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Cold Injuries 6/11/2019 Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Chapter 208: Cold Injuries T. Paddock Michael INTRODUCTION The occurrence of cold-related injuries depends on the degree of cold exposure, as well as environmental and individual factors. Frostbite is the prototypical freezing injury and is seen when ambient temperatures are well below freezing. Nonfreezing cold injuries occur as a result of exposure to wet conditions when temperatures are above freezing. The most common nonfreezing cold injuries are trench foot and chilblains. Although frostbite may result in permanent tissue damage, nonfreezing cold injuries are characterized by usually mild but uncomfortable inflammatory lesions of the skin. This chapter describes the occurrence, risk factors, treatment, and prevention of the nonfreezing cold injuries—trench foot and immersion foot, chilblains or pernio, panniculitis, and cold urticaria—and the freezing injury—frostbite. NONFREEZING COLD INJURIES TRENCH FOOT Trench foot and its more severe variant, immersion foot, are rare conditions in civilians but can be a significant problem in military operations. The pathophysiology of trench foot is multifactorial but involves direct injury to so tissue sustained from prolonged cooling, accelerated by wet conditions. The peripheral nerves seem to be the most sensitive to this form of injury. Early symptoms progress from tingling to numbness of the aected tissues. On initial examination, the foot is pale, mottled, anesthetic, pulseless, and immobile, with no immediate change aer rewarming. A hyperemic phase begins within hours aer rewarming and is associated with severe burning pain and reappearance of proximal sensation. As perfusion returns to the foot over 2 to 3 days, edema and possibly bullae form, and hyperemia may worsen. Anesthesia frequently persists for weeks and may be permanent. In more severe cases, tissue sloughing and gangrene may develop. Hyperhidrosis and cold sensitivity are common late features and may persist for months to years. Severe cases may be associated with prolonged convalescence and permanent disability.1 Treatment is supportive, but vasodilator drugs may be tried. Oral prostaglandins can increase skin temperatures, which suggests improved circulation.2 Feet should be kept clean, warm, dryly bandaged, eleLovadtiendg ,[ Caonndtr cibl]o/as1e1ly/ amccoenssiitboilritey-dm feonru e.jas rly signs of infection. Prophylaxis for trench foot includes keeping 1/18 6/11/2019 warm, ensuring good boot fit, changing out of wet socks several times a day, never sleeping in wet socks and boots, and, once early symptoms are identified, maximizing eorts to warm, dry, and elevate the feet. CHILBLAINS OR PERNIO Chilblains, or pernio, are characterized by mild but uncomfortable inflammatory lesions of the skin caused by long-term intermittent exposure to damp, nonfreezing ambient temperatures. Symptoms are precipitated by acute exposure to cold.3 The most common areas aected are the feet (toes), hands, ears, and lower legs. Chilblains are primarily a disease of women and children, and although rare in the United States, the disease is common in the United Kingdom and other countries with a cold or temperate, damp climate.3 In addition, young females with Raynaud's phenomenon and other immunologic abnormalities such as lupus erythematosus, as well as those in households with inadequate heating and lack of warm clothing, are at greatest risk. Some studies suggest that a low body mass index may be associated with increased risk.3,4 Early symptoms progress from tingling to numbness of the aected tissues. The cutaneous manifestations, which appear up to 12 to 24 hours aer acute exposure, include localized edema, erythema, cyanosis, plaques, nodules, and, in rare cases, ulcerations, vesicles, and bullae. Patients may complain of pruritus and burning paresthesias. Rewarming may result in the formation of tender blue nodules, which may persist for several days. Management is supportive. The aected skin should be rewarmed, gently bandaged, and elevated. Some European studies support the use of nifedipine, 20 milligrams PO three times daily; pentoxifylline, 400 milligrams PO three times daily; or an analog of prostaglandin E1, limaprost, 20 micrograms PO three times daily, as both prophylactic and therapeutic treatment for local cold injury.2,5 Topical corticosteroids (0.1% triamcinolone cream) are also eective.6 PANNICULITIS Panniculitis is characterized by mild degrees of necrosis of the subcutaneous fat tissue that develops during prolonged exposure to temperatures just above freezing. It is observed in children (e.g., "popsicle panniculitis" of the cheeks) and on the thighs and buttocks of young women involved in equestrian activities.7 During resolution of the mild inflammation, adipose fibrosis may result in cosmetic defects, such as unevenness of the skin. There is no eective treatment for the injury. COLD URTICARIA Cold urticaria is a distinctive example of hypersensitivity to cold air or water, which in rare cases may lead to fatal anaphylaxis.8 Most cases are idiopathic,9 but they can also be associated with increased ainity of immunoglobulin E to mast cells and viral infections.9 The diagnosis can be confirmed with the cold water test during follow-up. Young adults and children and those with atopy or other forms of inducible urticaria are Loading [Contrib]/a11y/accessibility-menu.js most commonly aected.8,10 2/18 6/11/2019 Cold urticaria is treated similarly to urticarial lesions from other causes. Antihistamines (H1) are recommended for acute cases, although higher than usual dosing may be required.11 Other potential therapies include leukotriene receptor antagonists (zafirlukast, montelukast)12,13 and topical capsaicin. For persistent cold urticaria, ketotifen or doxantrazole may be tried, but oral preparations of these mast cell stabilizers are not available in the United States. Prescribe epinephrine autoinjectors for patients with a history of cold-induced anaphylaxis. FREEZING INJURIES EPIDEMIOLOGY Groups at high risk for frostbite include military personnel, winter sports enthusiasts, outdoor workers, the elderly, the homeless, people who abuse drugs or alcohol, and those with psychiatric disorders. Individual attributes, such as anthropometry, physiology, behavior, and general health, aect an individual's likelihood of developing cold-related injuries14,15 (Table 208-1). Loading [Contrib]/a11y/accessibility-menu.js 3/18 6/11/2019 TABLE 208-1 Factors Influencing the Likelihood of Frostbite Environmental Temperature Wind Wetness Contact with cold objects or liquids (e.g., metals, petroleum, oil, lubricants) Duration of cold exposure Geographical area Hypoxia Altitude Physical/Anthropometric Characteristics Age Gender Race Behavioral Cold acclimatization Alcohol use Fatigue Dehydration Smoking Use of protective ointments Inappropriate or wet clothing Constrictive clothing (e.g., tight boots) Prolonged stationary posture Health-Related/Physiologic Raynaud's phenomenon Vibration-induced white finger Cold-induced vasodilation reactivity Other peripheral vascular diseases Diabetes Peripheral neuropathies Certain medications (e.g., vasoconstrictive drugs) Previous cold injury Psychiatric disorders or altered mental status The areas most commonly aected by frostbite are the head (31% to 39.1% of cases), hands (20% to 27.9%), Loading [Contrib]/a11y/accessibility-menu.js and feet (15% to 24.9%).16-18 Studies vary regarding which of these sites is most commonly aected, with 4/18 6/11/2019 military personnel reporting higher incidences of foot and hand involvement than civilians.18 Although most cases of frostbite are mild (frostnip), 12% of cases are more severe (Table 208-2). TABLE 208-2 Body Parts Aected by Frostbite (Lifetime Cumulative Incidence) Number of Frostbite Episodes Degree of Frostbite All Head Hands Feet All frostbite cases 2555 (44%) 1668 (31%) 1154 (20%) 810 (15%) First degree 2333 (41%) 1462 (28%) 1064 (19%) 738 (14%) Higher than first degree, deep 671 (12%) 459 (9%) 213 (4%) 174 (3%) Notes: Study population = 5839. Some persons had multiple locations and degrees of frostbite. RISK FACTORS FOR FROSTBITE Age and Gender Both age and gender influence the incidence of frostbite. Among Finnish teens, twice as many teenage boys as girls report having had frostbite of at least blister grade during the previous year (4.1% of boys and 2.4% of girls).19 Young men entering the military service report a cumulative lifetime incidence of 44%.16 Although frostbite injuries occur more frequently in men as they age, the same is not true of women.19 In general, the occurrence of frostbite is higher in men than in women,19,20 which is possibly related to dierent occupational and leisure time activity patterns. The smaller size of women and their larger surface area–to– mass ratio increase the cooling rate, which makes women more susceptible to cooling and cold injuries.15,21 Temperature and Windchill The incidence of frostbite among civilians is governed by latitude of residence, the annual number of days on which the ambient temperature is below –15°C (5°F), and the length of daily cold exposure.19 In the United States, the majority of occupational outdoor cold injuries occur during the few coldest days of winter. Wind strongly increases the injury rate. Rates of injury begin to increase when temperatures fall below –12°C (10.4°F) and wind speeds exceed 4.5 m/s (10 mph).22 Wind markedly increases the cooling rate by increasing convective heat loss
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