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The speaker discusses local cold-weather injuries such as crossbite, immersion foot, and frostbite. They explain the severity of these injuries and factors that contribute to them, such as exposure duration, temperature, and wind velocity. They also mention underlying factors that can worsen cold injuries, such as wet conditions, inadequate insulation, restricted circulation, fatigue, poor nutrition, circulatory disease, and alcohol/drug abuse. The speaker emphasizes the importance of not popping blisters and avoiding warming up frostbitten areas too quickly, as it can lead to tissue damage and potential amputation. They describe the symptoms of these injuries and provide tips for skin safety and patient care. Now we're talking about local cold-weather injuries. Most injuries from cold are confined to exposed parts of the body, carcinia, emergency, which is trench coat, and cross-bite. I'm going to talk about each one. So if you look here, you can see the damages. This is one of the reasons why we say remove rings, because look at the swelling, right? So this would be cross-bite in the hand, in the nose, and on the toes. You see that, first of all, never pop those blisters, okay, because if it's healthy skin underneath, you know, that's exposed dermis, that's how you get infections, you don't want to pop those. Cross-bite will produce, or cold and hot, will produce the same tissue damage in equal extremities or equal extremes. So 100 degrees Celsius above zero and 100 degrees Celsius below zero will produce the same tissue damage. Even though it's hot and cold, it's going to produce the same type of a burn, okay? Important factors in determining severity of a local cold injury, duration of the exposure. The longer you're exposed, the worse the exposure. Temperature to which the body part was exposed. The colder it is, the worse it will be. And the wind velocity. Remember, we talked about wind chill, very important. So consider underlying factors, exposure to wet conditions. Wet skin cools 20 times faster than dry skin. If you expose skin to water, it weakens it and it makes it more susceptible to cold. Inadequate insulation from cold or wind. Restricted circulation. If you have restricted circulation because you close it tight, you approach circulation to your skin, that's going to cause a more aggravated cold weather injury because circulation helps keep the extremity warm. Fatigue and poor nutrition, we talked about that. Or circulatory disease. If I have PVD, peripheral vascular disease, that can be caused by diabetes and that can also exacerbate a cold weather injury. Alcohol and drug abuse, because those affect circulation, those affect your blood vessels. Hypothermia, a systemic cold weather injury, you're more likely to have an extremity cold weather injury. Diabetes, cardiovascular disease in age. The very young and the very old are more susceptible to cold related injuries. Cross-nip. After prolonged exposure to cold, skin may freeze while the deeper tissues are unaffected. The epidermis may freeze, but the dermis and the lower levels do not. Usually affects the ears, nose, and fingers. It may not even be painful, but the patient will have, like their skin will be hard to their hands will be hard to use, right? They'll lose kind of circulation, they'll lose feeling in their hands. Immersion foot, this is called, the old term we called it trench foot, which was coined after World War I when soldiers would spend weeks in cold water in the trenches and they developed this trench foot. Occurs after prolonged exposure to cold water, common in hikers and hunters, and literally the foot gets damaged as the tissue begins to become weak and soft. Extremely painful, and you can actually get tissue degradation from it as well. Cool, pale skin. Normal skin does not return after palpation. So I push on the skin to blanch it, it doesn't turn red again. It stays white. It stays blanched. The skin of the foot may be wrinkled. When you go in water and you take a shower or you take a tub, your skin gets all wrinkled. Do you know why? Your skin doesn't wrinkle because of the moisture, it wrinkles as a nervous reaction. It gives us the ability to grip under the water. It's a neurological response. So that's people who are, if you take a person who has paralysis and you put their hand in cold water, in water, you can leave it there for hours and hours. It won't shrivel up. You only get shriveled up skin when you have neurological function. That's our ability to grab things underwater because of that. Kind of like frogs, like frogs. Loss of feeling and sensation in the injured extremity. Frostbite is the most serious local cold weather injury because the tissues are frozen. What happens is, what happens when water freezes? What does it do? It does two things. Expands. Expands and crystallizes. When you look at a crystal, is it like a round, smooth shape? No, it's got these sharp edges. What is 65% of our body's fluid volume is what? Water. Well, all of our fluid volume is like water, but 65% of it is located where? Intracellular. In our cells. What happens to water in cells when it freezes? Crystallizes. Expands and crystallizes. What does it do to the cell? Kills it. Ruptures it. Lices it. Destroys it. So that's the reason why it gets damaged. Okay? That's one of the reasons why if you have a patient that has frostbite, you know how grandma would always say, oh, your hands are so cold. Let me warm them up. Never do that to somebody with frostbite. What are you doing when you're rubbing the skin? You're destroying those cells. You're ripping those cells open. You do that to a patient with frostbite, their hand's gone. They're going to end up with this. You can survive frostbite if you do not use or manipulate the hand. If you use it, you're going to end up with this. This is what we call necrosis. That's actually gangrene. That's actually rotting. Okay? Now, technically you could survive this. These could just fall off. They literally, the skin would rot and they would fall off. But you could develop a term called gas gangrene. That's where it invades into your blood system and travels through your body and it causes bacteremia, sepsis, and death. So that's the problem with this. There's a book called Endurance, HMS Endurance, and it's all about Shackleton. It's up to, you know, a whole excellent, excellent book. And they made a movie about it. If I read the book, it's great. But they told the story about people that they'd get frostbite in their toes and they'd literally lop off the toes with a branch clipper. And they would heal up because their toes were just rotten and they would come right off. Now, if you get frostbite and your hand heals, you're more susceptible to it in the future, but it will heal up. But if you get frostbite and then it thaws and then freezes again immediately, the hand's gone, you'll develop this. Now, what'll happen is this person's probably going to have, I don't know, there's a little bit of white there, but I don't know, there's some, probably end up having this whole hand amputated. I don't know. I mean, that's a pretty bad one right there. Symptoms. Signs and symptoms. Hard, waxy feel to these affected tissues. The injured part feels firm. The patient may not feel it. Blisters and swelling may be present. The patient will only begin to feel pain when it starts to warm up, but that's when the nerve endings begin to fire. When they're frozen and cold, you're not going to get any sensation at all. It hurts a lot when they get cold. Once they're frozen, you don't feel it. Once they warm up again, oh, they throb. Oh, God, does it hurt. You do know. Yeah, I frosted an earlobe. Oh! And it was in a race, one of these winter erasings. And it warmed up later and throbbed. It was just unbelievable. And that's the cells. That's the nerves telling you, hey, dummy, you've got an injury. They're actually warming people. They're pulling people off that race. And they've, I said, how's my ear doing? He's like, you're fine. You're not going to lose it. This guy might lose his nose. He's trying to think he's got to throw up out of the race. Oh, my God. He has like a hand on his nose to try to warm it up. Oh. It's like running below. That's why I don't run. At least not in the cold, anyway. I only run when the bear's chasing me. The depth of skin damage will vary. With superficial frostbite, only the skin is frozen. The underlying tissues are healthy. It's almost like a little bit more than frostbite. Whereas with deep frostbite, deeper tissues are frozen. You can get freezing all the way down to the muscle and even the bone underlying. You may not be able to tell between superficial and deep frostbite. So we always plan for the worst, hope for the best. So if you have frostbite, it's deep tissue right to the bone. That's the way I consider it. Skin safety. Note the environmental conditions. Do not be exposed to the environment yourself. Make sure you have gloves on. Make sure you take care to protect yourself and your partner. Identify scene hazards such as icy roads, mud, or wet grass. Remember to consider things like ingress and egress. How you get to the patient and how you get out. Sometimes you're not going to be able to come out the same way you go in, right? Use standard precautions. Remember that patients with hypothermia should not be walking. They should not be manipulated in any way. They should be picked up and carried out on a stretcher or on some form of a basket or something. They should never walk. Consider the number of patients. Summon additional help as quickly as possible. And again, look for clues. The human body has the natural ability to assess uncomfortable conditions and to get out of it, right? People don't usually walk, stay, hang out at 120 degrees, and they don't go outside when it's negative 30, right? We kind of stay in. So you have to look at it in the sense that if a patient is out in the wilderness and they've been exposed, they have a cold weather or hot weather exposure, whatever it is, why? Why did they succumb to it? Did they have a medical condition? Did they have a stroke? Did they have a heart attack? Did they have some kind of neurological condition? Is there drugs and alcohol involved? Something caused them to be exposed, right? They didn't just decide to become exposed. Something happened. For a general impression, do your rapid scan. Check for light threats. Make sure you oxygenate these patients. Check your core temperature just by checking the abdomen. Is it cold? Do your ab pull and alter mental status can be affected by the intensity of cold weather injury. The colder or hotter a patient is, the more altered they will be. That's the way it is. If the patient is in cardiac arrest, begin compressions and use the AED. But you want to warm them. Ensure the patient has an adequate airway in his breathing. Put oxygen on. You can put warm, humidified oxygen. Now, this is the thing. We don't have warm, humidified oxygen. In the ambulance, we'll have the oxygen tank in the back of the ambulance. So if you have your ambulance heat going during the day and you keep it in a garage, it'll be warmer than the outside. But it's not going to be warm. If you put it through warmed fluid, like humidified, then it'll be a little warmer. But we don't have like 110 degree humidified water. They only have that in the hospital. But it's warmer than the outside. Make sense? You can also, we carry hot packs. You can open up a couple of hot packs. You put them on. Take the hot packs and put them on the large blood vessel points of the body. Neck, underarms, and groin. And that will help warm the core temperature of the patient. So you want to palpate for carotid pulse up to 60 seconds before you decide that they're pulseless. The AHA recommends CPR to be started on a patient who has no detectable pulse and no breathing. It's no breathing that's going to also give it. No pulse and no breathing. Diffusion will be compromised, bleeding. Now, this is important to understand with bleeding. If I have a wound and I become hypothermic, the bleeding will stop. Because blood vessels constrict and there's no blood flow. Once you start warm up the patient, I'm going to start bleeding like a stuck pig. Cold blood does not clot. It loses its clotting ability. Which means I will bleed much more. So if you have a patient that has an injury, or you have a patient that's hypothermic, look for wounds and bandage them before the patient starts to warm up. Because once they start bleeding, they're going to bleed significantly. And it's not going to clot readily. Rough handling of a hypothermic patient can cause a slow recart rate called ventricular, or a rapid recart rate called ventricular fibrillation. Maintain a medical history. Be alert for injury specific signs and symptoms. Usually of the cold weather injury and any further negatives. Get your sample history. Find out how long the patient was exposed, what they were exposed to, and how they were exposed. Why they were exposed. Because again, that may lead you down another medical path of something that happened. Focus on the severity of the hypothermia. Assess areas of the body directly affected by the cold. The face, the nose, the ears, the hands, the feet. Assess the degree and extent of damage. Vital signs. They will be altered by hypothermia. And basically, the more altered the vital signs are, the more severe the hypothermia. Respirations will be slow and shallow. Blood pressure will be low. Heart rate will be erratic. You'll have a change in mental status. Determine the core temperature. If you have a thermometer. I don't carry a thermometer, so basically the colder you feel, the worse your hypothermia is. Pulse oximetry will be inadequate because circulation, the body is going to shunt blood to the core. You're not going to have blood circulating through the fingers. So pulse oximetry is not going to be effective. Repeat your primary assessment, which is your level of consciousness, airway, breathing, circulation. Reassess your vitals. Achieve complaint. Do this every five minutes. Monitor the patient's vital signs. Rewarming can lead to a cardiac dysrhythmia. So we have to be very careful. We don't do active rewarming in the feet. We do passive rewarming. So I'll get the patient in. Remove wet clothing. Wrap the patient in a space blanket if we have one. Or wrap the patient in a dry blanket. Warm, humidified oxygen. And turn the heat on high in the ambulance. And treat the patient and go. We don't do active rewarming. Like warm IV fluids and things. Because what that can do in a patient with severe hypothermia is can lead them down the road of ventricular fibrillation. So if they have mild hypothermia, absolutely try and warm them up. If they have severe hypothermia, we don't want to actively rewarm. We passively rewarm. Communicate all information you've gathered to the receiving facility, like the patient's physical status, condition at the scene, and any changes while you're treating. Ah, you're starting to warm up the patient and they're starting to become conscious, right? What's going on? I like this right here because it shows that they put a blanket under the patient. A lot of times we find patients lying on the ground and we start treating and we throw a blanket over them, all that will keep them warm. They're conducting heat to the ground. The ground's still 30 degrees and they're laying on it. Put a blanket under and over. You've got to pick them up anyway, so you want the blanket under them, right? If available, give the patient warm, humidified oxygen. Do not handle the patient gently. We don't want ventricular fibrillation. Never massage the extremity of any cold weather injury. And do not give the patient anything to eat or drink. Don't smoke a cigarette. Don't use dips or chew tobacco. Don't drink any caffeine or anything like that, because those will all cause further vasoconstriction, which can lead to tissue damage. And we don't want them taking anything orally, because it's a potential for vomiting. Mild hypothermia. A patient is alert, shivering, and responds appropriately. Place the patient in a warm environment. Remove any wet clothing. Place heat packs or water bottles on the bone. Heat packs is what we have for the neck, groin, underarms. Turn the heat on high. Wrap the patient in blankets. Never give anything orally to a patient, unless it's a medication. Mild or severe hypothermia. Never try to actively re-warm. Only passively re-warm. Warm, humidified oxygen. Wrap the patient in a blanket and turn the heat on high. The goal is to prevent further heat loss, more than re-warm the patient. We want them to be re-warmed in the hospital, so if they develop ventricular fibrillation, they can treat it. Remove the patient from the cold environment. Cover them with a blanket. Remove the patient from exposure to the cold. And I always remember that when I was a kid. Somebody would fall in the water and they'd always take their clothes off. And I used to think to myself, why take the clothes off? It's cold out. Even if the clothes are wet, it's still some layer to protect them. But actually, no. It's better to be naked and dry than fully clothed and soaking wet. Believe it or not. That's one of the reasons why if you work in the Arctic, or you work in some sub-Arctic temperature, and you go out and you start doing work, if you start sweating, you immediately go in and change your clothes. Because you can develop pneumonia from that. Remove any wet or restrictive clothing from the injured part of the body. If transport is delayed, consider active re-warming. So if you have a localized cold weather injury, hands or feet, if you can get them to the hospital, take them to the hospital without warming them. If, let's say, you have a cold weather injury and your transport is going to be delayed. Let's say you're in the woods and it's going to be hours before you transport the patient. If you have access to warm water, you can do active re-warming. You can take the injured extremity, the cold weather extremity, and put it in temperatures of 102 to 105 degrees and insert it. And you can let that warm up. It's going to hurt, they're going to swell, but it will re-warm the tissues. Never do that if there's a chance of re-freezing again. Because if you warm it and then it freezes again, the tissue's gone. So we don't want to do that. We don't do that in the ambulance because we don't have running water. We don't have any way of heating water. So we don't actively re-warm extremities. Never rub or massage or never have them take a heat pack and put it between their hands like that. That's too much, too fast, and it can cause damage. If blisters form, do not break. And never attempt re-warming if the patient has potential to re-freeze again. You are at risk for hypothermia if you work in a cold environment. God bless you, and we all do. And you might be outside of the fire scene for hours or in a motor vehicle crash. So you might be on a search and rescue. If cold weather search and rescue is possible in your area, you need survival training and precautionary tips. Basically, you need to wear the appropriate clothing, hats, gloves, layers. Make sure you stay in communication. Don't be too far from health and wear the appropriate clothing. Heat exposure. In a hot environment, the body tries to rid itself of excess heat, sweating, and dilation of blood vessels at the skin. That hot blood evaporates that excess sweat because we sweat more, and that cools blood goes back to the core. Removal of clothing and relocation to a cooler environment is the best thing. So heat exposure. So hypothermia is a core temperature greater than 101. As a matter of fact, they say 100.9 is considered a fever. If you go and call the doctor and say, I think I'm sick, I've got a fever, they're going to ask you what it is. And if it's 100.1, and if it's less than 100.1, they're going to tell you don't even call. Maybe it's 100.9, I forgot. Risk factors for heat illness. High ambient temperature. If it's 100 degrees outside, you're not going to be able to radiate heat away from you. High humidity. Greater than 70% humidity, you won't be able to evaporate the sweat. It will stay on your skin and get hot. Lack of acclimation to the heat. I'm not used to the heat. It's April, and it's 80 degrees, so I'm going to go out for a run. Vigorous exercise, lots of fluids and electrolytes. A person at the greatest risk of heat illness are children, especially newborns and infants, because they don't properly thermoregulate. Geriatric patients, because they have a reduced thermoregulatory system because of their age. Patients with heart disease, COPD, diabetes, dehydration, and obesity. As well as patients with limited mobility, patients in wheelchairs, patients who are bed-bound. So there are heat cramps, heat exhaustion, and heat stroke. We're going to talk about each one of these. It's not like you go from heat cramps to heat exhaustion to heat stroke. Sometimes you can go right into heat exhaustion. Sometimes you can jump right into heat stroke. You could go anywhere in these. But there are three different layers. They can go up through it, so be watching for them. So first one is heat cramps. Painful muscle spasms that occur after vigorous exercise. Usually in the legs and the abdomen. Do not occur only when it's hot outside. You can get it in moderate temperature environments. The exact cause is not well understood. They believe it has to do with the loss of electrolytes. Usually occurring, again, in the legs or abdominal muscles. I used to see heat cramps all the time. I was a battalion aid station NCO. I used to run an aid station. We used to see heat cramps all the time. When I'd go to the field, I would bring Gatorade and granola bars. I'd give them a cup of Gatorade and a granola bar, and that would, you know, 30 minutes outside of the sun, cool the patient off, and that would usually work. In the military, we'd say, okay, you can go out and train again. In civilian, you're done for the day. You develop heat cramps, you're done for the day. Now, from heat cramps, we can go to heat exhaustion, or you can go directly to heat exhaustion. This is more commonly caused by hypovolemia. This is a loss of fluid volume. You sweat out more than you take in. High humidity and exertion in poorly ventilated areas. I'm not drinking, but I'm exercising, right? I'm not taking in as much as I'm sweating out. And these patients will develop a condition called orthostatic hypotension, or you'll have to take orthostatic vitals. What happens is when I stand up, my body has to fight against gravity to pump blood to my brain, so it takes more pressure to do that. The less volume I have, the less blood that goes to my brain. So what happens is if I'm lying down, I'm fine. But if I sit up or stand up, I don't have enough volume to perfuse my brain and I go, and I become sickable and I pass out. So we can tell heat exhaustion, one of the primary ways to identify it is through orthostatic vital signs and orthostatic hypotension. Patient lies down, take their blood pressure and pulse. Then they sit up, wait about three minutes or so, and take their blood pressure and pulse again. It should be the same. If their blood pressure goes down by 10 points or more and their pulse goes up by 10 points or more, that's positive for orthostatic hypotension. That right there is heat exhaustion. Now, you're supposed to have them stand up and do it again. Most of the time, if they're positive for orthostatics when they're sitting, if they stand up, they're going to go right over. So don't even bother. If you've got a change in their sitting position, that's positive orthostatics. And that way you can say, oh yeah, they're hypovolemic. These patients really need IV fluid and transport to the hospital. Heat cramps patients, you can take a refusal for it. They promise to get out of the environment and all that stuff. But heat exhaustion, they really need to go to the hospital. All ALS, they need to go to the hospital. So dizziness, weakness or syncope, nausea, vomiting or headache, cool, clammy skin. Cool, pale skin, clammy. Dry tongue and thirst. Maybe a furrowed tongue. Normal vital signs, not really. They might have some elevated body temperature. Their blood pressure may drop a little bit. Their heart rate may go up a little bit. Breathing a little more rapidly. Heat stroke is the least common but most serious cause by heat exposure. Heat stroke is universally fatal if not treated. You will die from it if it's not treated. Occurs mainly when the body is subjected to more heat than it can handle. When its mechanisms are overwhelmed. Untreated heat stroke always causes death. Typically onset is during vigorous physical activity. We had two guys, when I was in basic training, two guys in my company, two guys in the battalion, one guy in my company, and another guy in another company die from heat stroke while training. Outdoors in a closed, poorly ventilated human space, during heat waves without sufficient air conditioning or poor ventilation and children left unattended and locked for a hot day. I dare you, the next day it's 90. Sit in your car with the windows closed and see how long you last. I give you 5 minutes, maybe 10. The interior of a car, especially a dark colored car, can get up to 130 degrees. 120 degrees can burn skin and airway. So 130 degrees is bad. And children die from this. This is the one reason why in Massachusetts they passed a law. If you see an animal or a child in a car, you can actually break the window and rescue the child and you won't get in trouble for that. And you'll actually prosecute the owner. I do recommend, though, that if you are going to do that, you know about vehicles. Because this happened in Wellesley. A woman was walking by in surrogate. Kind of sitting up looking at her dog. Oh my God, the dog's overheating. And she broke the window of a Tesla. Tesla is an electric car. And they have a special button you push. What is it called? Animal climate. Or whatever it is. What is it? Dog mode. Dog mode. You push it, it'll keep the interior of the car a perfect 70 degrees. And do you know how much the windows on a Tesla cost? About 3 grand. And guess who had to pay for it? The woman who broke the window. So just make sure if you break in a window, feel the window first and see if it's cool. It says on the screen, actually. Does it? She didn't see it. What the temperature of the car is. So watch out for that. Also, babies in strollers. Babies in strollers, yes. Because a stroller, especially black strollers, when they close them off, they can get very hot inside. People don't even realize that. So signs and symptoms. So this is what happens. Generally, heat stroke most often will come after heat exhaustion. So heat exhaustion, your skin is cool, pale, and flammable. Because you're hypovolemic. Then your body's cool thermoregulatory system gets overridden, and now your blood pressure, your temperature starts to rise. Your body no longer thermoregulates properly. At the beginning of heat stroke, your skin will be hot and wet. There'll be a hot, wet sweat. As it progresses, that sweat starts to evaporate. When the skin becomes hot and flushed, then it spikes very rapidly. So it'll start going up. It'll still be hot and wet, hot and wet, hot and wet. And then once that stops, it'll jump really quickly. Temperatures of 108 are considered uniformly fatal. I did a call one time for a gentleman. We were behind cursed liquors. It was about 85, bright, sunny day. When we get there and the patient must have fallen, hit their head, and they were in the sun, we go out for the unresponsive, or the man down. We arrive, we feel him, and he's a little wet, but you can tell he's hot and flushed. His skin is hot and flushed. We've got him in the back of the ambulance. We have the A.C. on high. We took ice packs, neck, groin, underarms. Ripped off his clothes, soaked him with water, fanning him. We both gave him each, me and my partner, gave him a 16-gauge I.V. in each A.C., and we wrapped the I.V. tubing around ice packs so we'd cool the water. We had the patient maybe 10 minutes, and then we drove to St. V's. St. V's was only a couple miles away, if that. We get him into St. V's. They get him in the trauma room, which is already cooled because we told him it was a hypothermic patient, so they already brought the temperature down, and they began their active cooling, right? They took his body temperature at about 15 minutes. 15 minutes? Well, I'd say probably closer to 20 minutes from the actual week came upon the patient. He was 107.9. That was 15 minutes of active cooling, and he was still 107.9, so he was well above 108. So hot, flushed, dried skin. Maybe it'll be wet at the beginning. Quick rising body temperature, change of behavior that becomes severely altered, uptundant, lethargic, unresponsive. Seizures, weak rapid pulse, increased respiratory rate, and cessation of perspiration, which lead to the hot, flushed skin. A hypothermic patient, they can take a long time to warm up, and that's okay. Hyperthermic patients, we need to get that body temperature down as quickly as possible. No holds barred. You're going to get that temperature down as soon as you can. This is rapidly fatal. Hypothermia, patients can survive that, but this is rapidly fatal. Perform your environmental assessment.