of the hand. J Hand Surg Am. 2014;39(9):1863–1868.

19. Cauchy E, Davis CB, Pasquier M, et al. A new proposal for management of severe frostbite in the austere environment. Wilderness Environ Med. 2016;27(1):92–99.

20. Cauchy E, Chetaille E, Marchand V, et al. Retrospective study of 70 cases of severe frostbite lesions: a proposed new classification scheme. Wilderness Environ Med. 2001;12(4):248–255.

21. Nygaard RM, Lacey AM, Lemere A, et al. Time matters in severe frostbite: assessment of limb/digit salvage on the individual patient level. J Burn Care Res. 2017;38(1):53–59.

22. Twomey JA, Peltier GL, Zera RT. An open-label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite. J Trauma. 2005;59(6):1350–1354.

23. Cauchy E, Marsigny B, Allamel G, et al. The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities. J Hand Surg Am. 2000;25(5):969–978.

24. Heil K, Thomas R, Robertson G, et al. Freezing and non-freezing cold weather injuries: a systematic review. Br Med Bull. 2016;117(1):79–93.

25. Taves J, Satre T. Reducing amputation rates after severe frostbite. Am Fam Physician. 2015;92(8):716. Accessed July 25, 2019. https://www.aafp.org/afp/2015/1015/p716.html

26. Patel N, Srinivasa DR, Srinivasa RN, et al. Intra-arterial thrombolysis for extremity frostbite decreases digital amputation rates and hospital length of stay. Cardiovasc Intervent Radiol. 2017;40(12):1824–1831.

27. Lindford A, Valtonen J, Hult M, et al. The evolution of the Helsinki frostbite management protocol. Burns. 2017;43(7):1455–1463.

28. Drinane J, Kotamarti VS, O'Connor C, et al. Thrombolytic salvage of threatened frostbitten extremities and digits: a systematic review [published online ahead of print June 11, 2019]. J Burn Care Res. 2019. Accessed August 6, 2019. https://academic.oup.com/jbcr/advance-article-abstract/doi/10.1093/jbcr/irz097/5514180

29. Cauchy E, Cheguillaume B, Chetaille E. A controlled trial of a prostacyclin and rt-PA in the treatment of severe frostbite. N Engl J Med. 2011;364(2):189–190.

30. Pasquier M, Ruffinen GZ, Brugger H, et al. Pre-hospital wrist block for digital frostbite injuries. High Alt Med Biol. 2012;13(1):65–66.

31. Ingram BJ, Raymond TJ. Recognition and treatment of freezing and nonfreezing cold injuries. Curr Sports Med Rep. 2013;12(2):125–130.

32. Glennie JS, Milner R. Non-freezing cold injury. J R Nav Med Serv. 2014;100(3):268–271.

33. Cappel JA, Wetter DA. Clinical characteristics, etiologic associations, laboratory findings, treatment, and proposal of diagnostic criteria of pernio (chilblains) in a series of 104 patients at Mayo Clinic, 2000 to 2011. Mayo Clin Proc. 2014;89(2):207–215.

34. Prakash S, Weisman MH. Idiopathic chilblains. Am J Med. 2009;122(12):1152–1155.

 

 

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