Mountains
Cold Weather Injuries
R. Eugene Bailey, MD
Toggenburg Ski Patrol
Refresher Course 2008
SCENARIO DISCUSSION
FORUM
FALL REFRESHER 2002
Snowy Mountains Misty Valley
Tube Park Fun
Scenario 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 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 Triage
• Primary Survey
– ABCs
– Level of responsiveness
– Urgent treatment
• Secondary Survey
– Musculoskeletal
– Cold Weather injury
Cold Weather Injuries Windchill
Preventive Measures
Trenchfoot
Chilblain (Pernio)
Dehydration
Frost Nip
Frost bite
Hypothermia
Cold Weather Injuries –
Wind Chill
Cold Weather Injuries
PREVENTION
WINDCHILL
• 30oF and below (1oC)
• 25oF and below (4oC)
• 0oF and below (18oC)
• -10oF and below (23oC)
• -20oF and below (29oC)
PM MEASURES
• Alert team to potential for cold injury
• Inspect personnel for proper clothingProvide 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 - Trenchfoot
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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 Trenchfoot
• 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
First Aid For Trenchfoot
1.
2.
3.
4.
5.
6.
Prevent Further Exposure
Remove Wet, Constrictive
Clothing
Wash And Dry Injury Gently
Elevate, Cover With Layers
Of Loose, Warm Clothing,
And Allow To Rewarm (Pain
And Blisters May Develop)
Do Not Pop Blisters, Apply
Lotions Or Creams,
Massage, Expose To
Extreme Heat, Or Allow
Victim To Walk On Injury
Refer For Medical Treatment
Cold Weather Injuries-Chilblain
•
•
•
•
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
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Hormonal or nervous system factors that
affect the small blood vessel
Genetic influence
Diet problems
Atherosclerosis
Cold Weather Injuries
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
Dehydration
• 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
Cold Weather Injuries
Dehydration
• A general recommendation for
persons participating in coldweather 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.
Cold Weather Injuries
Dehydration
• The lighter the urine color, the better
hydrated, and that dark yellow urine is a
sure indicator that fluid consumption
should be increased.
Cold Weather Injuries
Dehydration
• 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 Frostnip
• 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 Frostbite
• 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
First Aid For Frostbite
1.
2.
3.
Prevent Further Exposure
Remove Wet, Constrictive Clothing
Rewarm Gradually By Direct Skin-To-Skin Contact
Between Injured Area And Noninjured Skin Of The
Victim Or A Buddy
Cold Weather Injuries
First 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 Hypothermia
• 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 deepbody temperature falls
below 95oF (35oC).
Cold Weather Injuries –
Hypothermia – 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 –
Hypothermia 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.
Cold Weather Injuries Hypothermia
• 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).
Cold Weather Injuries Hypothermia
• 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 III
List six signs and symptoms of mild
hypothermia:
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Violent shivering
Loss of concentration
Weakness
Difficulty speaking
Slow thinking
Mild Confusion
Cold Weather Injuries Hypothermia
• 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
For Hypothermia
•
•
•
•
•
Prevent Further Cold
Exposure
Remove Wet Clothing
Initiate CPR, Only If
Required
Rewarm By Covering
With Blankets, Sleeping
Bags, And By Body-ToBody Contact
Handle Gently During
Treatment And
Evacuation
Scenario 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 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 III
What management concerns
do you see arising from this
scenario?
Scenario Number III
• Identify and locate the adult
responsible for this child
• Prompt and proper emergency
care, and expeditious transport
to definitive hospital care
• Incident investigation
• Identify/correct the factors that
allowed the accident to occur
Scenario Number III
If you were to provide an
interface/communications
report before transferring
this young girl to the EMS,
what would you include in
your report?
Scenario Number III
9 y/o female with:
• A fracture deformity above the
right elbow, with diminished
sensation in the right palm, and
a loss of the right radial pulse
• Mild hypothermia, estimated core
o
body temperature above 90 F
Scenario Number III
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•
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No evidence of loss of responsiveness
No other significant injuries
Estimated body weight – 70 pounds
Accompanied by parent or guardian
Scenario Number III
• 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 Park
Snowy Bowl
The End
Substance abuse
• Whenever there is altered sensorum, one must
consider substance abuse.
• Classes
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Alcohol
Narcotics
Depressants
Stimulants
Cannabis
Hallucinogens
Nicotine
Substance 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 Tobacco
• Users of nicotine
develop a tolerance
and dependence on
the drug.
• Withdrawal
symptoms:
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irritability
anxiety
restlessness
difficulty in
concentrating
Assessment of Patient
• First ImpressionLook 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 Patient
• NonUrgent Survey• Ask the patient what
This is the stage
happened. Ask
where you will
about drugs being
determine if
taken. Assess vital
substance abuse is
signs.
the cause. Talk to the • Look for signs of
patient or
substance abuse.
companions. Get
medical history.
Emergency Care-Substance
Abuse
• 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
Abuse
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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
Alcoholics
• early Intoxication
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excitement
talkativeness
aggressiveness
dilated pupils
• late Intoxication
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disorientation
slurred speech
inability to concentrate
falling, stumbling
drowsiness
stupor
coma
Withdrawal from Alcohol
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anxiety
tremors
nausea
vomiting
seizures
agitation
hallucinations
Narcotics
• 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 Overdose
• may result in:
– coma
– respiratory failure
• withdrawal symptoms
include:
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rapid pulse
anxiety
goose bumps
nausea, vomiting
shakes
sniffling, runny nose
abdominal cramps
diarrhea
Depressants and Analgesics
• barbiturates
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Seconal
Amytal
Nembutal
Phenobarbital
• non- barbiturates
– Quaalude
– Valium
– Xanax
Symptoms
• symptoms of
overdose include:
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drowsiness
coma
slow pulse
slow breathing
low blood pressure
seizures
Symptoms
• symptoms of
withdrawal include:
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disoriented
insomnia
agitation
hallucinations
shock
seizure
Stimulants
• may also cause
paranoia,
disorganization,
irritability, anxiety,
hyperactivity, seizures
and insomnia
Cocaine
• is highly additive
because of the
intense high or
euphoria that it
produces
• is one of the most
widely abused drugs
today
• crack is a cheap
widely available form
of cocaine used by
smoking
• other forms of
cocaine are injected
or inhaled
Cocaine
• 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
Cocaine
• 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 Use
• anxiety
– panic
– rapid pulse and
respirations
– paranoia
– confusion
– dilated pupils
– hallucinations
– seizures
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heart attack
stroke
shock
gangrene of intestinal
system
– cardiac problems
– altered motor activities
(tremors, hyperactivity)
Cocaine
• chronic Cocaine
abuse can cause:
– neglect of family
responsibilities
– ignoring job demands.
– social isolation
– neglect of body needs
and hygiene
Cocaine
• withdrawal can
produce the following
symptoms:
– exhaustion
– anxiety
– depression
Amphetamines
• 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
Amphetamines
• amphetamine
examples:
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Desoxyn
Dexedrine
MDA
MDMA
MDEA
• non amphetamine
examples:
– Ritalin
– Preludin
– Tenuate
Symptoms of Amphetamine Use
– altered mental state
– rapid pulse and
breathing
– hyperactivity
– tremors
– increased blood
pressure
– inability to concentrate
– hallucinations
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anxiety, agitation
insomnia
irritability
excitement
paranoia
confusion
seizures
coma
cardiac arrhythmias
Stimulants
• withdrawal symptoms
are the same as
those for Cocaine
Symptoms 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
• 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
Cannabis
• symptoms of use:
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confusion
increased pulse
increased appetite
impaired memory
poor coordination
inability to do complex
work
– reddened eyes and
dilated pupils
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apathy
loss of ambition
loss of effectiveness
decline in work and
school performance
– difficulty concentrating
Cannabis
• withdrawal may
cause:
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anxiety
loss of appetite
irritability
nausea
Hallucinogens
• 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
Hallucinogens
• Common Types:
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LSD
magic mushrooms
mescaline
peyote
morning glory seeds
STP
PCP
• Designer Types:
– MDMA
– MDA
– MDEA
Hallucinogens
• effects include:
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euphoria
paranoia
hyperactivity
muscular rigidity
altered perception
diminished ability to
sense pain
– bizarre behavior
• serious reactions
include:
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panic
violent behavior
suicide attempts
serious mental
disturbance
– psychosis
Hallucinogens
• there are no clearly
defined effects of
withdrawal
• there may be
occasional
flashbacks of the
behavior shown when
on the drug
Stroke
• A cerebrovascular
accident (CVA) is
caused by
interference with the
blood supply to a part
of the brain.
– Ischemic (80%)
– Hemorrhagic (20%)
Stroke
Signs 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
Stroke
Signs 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 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 Care
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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 Impressions
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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 Attack
• Signs and symptoms
are caused by the
lack of oxygen to the
heart.
• Risk factors
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HTN
Hyperlipidemia
DM
smoking
Heart Attack-Signs and
Symptoms
• 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
Symptoms
• 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 Care
• With proper treatment
many heart attack
victims can have
many years of useful
life.
Heart 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 Care
• shield patient from by-standers
• watch for complications and treat as they
occur
• monitor and record vital signs
• give aspirin