Monday, November 27, 2006

Cold Weather Emergency

Cold Weather Emergency

By Dana Sterner, RN

With winter setting in, having firsthand knowledge of cold weather emergencies like frostbite is a necessary triage skill for emergent care nurses.
Frostbite occurs when skin temperature drops below freezing, causing ice crystals to form at the cellular level. Frostbite can occur quickly or take as long as several hours.

Certain predispositions can make individuals completely unaware of its occurrence, including dangerously cold situations or prolonged cold exposure; heat transfer by a chemical such as gasoline or thru a thermal conductor such as metal; constrictive boots, gloves or head gear; immobility; vasoconstrictive medications or drug intoxification.

Four Degrees of Injury
Frostbite is categorized according to degree or depth of tissue damage.1
First-degree frostbite presents with an erythema appearing skin. Patients complain of a stinging or burning sensation but are able to move appendages such as fingers and toes.
No tissue damage has occurred at this stage. It is considered superficial. Skin may feel stiff to the touch because ice crystal formation has started, but the tissue underneath is still warm and soft.
Second-degree frostbite may be erythemic, gray, white, bluish white or even yellowish in color. The appendages are edematous, extremely tender to touch, difficult to move and may have superficial blebs. Patients have described a feeling of pins and needles sensation. The tissue will feel hard and frozen. Tissue damage has begun and will continue if left exposed and untreated.
Third-degree frostbite appears waxy, white, blotchy or blue as if mottled. Edema is present along with hemorrhagic vesicles. Patient will complain of a numbness followed by a burning throbbing or shooting pain. As skin temperature continues to drop plasma leaks out from the blood vessels into the surrounding tissue causing ice crystals to form outside the cells. The tissue will feel hard and has been damaged. Appendages are difficult to move. Treatment is necessary to prevent further deeper tissue damage.
Fourth-degree frostbite consists of damage to the subcuticular, muscular and osseous tissues. The skin appears dry, blue, black, or rubbery. There may be little or no swelling with complaints of a deep aching joint pain. Obvious damage has occurred at the deepest level and tissue is unrecoverable and the area may appear deformed.1,2
Treatment Options
There are several different treatment options for the patient presenting with frostbite.
First, address medical conditions such as hypothermia and airway management. At the same time, remove the patient from cold environments and prevent partial thawing and refreezing of their skin.
Avoid friction or massage such as rubbing as it will exacerbate damage to the patient’s skin. Carefully remove any wet clothing. Remove rings, watches or anything that is constricting to affected areas.
Frozen tissue should be thawed by immersion in warm, circulating water 37-42° C. Avoid hot water. If no thermometer is available, use water that is warm to the touch, but never hot.
Hydrotherapy should continue after initial thawing of the skin. The frequency and length of time will depend on the extensiveness of damage. Do not use direct dry heat, such as a hair dryer or electric blanket. Direct heat can burn the tissue that has already been damage.
Administer analgesics and encourage patient to gently move parts. Some patients may experience severe pain with reperfusion of tissue and may need parenteral narcotics.
Appendages
Loosely wrap a warm moist towel around frostbitten appendages, such as the ears or nose.
Movement should be encouraged to prevent venous stasis but no weight bearing should be allowed until swelling is resolved.
When possible, keep appendages elevated to reduce swelling. Place a soft cloth between affect appendages to absorb moisture and prevent sticking or rubbing.
There is some controversy over aspirating clear vesicles. If broken, debride the affect area and dress with sterile gauze and ointment. If left intact, the fluid will usually reabsorb in a few days. Follow your facilities policy and procedures concerning this.
Leave hemorrhagic vesicles intact to prevent infection. Some swelling and color change will occur during rewarming. Reassure patient this is normal.1-3
Additional Measures
Tetanus toxoid should be administered if a booster has not been given within the last 5 years. Tetanus immune globulin is recommended for those greater than 10 years since their last booster.2
Some sources recommend an antibiotic if skin is edematous and blistering suggesting edema makes skin more susceptible to gram positive organisms.2 Other sources suggest antibiotic use only if there is clear evidence of infection. Patients who are considered immuno-compromised will most likely be ordered antibiotic prophylaxis.1
Assessing tissue after rewarming is important. Monitor for tissue compartment swelling, infection and continued pain. Decisions regarding amputation should be deferred up to several weeks unless infection has developed.1 Doppler studies and angiography preformed at 1-2 weeks will help assess the vascular status and any extensive damage.2
References
1. Kasper, D., et al. (Eds.). (2005). Harrison’s Principals of Internal Medicine. (16th Ed) Hypothermia and Frostbite, (pp123-125). USA: McGraw Hill Professional Medical Publishing Division.
2. Reamy, B.V. (1998, Jan.-Feb.). Frostbite: review and current concepts. Journal of the American Board of Family Practice, 11(1), 34-40. Retrieved Oct. 16, 2006 from the World Wide Web: URL no longer available. 3. National Agriculture Safety Database. (2004, March). Cold weather exposure. Retrieved Oct. 9, 2006 from the World Wide Web: http://www.cdc.gov/nasd/docs/d001601-d001700/d001677/d001677.html
Dana Sterner is a registered nurse and freelance writer from Boonsboro, MD.

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