Cold Weather Injuries

1. Cold Weather Injuries Knowledge Nuggets For Prevention And Management

2. Disclaimer This is an overview of injuries associated with various outdoor winter activities, not First Aid instruction. For more information on Wilderness First Aid, contact Deb Ajango info@safetyed.net http://www.safetyed.net/

3. Andrea Andraschko • Credentials: Wilderness EMT-2, volunteer medic with Alaska Mountain Rescue Group • Work: Alaska Regional LifeFlight (Dispatch), located in the ER • Outdoor winter activities: skiing, snowshoeing, hiking, climbing

4. Activities • Camping • Hiking • Snowshoeing • Skiing – Alpine and Nordic • Snowmachining

5. Camping • Hypothermia • Frostbite • Immersion foot • Burns • CO poisoning

6. Hiking & Snowshoeing • Chilblain • Hypothermia • Frostbite: Face, Ears, Feet, Hands • Immersion foot • Dehydration • Snow Blindness • Musculoskeletal injuries

7. Skiing • Hypothermia • Frostbite: Face, Ears • Dehydration • Snow Blindness • Musculoskeletal injuries: Knees • Skeletal injuries: Spine • Traumatic injuries: Head

8. Snowmachining • Hypothermia • Frostbite: Face, Ears, hands • Dehydration • Snow Blindness • Skeletal injuries: Spine • Traumatic injuries: Head, internal

9. Cold Injury Guidelines • Most current guidelines (rev. 2005), applicable to all levels of first aid training • Covers hypothermia, cold water near drowning, frostbite and avalanche rescue • Prepared by world-renown experts in cold weather injuries • Available by download from: www.chems.alaska.gov/EMS/ documents/AKColdInj2005.pdf

10. Hypothermia Symptoms • Mild • Core Temp: 95º to 90ºF • Ability to rewarm self: Good • Symptoms: intense shivering, “umbles”, denial • Moderate • Core Temp: 90º to 82ºF • Ability to rewarm self: Limited • Symptoms: gradual loss of shivering, decreasing level of consciousness, total loss of consciousness <86ºF • Severe • Core Temp: <82ºF • Ability to rewarm self: Unable • Symptoms: Rigid, HR and breathing may be unnoticeable, may appear dead. Move with extreme caution!

11. Hypothermia Management Mild (Person is able to ‘self rescue’) • Remove wet and/or restrictive clothing. • Get inside shelter if possible. • Eat – Mix of proteins, fats and carbs is best to fuel the furnace. • Drink – sugar is good, caffeine is bad. Should not be cold, does not need to be warm. • Exercise – move around to increase circulation. • It is ok to use chemical heat packs placed on pulse-points to assist rewarming (not directly on skin). • Warm showers or baths are ok.

12. Nuggets • It “costs” the body 70 kcal/hr to maintain normal body function at rest. Breathing in 0ºF air and warming it to body temperature costs an additional 40 kcal/hr. • Intense shivering rapidly depletes muscle glycogen stores, “costing” up to 220 kcal/hr. Shivering stops when there is no glycogen left to fuel muscle contractions. • Lactic acid is a by-product of muscle activity. High levels of lactic acid in the blood interferes with further muscle activity – i.e. the heart.

13. Nuggets • Carbohydrates rapidly provide 7-10 kcal heat per 100 kcal ingested; proteins slowly provide 27-30 kcal heat per 100 kcal ingested. • Snacks that provide both carbohydrates and protein should be consumed at regular intervals. • Warm Jell-o provides a protein and sugar source suitable for a quick warm-up or bedtime snack.

14. Nuggets • During rest, 10% of the body’s heat is lost through the head. During exercise, up to 55% is lost through the head. • A hooded parka can be used to help capture body heat generated by “warming” exercises – heat lost through the head can be redirected to the trunk via the hood. • A protein and carbohydrate snack followed by light exercise is a good way to manage mild hypothermia. • Circulation enhancing foods such as ginger and cayenne can help stimulate warmth.

15. Hypothermia Management Moderate(Person appears confused or disoriented) • Do not try to rapidly rewarm. • Cut off wet clothing and place in a hypobag or hypowrap. • Do not apply heat directly to skin; warm bottles or heat packs may be placed between layers in the hypowrap. • Do not allow person to exercise, sit or stand. • Do not give oral fluids or food. • Do not use warm baths or showers. • Transfer to a hospital ASAP.

16. Nuggets • A hypowrap is also known as “the human burrito.” • A hypowrap consists of dry clothing, 1-2 dry sleeping bags, an insulating pad, and a wind barrier such as a sheet of plastic, tarp or tent-fly. • Lay the tarp out first, then the pad, the sleeping bag(s) and then the patient. • Cover the head with a hat, and the face loosely with a scarf or face mask. Ensure breathing is not compromised. • Warm water bottles or hand-warmers may be placed between layers, but not directly on the skin.

17. Hypothermia Management Severe, with signs of life (pulse, respirations) • Handle very very gently. • Do not rub or massage patient. • Cut off wet clothing and place in a hypobag or hypowrap. • Do not add any external heat. • May assist respirations with mouth to mask rescue breathing if within scope of training.

18. Hypothermia Management Severe (no signs of life, but death not obvious) • Handle very carefully; avoid bumping or jarring patient. • May provide mouth to mask breathing. • CPR only if patient is greater than 3 hours from definitive care and properly trained providers are present. • Best treatment is careful and gentle evacuation.

19. Frostbite • Early stage (frostnip) is characterized by a soft waxy appearance, with numbness and decreased local motor skills. • It is safe to rewarm in the field by increasing peripheral circulation, skin-to-skin warming, or warm water immersion. Take care not to refreeze. • Late stage is characterized by complete loss of sensation and movement, skin feels hard and ice crystals may be visible. • Do not attempt to thaw in the field unless thawing and refreezing can not be avoided.

20. Nuggets • Avoid hypothermia • Avoid vasoconstricting gloves and socks, and use wicking liners. • Keep dry socks and gloves handy, and change frequently. • Do not use water-based lotions or sunscreen on the face. • Cover as much exposed skin as possible, especially when wind is a factor. • Use “buddy checks” to monitor for S/Sx of freezing injuries.

21. Chilblains • A recurring condition related to pre-existing peripheral circulatory issues. • Aggravated by exposure to wet windy conditions between 32º and 60ºF. • Causes decreased perfusion to the skin tissues which does not readily return with warming. • Affected areas may swell and blister. • Symptoms may persist up to 2 weeks. • Afflicted individuals should avoid cold, wet windy conditions, and should dress appropriately.

22. Trenchfoot • Caused by prolonged exposure to very cold water resulting in decreased perfusion to skin tissue. • Left untreated can lead to tissue death. • Exacerbated by constricting socks or boots. • Initial appearance is similar to frostbite. • Treatment is rewarming, which is very painful. • Avoid by keeping feet warm and dry. • Do foot inspections (socks and shoes off) and foot massages every 3-4 hours.

23. Snow Blindness • Sunburn to the eyes. • UV blocking eyewear is important when outdoors in a snowy environment, even if it isn’t that sunny. • Treatment includes prescription opthalmic ointments. • Field treatment includes loosely covering the eyes and evacuating the patient.

24. Burns • Burn injuries can be caused by stove flare-ups and campfires. • Burns to face, neck, arms and hands common. • Superheated inhaled air can be life-threatening. • Swelling from burns peaks within 24 hours. • Burns to face, neck and airway can cause swelling that compromises respiration. • Treatment includes cool compresses (not snow), anti-inflammatories, and evacuation. • Prevention includes fire and stove safety awareness

25. Dehydration • Fluid losses can be insensible. • Sweat, breathing and urination are modes of fluid loss. • Cold causes peripheral vasoconstriction which increases blood pressure, and in turn triggers the kidneys to produce more urine (cold diuresis). • Low ambient humidity contributes to fluid losses • Be sure to drink whenever snacking or eating. • Water or electrolyte drinks (Emergen-C) are good choices while exercising. • Soups, hot Jell-o, and hot Tang are good choices in camp.

26. Nuggets • Wear several easily removable layers while exercising to avoid overheating. • Exercise increases moisture loss through respiration. • Face masks that help capture expired air can help prevent dehydration.

27. Nuggets • Urination will be more frequent during winter activities – it may take some encouragement to get kids to drink enough fluids throughout the day. • Encourage kids to urinate as needed at night. A full bladder triggers stretch sensors that causes a sensation of cold.

28. Musculoskeletal Injuries • Skiing – knees and ankles most vulnerable to breaks, strains, sprains, and ligament injuries • Snowshoeing – knees and hips most vulnerable to muscle and connective tissue injuries. • Thumb injuries can occur when hands get tangled up in ski pole straps. • High velocity injuries (skiing, snowmachining sledding) can include breaks, dislocations, spinal injuries, head injuries and internal injuries.

29. High Velocity Injuries • Immediately check ABCs; carefully reposition only if airway is compromised. • Determine level of consciousness (Alert and responsive, responsive to voice, responsive to pain, unresponsive). • Leave helmet on unless airway is compromised. • Protect c-spine by holding stabilization. • Insulate from cold, including the ground. • Perform first aid assessment in position found if airway is not compromised. Patients with suspected spinal injuries do NOT need to be laid flat.

30. High Velocity – Internal Injuries • Internal injuries are always a possibility after collisions and airborne acrobatics. • Suspect internal injuries if patient experiences • pain when abdominal cavity is palpated; • pain or difficulty breathing; • unusual paleness, rapid heart rate that doesn’t decrease, increased respirations, and damp or clammy skin.

31. High Velocity – Head Injuries • Head injuries are more serious if the level of consciousness of the patient decreases over time, or they vomit more than once. • Unconsciousness followed by return to normal mentation with amnesia is indicative of a concussion and is less of an emergency. • C-spine precautions should always be taken when head injuries are present.

32. Other Considerations • Cold air can induce asthmatic attacks in some people. Breathing warm, humid air may be the only field treatment needed. • Cold decreases the perception of pain. Cuts and bruises may go unnoticed until body parts rewarm. • Cold weather significantly increases caloric needs, while associated dehydration suppresses appetite. Eat and drink frequently to maintain optimal bodily functions.

33. Other Considerations (con’t) • Insulated clothing and sleeping bags act like a thermos – they hold warmth in; they don’t provide external heat. • Air is an excellent insulator. A tight (wicking) next-to-skin layer for torso and legs is fine, but subsequent layers should be loose enough to allow air to be trapped. • Socks and gloves that provide compression can contribute to peripheral vasoconstriction and lead to a progression of cold-related injuries.

34. Thank You! Any Questions?