Mountains Cold Weather Injuries R. Eugene Bailey, MD Toggenburg Ski Patrol Refresher Course 2008

MountainsMountains

Cold Weather Injuries

R. Eugene Bailey, MD

Toggenburg Ski PatrolRefresher Course 2008

SCENARIO DISCUSSION SCENARIO DISCUSSION FORUMFORUM

FALL REFRESHER 2002FALL REFRESHER 2002

Snowy Mountains Misty ValleySnowy Mountains Misty Valley

Tube Park FunTube Park Fun

Scenario Number IIIScenario Number III 9 y/o female tubing at night on the

outside lane of a large tubing park, near the end of the tubing session. Her tube catapults over the outer berm and down an adjacent embankment into a stand of trees.

The girl is found lying on her left side, supporting her partially flexed right arm across her abdomen. She

Scenario Number IIIScenario Number III is sobbing and shivering violently - and

wearing only jeans, a windbreaker and no hat. Assessment reveals slow, slurred speech; palpable tenderness, swelling, and deformity of the right elbow; a diminished/absent radial pulse on the right; and a weakened grasp in the right hand. Vitals – P-108 & strong, R-20 & shallow.

Lets TriageLets Triage

• Primary Survey– ABCs– Level of responsiveness– Urgent treatment

• Secondary Survey– Musculoskeletal– Cold Weather injury

Cold Weather Injuries -Cold Weather Injuries -

WindchillPreventive Measures

TrenchfootChilblain (Pernio)

Dehydration Frost NipFrost bite

Hypothermia

Cold Weather Injuries – Cold Weather Injuries – Wind ChillWind Chill

Cold Weather Injuries Cold Weather Injuries PREVENTIONPREVENTION

WINDCHILL

• 30oF and below (-1oC)



• -10oF and below (-23oC)

• -20oF and below (-29oC)

PM MEASURES

• Alert team to potential for cold injury

• Inspect personnel for proper clothing- Provide warm up areas/hot beverages

• Inspect personnel for cold injuries/rotate outdoor assignments/discourage smoking

• Employ buddy system – check each other for cold injuries

• Modify/curtail non essential outdoor activities

Cold Weather Injuries - Cold Weather Injuries - TrenchfootTrenchfoot

• WW1 – soldiers in trenches• very serious nonfreezing cold

injury • develops when skin of the feet is

exposed to moisture and cold for prolonged periods (12 hours or longer)- no ice crystal formation

• cold and moisture softens skin, causing tissue loss and, often, infection.

• Untreated, can eventually require amputation.

• Early signs - itching, numbness, or tingling pain.

• Later signs – swelling of feet the feet may appear swollen, and the skin mildly red, blue, or black.

Cold Weather Injuries - Cold Weather Injuries - TrenchfootTrenchfoot

• Commonly, shows a distinct "water-line" coinciding with the water level in the boot

• Red or bluish blotches appear on the skin, sometimes with open weeping or bleeding.

• risk is high during wet weather or when working in wet areas

• Risk from wearing rubberized or tight-fitting boots regardless of weather conditions - can cause sweat accumulation and keep the feet wet.

Cold Weather Injuries Cold Weather Injuries First Aid For TrenchfootFirst Aid For Trenchfoot

1. Prevent Further Exposure 2. Remove Wet, Constrictive

Clothing 3. Wash And Dry Injury Gently 4. Elevate, Cover With Layers

Of Loose, Warm Clothing, And Allow To Rewarm (Pain And Blisters May Develop)

5. Do Not Pop Blisters, Apply Lotions Or Creams, Massage, Expose To Extreme Heat, Or Allow Victim To Walk On Injury

6. Refer For Medical Treatment

Cold Weather Injuries-Cold Weather Injuries-ChilblainChilblain• Chilblain is a nonfreezing cold

injury which, while painful, causes little or no permanent impairment.

• It appears as red, swollen skin which is tender, hot to the touch, and may itch. This can worsen to an aching, prickly ("pins and needles") sensation, and then numbness.

• It can develop in only a few hours in skin exposed to cold.

• Risk Factors– Hormonal or nervous system factors that

affect the small blood vessel– Genetic influence– Diet problems– Atherosclerosis

Cold Weather InjuriesCold Weather Injuries First Aid For Chilblain First Aid For Chilblain

1. Prevent Further Exposure– Using lambswool insoles in shoes or wrapping toes in lambswool. – Wearing woollen socks or lambswool slippers at home. DO NOT go

barefoot, especially on cold tiles.

2. Remove Wet, Constrictive Clothing 3. Wash And Dry Injury Gently 4. Elevate, Cover With Layers Of Loose,Warm Clothing, And Allow To

Rewarm (Pain And Blisters May Develop) 5. Do Not Pop Blisters, Apply Lotions Or Creams, Massage, Expose To

Extreme Heat, Or Allow Victim To Walk On Injury 6. Refer For Medical Treatment

Cold Weather Injuries Cold Weather Injuries DehydrationDehydration

• Responders must drink even when they are not thirsty

• Leaders should establish a program of regularly scheduled enforced drinking

• Inactive persons in comfortable climates need a minimum of 2 quarts of water a day


• A general recommendation for persons participating in cold-weather operations is to consume about half a quart (half a canteen) of water with breakfast, lunch, dinner, and before going to sleep at night, with an additional half quart drunk every hour during the workday (more if the work is strenuous enough to cause the individual to sweat), for a total of at least 5-6 quarts per day.


• The lighter the urine color, the better hydrated, and that dark yellow urine is a sure indicator that fluid consumption should be increased.


• Monitor urine color of team members.

• In snow covered areas - The appearance of a dark yellow stain in open urination areas will be noticeable

• Even if the particular individual cannot be identified, the team leader can intensify efforts to encourage all members to increase fluid consumption

Cold Weather Injuries - Cold Weather Injuries - FrostnipFrostnip

• Frostnip involves freezing of water on the skin surface– the skin will become reddened

and possibly swollen– although painful, there is

usually no further damage after rewarming

– repeated frostnip in the same spot can dry the skin, causing it to crack and become very sensitive

– it is difficult to tell the difference between frostnip and frostbite. Frostnip should be taken seriously, since it may be the first sign of impending frostbite.

Cold Weather Injuries - Cold Weather Injuries - FrostbiteFrostbite

• Skin freezes at about 28oF (-2oC )

• skin will become numb and turn to a grey or waxy-white color

• The area will be cold to the touch and may feel stiff or woody

• ice crystal formation and lack of blood flow to the frozen area damages the tissues

• After thawing, swelling may occur, worsening the injury.

Cold Weather Injuries Cold Weather Injuries First Aid For FrostbiteFirst Aid For Frostbite

1. Prevent Further Exposure

2. Remove Wet, Constrictive Clothing

3. Rewarm Gradually By Direct Skin-To-Skin Contact Between Injured Area And Noninjured Skin Of The Victim Or A Buddy

Cold Weather Injuries Cold Weather Injuries First Aid For FrostbiteFirst Aid For Frostbite

4. Evacuate For Medical Treatment 5. Do Not Allow Injury To Refreeze During

Evacuation • Note: 1. Do Not Rewarm A Frostbite Injury If It Could

Refreeze During Evacuation; 2. Do Not Rewarm Frostbitten Feet If Victim Must

Walk For Medical Treatment; 3. Do Not Rewarm Injury Over Open Flame

Cold Weather Injuries - Cold Weather Injuries - HypothermiaHypothermia

• Hypothermia is a medical emergency; untreated, it results in death.

• Body temperature falls when the body cannot produce heat as fast as it is being lost. Hypothermia is a life-threatening condition in which deep-body temperature falls below 95oF (35oC).

Cold Weather Injuries – Cold Weather Injuries – Hypothermia – In WaterHypothermia – In Water

• can occur rapidly during cold-water immersion (one hour or less when water temperature is below 45oF or 7oC)

• water has a tremendous capacity to drain heat from the body– immersion in water

considered even slightly cool (e.g., 60oF or 16oC) can cause hypothermia, if the immersion is prolonged for several hours.

Cold Weather Injuries – Cold Weather Injuries – Hypothermia on LandHypothermia on Land

• Requires many hours of continuous exposure to cold air for body temp to fall (healthy, physically active, and reasonably dressed individual)

• But remember - wet skin and wind accelerate body heat loss, and the body produces less heat during inactive periods

• Body temperature can fall even when air temperatures are above freezing if conditions are windy, clothing is wet, and/or the individual is inactive.


• difficult to recognize in its early stages

• watch for: unusually withdrawn or bizarre behavior, irritability, confusion, slowed or slurred speech, altered vision, uncoordinated movements, and unconsciousness.

• Even mild hypothermia can cause victims to make poor decisions or act drunk (e.g., removing clothing when it is clearly inappropriate).


• Vital signs may be greatly reduced,faint or undetectable

• If hypothermia has resulted from submersion in cold water, initiate CPR without delay

• when victims are found on land, it is important to take a little extra time searching for vital signs to determine whether CPR is really required.

Scenario Number IIIScenario Number IIIList six signs and symptoms of mild List six signs and symptoms of mild

hypothermia:hypothermia:

• Violent shivering• Loss of concentration• Weakness• Difficulty speaking• Slow thinking• Mild Confusion


• Treat victims gently during treatment and evacuation

• function of the heart can be seriously impaired in hypothermia victims

• Rough handling can cause life-threatening disruptions in heart rate.

• All hypothermia victims, even those who do not appear to be alive, must be evaluated by trained medical personnel.

Cold Weather Injuries - First Aid Cold Weather Injuries - First Aid For Hypothermia For Hypothermia

• Prevent Further Cold Exposure

• Remove Wet Clothing

• Initiate CPR, Only If Required

• Rewarm By Covering With Blankets, Sleeping Bags, And By Body-To-Body Contact

• Handle Gently During Treatment And Evacuation

Scenario Number IIIScenario Number III 9 y/o female tubing at night on the

outside lane of a large tubing park, near the end of the tubing session. Her tube catapults over the outer berm and down an adjacent embankment into a stand of trees.

The girl is found lying on her left side, supporting her partially flexed right arm across her abdomen. She

Scenario Number IIIScenario Number III is sobbing and shivering violently - and

wearing only jeans, a windbreaker and no hat. Assessment reveals slow, slurred speech; palpable tenderness, swelling, and deformity of the right elbow; a diminished/absent radial pulse on the right; and a weakened grasp in the right hand. Vitals – P-108 & strong, R-20 & shallow.

Scenario Number IIIScenario Number III

What management concerns

do you see arising from this scenario?


• Identify and locate the adult responsible for this child

• Prompt and proper emergencycare, and expeditious transportto definitive hospital care

• Incident investigation• Identify/correct the factors that

allowed the accident to occur


If you were to provide an interface/communications report before transferring this young girl to the EMS, what would you include in your report?


9 y/o female with:• A fracture deformity above the

right elbow, with diminished sensation in the right palm, anda loss of the right radial pulse

• Mild hypothermia, estimated core body temperature above 90

oF


• No evidence of loss of responsiveness

• No other significant injuries

• Estimated body weight – 70 pounds

• Accompanied by parent or guardian


• Emergency care rendered up until the time of transfer: long arm splint, sling and swathe active/passive rewarming with blankets and hot

water bottles nothing to eat or drink (reduce aspiration risk)

• Vital signs at the time of transfer

Tube ParkTube Park

Snowy BowlSnowy Bowl

The EndThe End

Substance abuseSubstance abuse

• Whenever there is altered sensorum, one must consider substance abuse.

• Classes– Alcohol– Narcotics– Depressants– Stimulants– Cannabis– Hallucinogens– Nicotine

Substance AbuseSubstance Abuse

• Substance abuse should be suspected in any person exhibiting inappropriate behavior or whose normal state of responsiveness is altered without obvious cause.

• The users may not admit substance abuse.

• Other serious conditions such as diabetic coma, head injury epilepsy, can be mistaken for substance abuse.

Nicotine and TobaccoNicotine and Tobacco

• Users of nicotine develop a tolerance and dependence on the drug.

• Withdrawal symptoms:– irritability– anxiety– restlessness– difficulty in

concentrating

Assessment of PatientAssessment of Patient

• First Impression- Look at the surroundings. Is the person sick or injured? Use universal precautions.

• Urgent Survey - Is patient responsive? What is the level of responsiveness? Open and maintain airway. Check pulse, assess chest, pulse, abdomen. Check neck and head if unresponsive.

Assessment of PatientAssessment of Patient

• NonUrgent Survey- This is the stage where you will determine if substance abuse is the cause. Talk to the patient or companions. Get medical history.

• Ask the patient what happened. Ask about drugs being taken. Assess vital signs.

• Look for signs of substance abuse.

Emergency Care-Substance Emergency Care-Substance AbuseAbuse

• open and maintain the airway

• provide care for unresponsiveness if needed

• monitor and record vital signs

• anticipate vomiting

• support breathing as needed

Emergency Care-Substance Emergency Care-Substance AbuseAbuse

• treat for shock if it develops

• treat for hypothermia or hypothermia

• calm an agitated patient

• treat for convulsions if possible

• stay with patient.

• preserve vomitus, bottles, pills, to send with the patient

AlcoholicsAlcoholics

• early Intoxication– excitement– talkativeness– aggressiveness– dilated pupils

• late Intoxication– disorientation– slurred speech– inability to concentrate– falling, stumbling– drowsiness– stupor– coma

Withdrawal from AlcoholWithdrawal from Alcohol

– anxiety– tremors– nausea– vomiting– seizures– agitation– hallucinations

NarcoticsNarcotics

• central nervous and respiratory system depressants

• tolerance develops rapidly

• can be smoked, injected or taken orally

• symptoms of use include:– lethargy– stupor– slowed pulse,

breathing– low blood pressure– pinpoint pupils– nasal stuffiness– chronic constipation

Narcotics OverdoseNarcotics Overdose

• may result in:– coma– respiratory failure

• withdrawal symptoms include:– rapid pulse– anxiety– goose bumps– nausea, vomiting– shakes– sniffling, runny nose– abdominal cramps– diarrhea

Depressants and AnalgesicsDepressants and Analgesics

• barbiturates– Seconal– Amytal– Nembutal– Phenobarbital

• non- barbiturates– Quaalude– Valium– Xanax

SymptomsSymptoms

• symptoms of overdose include:– drowsiness– coma– slow pulse– slow breathing– low blood pressure– seizures

SymptomsSymptoms

• symptoms of withdrawal include:– disoriented– insomnia– agitation– hallucinations– shock – seizure

StimulantsStimulants

• may also cause paranoia, disorganization, irritability, anxiety, hyperactivity, seizures and insomnia

CocaineCocaine

• crack is a cheap widely available form of cocaine used by smoking

• other forms of cocaine are injected or inhaled

• is highly additive because of the intense high or euphoria that it produces

• is one of the most widely abused drugs today

CocaineCocaine

• not only highly additive but use can kill

• produces an accelerated heart rate at the same time constricting blood vessels

• blood pressure rises and may cause stroke, seizures, cardiac arrest or stroke

CocaineCocaine

• stuffiness and runny nose are typical of cocaine users

• prolonged use may cause disintegration of the mucous membrane

• heavy use can cause collapse of the nasal septum

Symptoms of Cocaine UseSymptoms of Cocaine Use

– heart attack– stroke– shock– gangrene of intestinal

system– cardiac problems– altered motor activities

(tremors, hyperactivity)

• anxiety– panic– rapid pulse and

respirations– paranoia– confusion– dilated pupils– hallucinations– seizures

CocaineCocaine

• chronic Cocaine abuse can cause:– neglect of family

responsibilities– ignoring job demands.– social isolation – neglect of body needs

and hygiene

CocaineCocaine

• withdrawal can produce the following symptoms:– exhaustion– anxiety– depression

AmphetaminesAmphetamines

• originally used as a appetite suppressant or mood elevator

• very few legitimate medical uses

• cause wakefulness and are sometimes used by students while cramming

• can be taken by injection, ingestion or inhalation

AmphetaminesAmphetamines

• amphetamine examples:– Desoxyn– Dexedrine– MDA– MDMA– MDEA

• non amphetamine examples:– Ritalin– Preludin– Tenuate

Symptoms of Amphetamine UseSymptoms of Amphetamine Use

– altered mental state– rapid pulse and

breathing– hyperactivity– tremors– increased blood

pressure– inability to concentrate– hallucinations

– anxiety, agitation– insomnia– irritability– excitement– paranoia– confusion– seizures– coma– cardiac arrhythmias

StimulantsStimulants

• withdrawal symptoms are the same as those for Cocaine

Symptoms of Cannabis UseSymptoms of Cannabis Use

• many people do not believe that these are harmful substances

• marijuana available today is 275% more potent than that available in the 60’s

Cannabis Cannabis

• even small amounts can impair memory function, decrease motor skills, and impair judgement

• the effects last for 4 to 6 hours after smoking of a single cigarette

• the effects are even more pronounced if combined with alcohol

CannabisCannabis

• symptoms of use:– confusion– increased pulse– increased appetite– impaired memory– poor coordination– inability to do complex

work– reddened eyes and

dilated pupils

– apathy– loss of ambition– loss of effectiveness– decline in work and

school performance– difficulty concentrating

CannabisCannabis

• withdrawal may cause:– anxiety– loss of appetite– irritability– nausea

HallucinogensHallucinogens

• substances that alter perception and produce delusions or hallucinations

• individuals may have a distorted perception of their physical abilities and try such things as flying


• Common Types:– LSD– magic mushrooms– mescaline– peyote– morning glory seeds– STP– PCP

• Designer Types:– MDMA– MDA– MDEA


• effects include:– euphoria– paranoia– hyperactivity– muscular rigidity– altered perception– diminished ability to

sense pain– bizarre behavior

• serious reactions include:– panic – violent behavior– suicide attempts– serious mental

disturbance– psychosis


• there are no clearly defined effects of withdrawal

• there may be occasional flashbacks of the behavior shown when on the drug

StrokeStroke

• A cerebrovascular accident (CVA) is caused by interference with the blood supply to a part of the brain.– Ischemic (80%)– Hemorrhagic (20%)

StrokeStrokeSigns and SymptomsSigns and Symptoms

• normal or high blood pressure

• confusion• impaired responsiveness• head and eyes turned to

one side• weakness, paralysis,

numbness, and/or tingling on one side of the body or occasionally both sides

StrokeStrokeSigns and SymptomsSigns and Symptoms

• drooping of one side of the face, drooling, difficulty in swallowing, and slurred speech

• difficulty with the airway• visual disturbances and

vertigo• seizures, headaches, or

dizziness• aphasia

Stroke-Emergency CareStroke-Emergency Care

• provide care for unresponsiveness if needed

• maintain the patients airway

• use suction as needed

• administer high flow oxygen

• keep the patient lying down in recovery position (head and body slightly elevated)

Stroke-Emergency CareStroke-Emergency Care

• maintain the patients body temperature

• don’t give the patient anything by mouth

• care for seizures if they occur

• transport the patient rapidly to the hospital

Initial ImpressionsInitial Impressions

• The Scene Survey• Presence of hazards to rescuer or patient• Number of patients• Possible need for triage• Probable mechanism of Injury• Is there a need for extrication or additional help• Recognizing Obvious characteristics of each patient• Obviously responsive or not• Obvious bleeding• Does the patient appear critically injured or ill

Heart AttackHeart Attack

• Signs and symptoms are caused by the lack of oxygen to the heart.

• Risk factors– HTN– Hyperlipidemia– DM– smoking

Heart Attack-Signs and Heart Attack-Signs and SymptomsSymptoms

• pain- described as crushing or burning in the stomach, chest or between shoulders

• anxiety and fear of death

• respiratory distress

• pale, cold, cyanotic skin

• profuse sweating

Heart Attack-Signs And Heart Attack-Signs And SymptomsSymptoms

• pulse that is normal, fast, slow, irregular, strong or weak

• blood pressure that is abnormal or normal

• patient prefers to sit up

• complications including– cardiac arrest, cardiogenic shock, pulmonary

edema

Heart Attack - Emergency CareHeart Attack - Emergency Care

• With proper treatment many heart attack victims can have many years of useful life.

Heart Attack Emergency CareHeart Attack Emergency Care

• perform survey, manage airway, give CPR and attend other serious problems

• contact EMS

• keep patient comfortable

• give oxygen at high rate

• calm and reassure patient

Heart Attack-Emergency CareHeart Attack-Emergency Care

• shield patient from by-standers

• watch for complications and treat as they occur

• monitor and record vital signs

• give aspirin

Documents

Mountains Cold Weather Injuries R. Eugene Bailey, MD Toggenburg Ski Patrol Refresher Course 2008