Advanced Burn Life Support CourseHypothermia Frostbite Dr. Aidad Abu Elsoud Alkaisi BA law, RN, BSc, MSc, PhD Specialist in Intensive Care Nursing, Anaesthetic Nursing & Nursing Education
Hypothermia Frostbite • Upon completion of this topic, the participants will be able to: • Understand the types of cold injury • Understand initial management of cold injuries
Overview • A- Cold injury most commonly occurs secondary to environmental exposure without appropriate protection. • Injury can be localized (frostbite) or systemic (hypothermia). • The physiological changed associated with cold injuries are distinct from heat injury and a distinct therapeutic approach is required. Military personnel, older adults, and the homeless are the populations most at risk for these injuries.
B- Exposure to cold may result in frostbite or systemic hypothermia. • Hypothermia is a common problem in the northern hemisphere particularly among the elders and the homeless, alcoholics, winter Sports enthusiasts, and children under five are most susceptible to hypothermia.
C. Systemic hypothermia occurs when the core body temperature falls below 93 degrees Fahrenheit. • This occurs when the heat lost to the environment is greater than the body's heat production, resulting in a drop in the core body temperature.
Pathophysiology • A. Compensatory measures following a reduction in body temperature include: • 1. T'achypnea and elevation of blood pressure • 2. Increased muscle activity • 3. Involuntary shivering • B. When these compensatory measures are unable to match body heat loss, hypothermia develops
Hypothermia syndromes: • The clinical syndromes of hypothermia include frostbite and systemic hypothermia. • Frostbite • 1. Frostbite is the result of prolonged exposure of body parts to intense cold. • Those body parts most frequently involved are the ears, nose, hands, and feet.
2. The patient presents with coldness of the extremity, and most report that the affected area is insensate, clumsy (not elegant or graceful in expression) or feels as though it is missing. • The limb appears mottled (having spots or patches of color) blue or yellow-white. • It is difficult to discern the depth of injury on early examination
3. Frostbite is seldom accompanied by systemic hypothermia. • 4. Stages of Frostbite • a. Freeze-thaw cycles: cellular dehydration occurs following ice-crystal formation in the tissues. • b. Stasis: venous dilitation and vasoconstriction occur, resulting in peripheral polling of blood. • c. Ischemia Stage: ischemia results in frank (to mark) tissue necrosis
5. Manifestations of Frostbite • the physical signs and symptoms of frostbite may include the following: • a. reddened, blue, or pale skin • b. Prickling painful sustain with superficial frostbite • c. painless, rigid skin with deep frostbite • d. functional impairment
6. Pre-hospital Management • a. The Initial therapy for frostbite is the same regardless of the perceived depth of injury. • All constrictive and damp clothing should he removed and replaced with dry, loose garments. • No attempt should be made to rewarm the extremity prior to transfer to a specializd treatment unit (if possible within 2 hours).
The extremity should be padded, splinted and elevated. • Exposure to car heaters or campfires that might produce a partial rewarming should he avoided. • The injured limb should not he rubbed or massaged, as this might exacerbate the injury.
b. lf transport in prolonged and the extremity thaws (To change from a frozen solid to a liquid by gradual warming), great care should be taken to prevent re-freezing of the extremity, and the patient should be protected from cold exposure. • Care must be taken to diagnose and treat concomitant (an event or situation that happens at the same time as or in connection with another) injuries, including systemic hypothermia. • Fluid resuscitation is rarely required for isolated frostbite. • Move the patient to a warm environment.
C. Frostbite wound management will depend on the distance from the nearest hospital: • 1. If the transport time is less than 60 minutes, transport to the nearest appropriate facility. • Cover the wound with a clean sheet. • Do not puncture or drain blisters. • Elevate the injured area to reduce swelling.
2. If transport time is greater than 60 minute, remove all clothing from the affected part. • Rewarm the frostbitten area by immersion in water at 100-105 degrees Fahrenheit. • Continuously check the temperature of the water. Avoid dry heat to thaw the involved aea. • The process of rewarming may take 30-45 minutes. A return of color and sensation to the affected part are signs that thawing has taken place. Do not allow the patient to smoke.
B. Systemic hypothermia: • Primary accidental hypothermia due to overwhelming environmental exposure or cold water immersion is relatively rare, accounting for approximately 500 deaths per year in the United States. • Alternatively, secondary accidental hypothermia occurs when a mild cold stress is combined with illness, injury such as a major burn wound or drug-induced alterations in heat production and thermoregulation.
For example older adults have impaired ability to increase heat production and decrease heat loss by vasoconstriction, placing them at risk for hypothermia even in moderately cold environments.
This is often a much more lethal situation; a core temperature reduction to 32C in secondary accidental hypothermia is almost always fatal. • Moderate hypothermia occurs when body temperature falls to 90-93. F (32 - 34. C). Severe hypothermia is defined as a core body temperature below 90 F (32-34 C).
1. The clinical manifestations if hypothermia include the following: • a. a core body temperature of less than 93F (34. C). • b. lethargy, confusion, or stupor • c. uncontrollable shivering • d. an acetone odor on the breath • e. pale and cool skin • f. bradycardia, ventricular fibrillation, or asystole
Pre-hospital management • a.The prompt initiation of rewarming is important. • A1l wet clothes are removed. • If the patient has mild hypothermia and alert, wrapping the patient with warm blankets and.giving him or her hot liquids to drink is the preferred method of rewarming.
Shivering will generate body heat, albeit (Even though) at a metabolic cost. • Even with moderate hypothermia, passive warming is affective if shivering is present. • Since many of these patients are unconscious, warm intravenous fluids are also highly effective.
B. Active rewarming is accomplished by placing the patient in a circulating water bath at 40C. • Warm water immersing is the most effective conductive rewarming technique. • However, it is complicated by sudden ventricular fibrillation, especially in hypovolemic patients. • lf this occurs the patient must be dried prior to defibrillation or the charge can short to the ground making it ineffective or even causing burn injury.
C. External heating using connective heating blankets is more effective than electric or cotton hospital blankets and is based on the principle that nearly all heat loss occurs through the skin surface.
D. lf asystole ventricular defibrillation occurs, CPR should be initiated and should continue during rewarming efforts. • CPR should not be discontinued until the patient's temperature reaches 36 degrees C. or until unassisted perfusion returns to normal. • Patients in cardiac arrest should not be declared dead until they are rewarmed and continue to fail to respond to CPR. • E . Transport the patient immediately to the nearest appropriate emergency facility.
F. Assess and stabilize the airway, breathing, and circulation. • provide 100% oxygen via non-rebreathing mask as needed. • lf transport time to the nearest appropriate emergency facility is greater than 60 minutes, begin fluid resuscitation with 5% glucose in Ringer's Lactate. • (Always maintain compliance with local pre-hospital medical protocols) Monitor cardiac rhythm closely. The presence of asystole is not irreversible.
Summary: • Exposure to cold may result in frostbite, a localized injury, or systemic hypothermia. • Frostbite commonly involves the face, hands, or feet resulting in varying degrees of injury to the tissues. • Frostbite is managed in the pre-hospital setting by moving the patient to a warm environment and transporting him or her to the nearest appropriate medical facility.
Hypothermia results when the body temperature drops below 93 F (34 C). • Severe hypothermia occurs when the core body temperature falls below 90 F (32 C). • The patient may be comatose, shivering, and bradycardic.
Asystole and apnea are potentially reversible findings in profound hypothermia. • The immediate management in the pre-hospital setting is to provide 100% oxygen via non-recreating mask, initiate warming procedures and the patient to the nearest appropriate medical facility.