George R.R. Martin, A Game of Thrones

Truer words have never been spoken. Cold like heat can burn, just differently. This time of year, as my fellow pre-hospital providers go forth to save lives, cold related injuries should be in the forethought of every provider. Let’s take a look at some of the most common cold related injuries and preventive measures we can take.

How do we lose heat or thermolysis? Conduction, convection, radiate, and evaporation. Much like heat related emergencies, the body makes its own heat via the hypothalamus setting the BMI or basal metabolic rate. When in a cold environment we lose heat faster than our body can make it, hence cold injuries can occur.

Lets take a look at some cold related injury patterns and their causes. Since most cold injuries reside in the extremities, we can use a rhyming line up of fingers, nose, toes, and hose to describe the most vulnerable parts of the human body.

Frost nip, the mildest form is generally not painful and most commonly found in people who spend too much time in the cold, a great example is people who participate in winter sports. Characterized by redness and numb extremities, primarily the fingers, nose, and ear. Easily treated by wind milling the arms, placing the cold hands in your armpits or covering your ears with warm hands.

Risk factors for superficial and deep frost bite include:

1. Inadequately clothed for the cold environment

2. Impeding circulation with tight clothing, smoking, or alcohol

3. Fatigue, hunger, or dehydration

4. Coming in direct contact with cold objects

Superficial frost bite is characterized by alteration of sensations, white and waxy appearance with a firm to the touch dermal area and a soft underlying tissue with palpation.

Deep frostbite has the firm to palpation of superficial frost bite but now the underlying tissues are also firm to the touch. The skin is white to blue and all sensation is gone. This form of frost bite is most dangerous if you cannot guarantee a rapid re-warming. If allowed to warm slowly, a partial refreezing may occur, which could cause the ice crystal in cells to grow much larger and cause more damage than the initial freezing injury. Even with appropriate re-warming and care cellular damage may be significant and gangrene may set in.

Treatment does not differ between deep and superficial frost bite. Re-warming, pain control, and dry sterile dressings for blisters are the general cold related protocols. If concerned about refreezing leave the extremity cold and transport to the hospital.

Cold injuries can not only occur in the patient lying in the street after a car accident, in the elderly patient lying on the cold bathroom floor for hours and to you the pre-hospital professional, who is ill prepared for the environment you will be working in. Let’s think healthy, stay hydrated, dress in layers, keep warm as your health effect the patients you come into contact with.

Butterfras, Bruce, M.S., Jensen, Barry, NREMT-P, Brocato, Chad DHc, Et. al, Nancy Caroline’s Emergency care in the streets. Burling, MA; AAOS, 2013