Cold Injuries

Cold injuries are most likely to occur when an unprepared individual is exposed to winter temperatures. They can occur even with proper planning and equipment. The cold weather and the type of combat operation in which the individual is involved impact on whether he is likely to be injured and to what extent. His clothing, his physical condition, and his mental makeup also are determining factors. However cold injuries can usually be prevented. Well-disciplined and well-trained individuals can be protected even in the most adverse circumstances They and their leaders must know the hazards of exposure to the cold. They must know the importance of personal hygiene, exercise, care of the feet and hands, and the use of protective clothing.

a. Contributing Factors.

(1) Weather. Temperature, humidity, precipitation and wind modify the loss of body heat. Low temperatures and low relative humidity--dry cold--promote frostbite. Higher temperatures, together with moisture, promote immersion syndrome. Windchill accelerates the loss of body heat and may aggravate cold injuries. These principles and risks apply equally to both men and women.

(2) Type of combat operation. Defense, delaying observation-post, and sentinel duties do create to a greater extent--fear fatigue, dehydration, and lack of nutrition. These factors further increase the soldier's vulnerability to cold injury. Also, a soldier is more likely to receive a cold injury if he is--

• Often in contact with the ground.

• Immobile for long periods, such as while riding in a crowded vehicle.

• Standing in water, such as in a foxhole.

• Out in the cold for days without being warmed.

• Deprived of an adequate diet and rest.

• Not able to take care of his personal hygiene.

(3) Clothing. The soldier should wear several layers of loose clothing. He should dress as lightly as possible consistent with the weather to reduce the danger of excessive perspiration and subsequent chilling. It is better for the body to be slightly cold and generating heat than excessively warm and sweltering toward dehydration. He should remove a layer or two of clothing before doing any hard work. He should replace the clothing when work is completed. Most cold injuries result from soldiers having too few clothes available when the weather suddenly turns colder. Wet gloves, shoes, socks, or any other wet clothing add to the cold injury process.

(4) Physical makeup. Physical fatigue contributes to apathy, which leads to inactivity, personal neglect, carelessness, and reduced heat production. In turn, these increase the risk of cold injury Soldiers with prior cold injuries have a higher-than-normal risk of subsequent cold injury, not necessarily involving the part previously injured.

(5) Psychological factor. Mental fatigue and fear reduces the body's ability to rewarm itself and thus increases the incidence of cold injury. The feelings of isolation imposed by the environment are also stressful. Depressed and/or unresponsive soldiers are also vulnerable because they are less active. These soldiers tend to be careless about precautionary measures, especially warming activities, when cold injury is a threat.

b. Signs/Symptoms. Once a soldier becomes familiar with the factors that contribute to cold injury, he must learn to recognize cold injury signs/symptoms.

(1) Many soldiers suffer cold injury without realizing what is happening to them. They may be cold and generally uncomfortable These soldiers often do not notice the injured part because it is already numb from the cold.

(2) Superficial cold injury usually can be detected by numbness, tingling, or "pins and needles" sensations. These signs/symptoms often can be relieved simply by loosening boots or other clothing and by exercising to improve circulation. In more serious cases involving deep cold injury, the soldier often is not aware that there is a problem until the affected part feels like a stump or block of wood.

(3) Outward signs of cold injury include discoloration of the skin at the site of injury. In light-skinned persons, the skin first reddens and then becomes pale or waxy white. In dark-skinned persons, grayness in the skin is usually evident. An injured foot or hand feels cold to the touch. Swelling may be an indication of deep injury. Also note that blisters may occur after rewarming the affected parts. Soldiers should work in pairs--buddy teams--to check each other for signs of discoloration and other symptoms. Leaders should also be alert for signs of cold injuries.

c. Treatment Considerations. First aid for cold injuries depends on whether they are superficial or deep. Cases of superficial cold injury can be adequately treated by warming the affected part using body heat. For example, this can be done by covering cheeks with hands, putting fingertips under armpits, or placing feet under the clothing of a buddy next to his belly. The injured part should NOT be massaged, exposed to a fire or stove, rubbed with snow, slapped, chafed, or soaked in cold water. Walking on injured feet should be avoided. Deep cold injury (frostbite) is very serious and requires more aggressive first aid to avoid or to minimize the loss of parts of the fingers, toes, hands, or feet. The sequence for treating cold injuries depends on whether the condition is life-threatening. That is, PRIORITY is given to removing the casualty from the cold. Other-than-cold injuries are treated either simultaneously while waiting for evacuation to a medical treatment facility or while en route to the facility.

The injured soldier should be evacuated at once to a place where the affected part can
be rewarmed under medical supervision.

d. Conditions Caused by Cold. Conditions caused by cold are chilblain, immersion syndrome (immersion foot/trench foot), frostbite snow blindness, dehydration, and hypothermia.

(1) Chilblain.
• Signs/Symptoms. Chilblain is caused by repeated prolonged exposure of bare skin at temperatures from 60�F, to 32�F, or 20�F for acclimated, dry, unwashed skin. The area may be acutely swollen, red, tender, and hot with itchy skin. There may be no loss of skin tissue in untreated cases but continued exposure may lead to infected, ulcerated, or bleeding lesions.

• Treatment. Within minutes, the area usually responds to locally applied body heat. Rewarm the affected part by applying firm steady pressure with your hands, or placing the affected part under your arms or against the stomach of a buddy. DO NOT rub or massage affected areas. Medical personnel should evaluate the injury, because signs and symptoms of tissue damage may be slow to appear.

• Prevention. Prevention of chilblain depends on basic cold injury prevention methods. Caring for and wearing the uniform properly and staying dry (as far as conditions permit) are of immediate importance.

(2) Immersion syndrome (immersion foot/trench foot). Immersion foot and trench foot are injuries that result from fairly long exposure of the feet to wet conditions at temperatures from approximately 50� to 32�F. Inactive feet in damp or wet socks and boots or tightly laced boots which impair circulation are even more susceptible to injury. This injury can be very serious; it can lead to loss of toes or parts of the feet. If exposure of the feet has been prolonged and severe, the feet may swell so much that pressure closes the blood vessels and cuts off circulation. Should an immersion injury occur, dry the feet thoroughly; and evacuate the casualty to a medical treatment facility by the fastest means possible.
• Signs/Symptoms. At first, the parts of the affected foot are cold and painless, the pulse is weak, and numbness may be present. Second, the parts may feel hot, and burning and shooting pains may begin. In later stages, the skin is pale with a bluish cast and the pulse decreases. Other signs/symptoms that may follow are blistering swelling, redness, heat, hemorrhages (bleeding), and gangrene.

• Treatment. Treatment is required for all stages of immersion syndrome injury. Rewarm the injured part gradually by exposing it to warm air. DO NOT massage it. DO NOT moisten the skin and DO NOT apply heat or ice. Protect it from trauma and secondary infections. Dry, loose clothing or several layers of warm coverings are preferable to extreme heat. Under no circumstances should the injured part be exposed to an open fire. Elevate the injured part to relieve the swelling. Evacuate the casualty to a medical treatment facility as soon as possible. When the part is rewarmed, the casualty often feels a burning sensation and pain. Symptoms may persist for days or weeks even after rewarming.

• Prevention. Immersion syndrome can be prevented by good hygienic care of the feet and avoiding moist conditions for prolonged periods. Changing socks at least daily (depending on environmental conditions) is also a preventive measure. Wet socks can be air dried, then can be placed inside the shirt to warm them prior to putting them on.

(3) Frostbite. Frostbite is the injury of tissue caused from exposure to cold, usually below 32�F depending on the windchill factor, duration of exposure, and adequacy of protection. Individuals with a history of cold injury are likely to be more easily affected for an indefinite period. The body parts most easily frostbitten are the cheeks, nose, ears, chin, forehead, wrists, hands, and feet. Proper treatment and management depend upon accurate diagnosis. Frostbite may involve only the skin (superficial), or it may extend to a depth below the skin (deep). Deep frostbite is very serious and requires more aggressive first aid to avoid or to minimize the loss of parts of the fingers, toes, hands, or feet.

Casualty should be continually monitored for development of conditions which may
require the performance of necessary basic lifesaving measures, such as clearing the
airway, performing mouth-to-mouth resuscitation, preventing shock, and/or bleeding
control.

Progressive signs/symptoms (081-831-1009). o Loss of sensation, or numb feeling in any part of the body. o Sudden blanching (whitening) of the skin of the affected part, followed by a momentary "tingling" sensation. o Redness of skin in light-skinned soldiers grayish coloring in dark-skinned individuals. o Blister. o Swelling or tender areas. o Loss of previous sensation of pain in affected area. o Pale, yellowish, waxy-looking skin. o Frozen tissue that feels solid (or wooden) to the touch.

Deep frostbite is a very serious injury and requires immediate first aid and subsequent
medical treatment to avoid or minimize loss of body parts.

Treatment (O81-831-1009). o Face, ears, and nose. Cover the casualty affected area with his and/or your bare hands until sensation and color return. o Hands. Open the casualty's field jacket and shirt. (In a chemical environment never remove the clothing.) Place the affected hands under the casualty's armpits. Close the field jacket and shirt to prevent additional exposure. o Feet. Remove the casualty's boots and socks if he does not need to walk any further to receive additional treatment. (Thawing the casualty's feet and forcing him to walk on them will cause additional pain/ injury.) Place the affected feet under clothing and against the body of another soldier. WARNING (081-831-1009) DO NOT attempt to thaw the casualty's feet or other seriously frozen areas if he will be required to walk or travel to receive further treatment. The casualty should avoid walking if possible, because there is less danger in walking while the feet are frozen than after they have been thawed. Thawing in the field increases the possibilities of infection, gangrene, or other injury. NOTE Thawing may occur spontaneously during transportation to the medical facility; this cannot be avoided since the body in general must be kept warm. In all of the above areas, ensure that the casualty is kept warm and that he is covered (to avoid further injury). Seek medical treatment as soon as possible. Reassure the casualty, protect the affected area from further injury by covering it lightly with a blanket or any dry clothing, and seek shelter out of the wind. Remove/minimize constricting clothing and increase insulation. Ensure that the casualty exercises as much as possible, avoiding trauma to the injured part, and is prepared for pain when thawing occurs. Protect the frostbitten part from additional injury. DO NOT rub the injured part with snow or apply cold water soaks. DO NOT warm the part by massage or exposure to open fire because the frozen part may be burned due to the lack of feeling. DO NOT use ointments or other medications. DO NOT manipulate the part in any way to increase circulation. DO NOT allow the casualty to use alcohol or tobacco because this reduces the body's resistance to cold. Remember when freezing extends to a depth below the skin, it involves a much more serious injury. Extra care is required to reduce or avoid the chances of losing all or part of the toes or feet. This also applies to the fingers and hands.

• Prevention. Prevention of frostbite or any cold injury depends on adequate nutrition, hot meals and warm fluids. Other cold injury preventive factors are proper clothing and maintenance of general body temperature. Fatigue, dehydration, tobacco, and alcoholic beverages should be avoided.

  o Sufficient clothing must be worn for protection against cold and wind. Layers of clothing that can be removed and replaced as needed are the most effective. Every effort must be made to keep clothing and body as dry as possible. This includes avoiding any excessive perspiration by removing and replacing layers of clothing. Socks should be changed whenever the feet become moist or wet. Clothing and equipment should be properly fitted to avoid any interference with blood circulation. Improper blood circulation reduces the amount of heat that reaches the extremities. Tight fitting socks, shoes, and hand wear are especially hazardous in very cold climates. The face needs extra protection against high winds, and the ears need massaging from time to time to maintain circulation. Hands may be used to massage and warm the face. By using the buddy system, individuals can watch each other's face for signs of frostbite to detect it early and keep tissue damage to a minimum. A mask or headgear tunneled in front of the face guards against direct wind injury. Fingers and toes should be exercised to keep them warm and to detect any numbness. Wearing windproof leather gloves or mittens and avoiding kerosene, gasoline, or alcohol on the skin are also preventive measures. Cold metal should not be touched with bare skin; doing so could result in severe skin damage.

  o Adequate clothing and shelter are also necessary during periods of inactivity.

(4) Snow blindness. Snow blindness is the effect that glare from an ice field or snowfield has on the eyes. It is more likely to occur in hazy, cloudy weather than when the sun is shining. Glare from the sun will cause an individual to instinctively protect his eyes. However, in cloudy weather, he may be overconfident and expose his eyes longer than when the threat is more obvious. He may also neglect precautions such as the use of protective eyewear. Waiting until discomfort (pain) is felt before using protective eyewear is dangerous because a deep burn of the eyes may already have occurred.
• Signs/Symptoms. Symptoms of snow blindness are a sensation of grit in the eyes with pain in and over the eyes, made worse by eyeball movement. Other signs/symptoms are watering, redness, headache, and increased pain on exposure to light. The same condition that causes snow blindness can cause snowburn of skin, lips, and eyelids. If a snowburn is neglected, the result is the same as a sunburn.

• Treatment. First aid measures consist of blindfolding or covering the eyes with a dark cloth which stops painful eye movement. Complete rest is desirable. If further exposure to light is not preventable, the eyes should be protected with dark bandages or the darkest glasses available. Once unprotected exposure to sunlight stops the condition usually heals in a few days without permanent damage. The casualty should be evacuated to the nearest medical facility.

• Prevention. Putting on protective eye wear is essential not only to prevent injury, but to prevent further injury if any has occurred. When protective eye wear is not available, an emergency pair can be made from a piece of wood or cardboard cut and shaped to the width of the face. Cut slits for the eyes and attach strings to hold the improvised glasses in place. Slits are made at the point of vision to allow just enough space to see and reduce the risk of injury. Blackening the eyelids and face around the eyes absorbs some of the harmful rays.

(5) Dehydration. Dehydration occurs when the body loses too much fluid, salt, and minerals. A certain amount of body fluidis lost through normal body processes. A normal daily intake of food and liquids replaces these losses. When individuals are engaged in any strenuous exercises or activities, an excessive amount of fluid and salt is lost through sweat. This excessive loss creates an imbalance of fluids, and dehydration occurs when fluid and salt are not replaced. It is very important to know that it can be prevented if troops are instructed in its causes, symptoms, and preventive measures. The danger of dehydration is as prevalent in cold regions as it is in hot regions. In hot weather the individual is aware of his body losing fluids and salt. He can see, taste, and feel the sweat as it runs down his face, gets into his eyes, and on his lips and tongue, and drips from his body. In cold weather, however, it is extremely difficult to realize that this condition exists. The danger of dehydration in cold weather operations is a serious problem. In cold climates, sweat evaporates so rapidly or is absorbed so thoroughly by layers of heavy clothing that it is rarely visible on the skin. Dehydration also occurs during cold weather operations because drinking is inconvenient. Dehydration will weaken or incapacitate a casualty for a few hours, or sometimes, several days. Because rest is an important part of the recovery process, casualties must take care that limited movement during their recuperative period does not enhance the risk of becoming a cold weather casualty.
• Signs/Symptoms. The symptoms of cold weather dehydration are similar to those encountered in heat exhaustion. The mouth, tongue, and throat become parched and dry, and swallowing becomes difficult. The casualty may have nausea with or without vomiting along with extreme dizziness and fainting. The casualty may also feel generally tired and weak and may experience muscle cramps (especially in the legs). Focusing eyes may also become difficult.

• Treatment. The casualty should be kept warm and his clothes should be loosened to allow proper circulation. Shelter from wind and cold will aid in this treatment. Fluid replacement, rest, and prompt medical treatment are critical. Medical personnel will determine the need for salt replacement.

• Prevention. These general preventive measures apply for both hot and cold weather. Sufficient additional liquids should be consumed to offset excessive body losses of these elements. The amount should vary according to the individual and the type of work he is doing (light, heavy, or very strenuous). Rest is equally important as a preventive measure. Each individual must realize that any work that must be done while bundled in several layers of clothing is extremely exhausting. This is especially true of any movement by foot, regardless of the distance.

(6) Hypothermia (general cooling). In intense cold a soldier may become both mentally and physically numb, thus neglecting essential tasks or requiring more time and effort to achieve them. Under some conditions (particularly cold water immersion), even a soldier in excellent physical condition may die in a matter of minutes. The destructive influence of cold on the body is called hypothermia. This means bodies lose heat faster than they can produce it. Frostbite may occur without hypothermia when extremities do not receive sufficient heat from central body stores. The reason for this is inadequate circulation and/or inadequate insulation. Nonetheless, hypothermia and frostbite may occur at the same time with exposure to below-freezing temperatures. An example of this is an avalanche accident. Hypothermia may occur from exposure to temperatures above freezing, especially from immersion in cold water, wet-cold conditions, or from the effect of wind. Physical exhaustion and insufficient food intake may also increase the risk of hypothermia. Excessive use of alcohol leading to unconsciousness in a cold environment can also result in hypothermia. General cooling of the entire body to a temperature below 95�F is caused by continued exposure to low or rapidly dropping temperatures, cold moisture, snow or ice. Fatigue, poor physical condition, dehydration, faulty blood circulation, alcohol or other drug intoxication, trauma, and immersion can cause hypothermia. Remember, cold affects the body systems slowly and almost without notice. Soldiers exposed to low temperatures for extended periods may suffer ill effects even if they are well protected by clothing.
• Signs/Symptoms. As the body cools, there are several stages of progressive discomfort and impairment. A sign/symptom that is noticed immediately is shivering. Shivering is an attempt by the body to generate heat. The pulse is faint or very difficult to detect. People with temperatures around 90�F may be drowsy and mentally slow. Their ability to move may be hampered, stiff, and uncoordinated, but they may be able to function minimally. Their speech may be slurred. As the body temperature drops further, shock becomes evident as the person's eyes assume a glassy state, breathing becomes slow and shallow, and the pulse becomes weaker or absent. The person becomes very stiff and uncoordinated. Unconsciousness may follow quickly. As the body temperature drops even lower, the extremities freeze, and a deep (or core) body temperature (below 85�F) increases the risk o irregular heart action. This irregular heart action or heart standstill can result in sudden death.

• Treatment. Except in cases of the most severe hypothermia (marked by coma or unconsciousness, a weak pulse, and a body temperature of approximately 90�F or below), the treatment for hypothermia is directed towards rewarming the body evenly and without delay. Provide heat by using a hot water bottle, electric blanket, campfire, or another soldier's body heat. Always call or send for help as soon as possible and protect the casualty immediately with dry clothing or a sleeping bag. Then, move him to a warm place. Evaluate other injuries and treat them. Treatment can be given while the casualty is waiting evacuation or while he is en route. In the case of an accidental breakthrough into ice water, or other hypothermic accident, strip the casualty of wet clothing immediately and bundle him into a sleeping bag. Mouth-to-mouth resuscitation should be started at once if the casualty's breathing has stopped or is irregular or shallow. Warm liquids may be given gradually but must not be forced on an unconscious or semiconscious person because he may choke. The casualty should be transported on a litter because the exertion of walking may aggravate circulation problems. A physician should immediately treat any hypothermia casualty. Hypothermia is life-threatening until normal body temperature has been restored. The treatment of a casualty with severe hypothermia is based upon the following principles: stabilize the temperature, attempt to avoid further heat loss, handle the casualty gently, and evacuate as soon as possible to the nearest medical treatment facility! Rewarming a severely hypothermic casualty is extremely dangerous in the field due to the great possibility of such complications as rewarming shock and disturbances in the rhythm of the heartbeat.

Hypothermia is a MEDICAL EMERGENCY! Prompt medical treatment is necessary. Casualties with hypothermic complications should be transported to a medical treatment facility immediately.

The casualty is unable to generate his own body heat. Therefore, merely placing him in a blanket or sleeping bag is not sufficient.

• Prevention. Prevention of hypothermia consists of all actions that will avoid rapid and uncontrollable loss of body heat. Individuals should be properly equipped and properly dressed (as appropriate for conditions and exposure). Proper diet, sufficient rest, and general principles apply. Ice thickness must be tested before river or lake crossings. Anyone departing a fixed base by aircraft, ground vehicle, or foot must carry sufficient protective clothing and food reserves to survive during unexpected weather changes or other unforeseen emergencies. Traveling alone is never safe. Expected itinerary and arrival time should be left with responsible parties before any departure in severe weather. Anyone living in cold regions should learn how to build expedient shelters from available materials including snow.

e. Table. See Table 5-2 for further information.

Table 5-2. Cold and Wet Injuries (081-831-1009)

INJURIES	SIGNS/SYMPTOMS	FIRST AID
Chilblain	Red, swollen, hot, tender, itching skin. Continued exposure may lead to infected (ulcerated or bleeding) skin lesions.	1. Area usually responds to locally applied rewarming (body heat). 2. DO NOT rub or massage area. 3. Seek medical treatment.
Immersion foot/ Trench foot	Affected parts are cold, numb, and painless. Parts may then be hot, with burning and shooting pains. Advanced stage: skin pale with bluish cast; pulse decrease; blistering, swelling, heat, hemorrhages, and gangrene may follow.	1. Gradual rewarming by exposure to warm air. 2. DO NOT massage or moisten skin. 3. Protect affected parts from trauma. 4. Dry feet thoroughly, avoid walking. 5. Seek medical treatment.
Frostbite	Loss of sensation, or numb feeling in any part of the body. Sudden blanching (whitening) of the skin of the affected part, followed by a momentary "tingling" sensation. Redness of skin in light-skinned soldiers; grayish coloring in dark-skinned individuals. Blisters. Swelling or tender areas. Loss of previous sensation of pain in affected area. Pale yellowish, waxy-looking skin. Frozen tissue that feels solid (or wooden) to the touch.	1. Warm the area at the first sign of frostbite, using firm, steady pressure of hand, underarm or abdomen. 2. Face, ears, nose--cover area with hands (casualty's own or buddy's). 3. Hand(s)--open field jacket and place casualty's hand(s) against body, then close jacket to prevent heat loss. 4. Feet--casualty's boots/socks removed and exposed feet placed under clothing and against body of another soldier. 5. Warning: Do not attempt to thaw the casualty's feet or other seriously frozen areas if he will be required to walk or travel to a medical center in order to receive additional treatment. The possibility of injury from walking is less when the feet are frozen than after they have been thawed. (However, if possible, avoid walking.) Thawing in the field increases the possibility of infection, gangrene, or injury. 6. Loosen or remove constricting clothing and remove any jewelry. 7. Increase insulation (cover with blanket or other dry material). Ensure casualty exercises as much as possible, avoiding trauma to injured part.
Snow Blindness	Eyes may feel scratchy. Watering, redness, headache, and increased pain with exposure to light can occur.	1. Cover eyes with a dark cloth. 2. Seek medical treatment.
Dehydration	Similar to heat exhaustion. See Table 5-1.	1. Keep warm, loosen clothes. 2. Casualty needs fluid replacement, rest and prompt medical treatment.
Hypothermia	Casualty is cold. Shivering stops. Core temperature is low. Consciousness may be altered. Uncoordinated movements may occur. Shock and coma may result as body temperature drops.	Mild Hypothermia 1. Rewarm body evenly and without delay. (Need to provide heat source; casualty's body unable to generate heat). 2. Keep dry, protect from elements. 3. Warm liquids may be given gradually (to conscious casualties only). *4. Seek medical treatment immediately! Severe Hypothermia 1. Stabilize the temperature. 2. Attempt to avoid further heat loss. 3. Handle the casualty gently. 4. Evacuate to the nearest medical treatment facility as soon as possible.

*CAUTION: Hypothermia is a MEDICAL EMERGENCY! Prompt medical treatment is necessary.