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Epidemiology and treatment outcome of frostbite at high altitudes in North India – A cross-sectional study

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Context: Frost bite is an important cause of morbidity among armed forces personnel who are employed in high altitude areas. Aims: The aim of the present study was to evaluate the epidemiological aspects and treatment outcome of frostbite injuries among healthy adults working in sub-zero temperatures of the Himalayas. Settings and Design: The study was carried out as a retrospective observational study among all frost bite patients (n = 72) reporting to two zonal hospitals in Northern sector of India from during January 2014 to November 2016. Methods and Material: Patients who had no signs of life on arrival, and patients with injuries due to sunburn / UV rays were excluded from the study. Statistical Analysis Used: Means and proportions were calculated for continuous and nominal variables respectively. Results: All patients were males with mean age of 27.8±2.5 years. Majority of cases 57 (79.2%) had first and second degree frost bite while, third and fourth degree frost bites were noted in 10 and five patients respectively. Maximum cases were reported during the months of December and January. Wound debridement (6.9%), and hyperbaric oxygen therapy (5.6%) were the most common adjunct procedures. Auto amputation was observed in 8.3%. Full recovery was noted in most of the patients except four, who had to undergo amputation of the affected part. Conclusion: Frostbite can result in a wide spectrum of injury, ranging from complete resolution without significant sequelae to major limb amputation and its functional morbidity. First and second degree frost bite were the most common, predominantly noticed in young individuals during peak winter months of December and January.
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136
Original Article
IntroductIon
Initial reports on frostbite injuries date back up to 5000 years
old are described in pre-Columbian mummies.[1] Frostbite
is not uncommon in military medicine because of soldiers’
deployment in the extremes of weather. During WWII,
frostbite accounted for 2%–4% of the combat surgical trauma
and 1%–2% of the total mortality and morbidity among
the Red Army.[2] Indian troops are posted at the altitudes
of 12,000–22,000 feet above the sea level in the northern
regions to man the international borders. Medical care to
these personnel at peripheral farthest posts is provided by the
echelons of eld hospitals comprising doctors, paramedics,
equipment for rst aid, and essential medicines. Frostbite
remains one of the major health hazards in the troops posted in
that area and mountaineers. Young people who are active are
the most commonly affected. The frequently involved include
armed forces personnel, agricultural workers, mountaineers,
cross-country skiers, expedition members, and climbers. In
most occurrences, the patients are not aware about the onset
and progress of frostbite until it is severe. Vasoconstriction
following blood clotting results from exposure to extreme cold
weather. Ice crystals form in the tissues and the capillaries,
when the atmospheric temperature drops below −4°C,
ultimately leading to cell membrane damage. As the dead cells
are replaced by broblasts, scar tissue forms.[3] Insensitivity and
clumsiness are the common symptoms noted by the affected
individual, at rst. When remedial measures such as rewarming
are instituted, these symptoms tend to disappear rapidly. The
spectrum of illness presented by frostbite patients varies widely
Epidemiology and Treatment Outcome of Frostbite at High
Altitudes in North India – A Cross‑Sectional Study
Dr. Vivek Agrawal, Dr MS Prakash1, Dr Pallab Chatterjee2, Dr Vishnuprasad R3, Dr Abhimannyu Choudhury4, Dr Abhijeet Lal5, Dr Atul Kotwal6
Department of Vascular Surgery, Army Hospital R&R, Delhi Cantt, 1Prof Nephrology, Rajarajeswari Medical College and Hospital, Bangalore, 2Depatment of Plastic
Surgery, Army Hospital R&R, Delhi Cantt, 3Public Health Specialist, Firozepur Cantt, 4Deparmtent of General Surgery, Military Hospital, Namkum, 5Deparmtent of
General Surgery, Air Force Hospital, Jodhpur, 6Public Health Specialist, Jalandhar Cantt, India
Context: Frost bite is an important cause of morbidity among armed forces personnel who are employed in high altitude areas. Aims: The aim of
the present study was to evaluate the epidemiological aspects and treatment outcome of frostbite injuries among healthy adults working in sub-
zero temperatures of the Himalayas. Settings and Design: The study was carried out as a retrospective observational study among all frost bite
patients (n = 72) reporting to two zonal hospitals in Northern sector of India from during January 2014 to November 2016. Methods and Material:
Patients who had no signs of life on arrival, and patients with injuries due to sunburn / UV rays were excluded from the study. Statistical Analysis
Used: Means and proportions were calculated for continuous and nominal variables respectively. Results: All patients were males with mean
age of 27.8±2.5 years. Majority of cases 57 (79.2%) had rst and second degree frost bite while, third and fourth degree frost bites were noted in
10 and ve patients respectively. Maximum cases were reported during the months of December and January. Wound debridement (6.9%), and
hyperbaric oxygen therapy (5.6%) were the most common adjunct procedures. Auto amputation was observed in 8.3%. Full recovery was noted
in most of the patients except four, who had to undergo amputation of the affected part. Conclusion: Frostbite can result in a wide spectrum of
injury, ranging from complete resolution without signicant sequelae to major limb amputation and its functional morbidity. First and second
degree frost bite were the most common, predominantly noticed in young individuals during peak winter months of December and January.
Keywords: Epidemiology, Frost bite, High altitude
Address for correspondence:(Dr) R Vishnuprasad,
NP23 Site 10 Jhoke Road, Firozepur Cantt, Punjab, India.
E‑mail:vishnuprasath2@gmail.com
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DOI:
10.4103/jmms.jmms_60_19
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How to cite this article: Agrawal V, Prakash MS, Chatterjee P, Vishnuprasad R,
Choudhury A, Lal A, et al. Epidemiology and treatment outcome of frostbite
at high altitudes in North India – A cross-sectional study. J Mar Med Soc
2020;22:136-40.
Abstract
Submission: 08-Sep-2019 Accepted: 12-Jan-2020 Published: 14-Aug-2020
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Agrawal, et al.: Epidemiology of frostbite at high altitudes
Journal of Marine Medical Society ¦ Volume 22 ¦ Issue 2 ¦ July-December 2020 137
from minimal tissue loss with mild long-term sequelae to
major necrosis of the distal limbs, even leading to amputations
of the affected part, thus, resulting in signicant morbidity,
loss of extremities, or even mortality in extreme cases.
Some of the common predisposing factors include alcohol
consumption (46%), psychiatric illness (17%), vehicular
failure (19%), and drug misuse (4%).[4] Temperature, wind chill
factor, duration of exposure, wet/dry cold, immersion, clothing,
and patient comorbidities such as smoking, peripheral vascular
disease, neuropathies, and Raynaud’s disease tend to determine
the severity of illness.[5,6] Many soldiers have even lost their
limbs/lives due to adverse climatic conditions while occupying
the strategic heights in the extreme adverse climatic conditions
of North Indian borders. These incidents highlight the extreme
risks that soldiers face in manning the inhospitable terrain at
heights of 21,000 feet under extreme weather conditions on
the world’s highest battleeld (redundant). There is a lack of
comprehensive Indian statistics about the epidemiology of
frostbite injuries occurring in these regions. The purpose of this
study is to evaluate the epidemiological aspects and treatment
outcome of frostbite injuries among healthy adults working in
subzero temperatures of the Himalayas.
MaterIals and Methods
The present study was carried out as a retrospective observational
study of frostbite patients reporting to two zonal hospitals in the
northern sector of India during the study period starting from
January 2014 to November 2016. The hospital catered to the
population of the defence services in the northern sector. All
serving personnel who are deployed in such areas are screened for
any comorbidities and those who are found t were only engaged.
All patients reporting to the hospital with frostbite were included in
the study. Patients who had no signs of life on arrival and patients
with injuries due to sunburn/ultraviolet rays were excluded from
the study. On arrival, patients were evaluated and managed as per
the hospital management protocols, which are predesigned based
on the existing updated medical knowledge.[7,8] Predisposing or
precipitating factors were assessed, including the duration of
exposure, time interval of onset of disease, and initiation of First
Aid were documented by the authors. The lesions were divided
into four degrees and treated accordingly. The affected parts were
cleaned and kept in lukewarm water (37°C–39°C) for 15 min to
1 h. Thereafter, dressing was done with frostbite cream which
was made by mixing soframycin cream, lignocaine ointment,
and silver sulfadiazine ointment and subsequently covered with
framycetin sulfate (Sofra Tulle ®) dressing and highly absorbent
padding.[7,8] Bullas were punctured to remove the uid collection;
however, the overlying skin was left intact. Patients were kept in
ambient environment at 26°C–30°C temperature. A predesigned
pro forma was used for data collection by the investigators,
which included detailed description demographic factors, various
possible risk factors, symptoms/signs of various degrees of
frostbite, severity of the disease, and management. The patients
were asked to dene the body parts affected (by choosing from a
list of locations, namely the hands, feet, nose, and ears), height of
post, duration of exposure, the season in which the injury occurred,
the appropriateness of the equipment being used (checked against
a list of indispensables consisting of proper boots, socks, gloves
with cover, and windbreaker), whether they were properly trained
or educated by a designated trainer and patients’ perception on the
cause of frostbite. An inquiry was also made regarding alcohol
and tobacco consumption and/or the use of other drugs. The dead
tissues were excised only after a clear line of demarcation. In
the absence of infection, amputations were usually delayed up
to 3 months to give all possible chances to the deeper tissues to
recover spontaneously.[7,8] The Institutional Ethical Committee
Clearance was sought and obtained before the study was begun.
Informed written consent was obtained from all the patients
before including them in the study. Statistical analysis: data entry
was carried out using MS Excel 2013, and data analysis was
carried out using IBM SPSS (Statistical Package for the Social
Sciences) software version 21.0, New York, United States. Means
and proportions were calculated for the continuous and nominal
variables, respectively.
results
The present study included 72 patients who reported with
frostbite during the study period. All patients were males,
with a mean age of 27.8 ± 2.5 years. Only four patients were
under the age of 20 years, 48 (66.7%) were between 20 and
30 years, 18 (25%) were between 30–40 years, and 2 (2.8%)
were over 40 years. None of the patients were suffering from
any chronic disease such as coronary heart disease, diabetes
mellitus, and hypertension. Majority of the patients (57; 79.2%)
reported with frostbite who were exposed to freezing cold of
up to 3–6 h. Of these, 22 of them were caught in blizzards with
freezing cold and developed frostbite in <3 h of exposure. After
6–12 h of cold exposure, 10 patients (13.9%) developed frostbite,
whereas ve cases (6.9%) had exposure of more than 12 h. Only
27 (37.5%) patients could be evacuated to the nearest hospital
within 6 h from the site of occurrence, and 39 patients (54.7%)
were evacuated in 6–12 h time. The rest six patients (8.3%)
could reach the hospital only after 12 h of incident. A history of
smoking of 6–10 cigarettes/day was given by the six patients.
These patients also had delayed recovery and poor prognosis
than nonsmokers. On evaluation, two patients were found to have
evidence of peripheral vascular disease. They developed frostbite
only in 3–4 h of cold exposure. The majority of the cases (42,
58.3%) developed frostbite at an altitude between 12,000 and
17,000 feet above the sea level, followed by 27 (37.5%) patients
who developed frostbite between 17,000 and 21,000 feet. Only
3 cases (4.2%) had frostbite above 21,000 feet. The maximum
cases affected were during the month of January (n = 13) followed
by December (n = 11), November (n = 9), and October (n = 8).
From October to January, there are more blizzards and “wind-chill
effect” due sudden fall in atmospheric temperature (up
to − 35°C). Only 13 cases (18%) had frostbite during the summer
months (April to September) [Table 1]. Feet were the most
frequently affected part (44, [61.1%]). In 23 cases (31.9%), hands
were affected. Head-and-neck exposure usually involved nose
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Agrawal, et al.: Epidemiology of frostbite at high altitudes
Journal of Marine Medical Society ¦ Volume 22 ¦ Issue 2 ¦ July-December 2020
138
and ears and was observed in ve cases (6.9%). At least, two
body parts were involved in 45 cases (62.5%), and 21 (29.2%)
had one body part affected. Six patients were noted having the
involvement of three body parts. Majority of cases (57, [79.2%])
had the rst- and second-degree frostbite, whereas third- and
fourth-degree frostbites were noted in 10 and ve patients,
respectively [Figures 1 and 2]. Majority of the patients required
only a conservative dressing (65%), whereas nearly one third
of the patients required adjunctive procedures in the course of
management. Wound debridement (6.9%) and hyperbaric oxygen
therapy (5.6%) were the most common adjunct procedures.
Amputation was done in 6.9% cases, whereas autoamputation
was observed in 8.3% of the study participants [Table 2].
Complete healing and full recovery were noted in the rest of the
patients. Causalgia (8.3%) and infection (6.9%) were the most
common sequelae following frostbite [Table 3].
dIscussIon
In the past years, frostbite was chiey encountered in the
military populations; however, the demographic trends have
now loosened to include homeless individuals, outdoor workers,
mountaineers, and winter sports enthusiasts.[9,10] In patients with
frostbite, early recognition and timely evacuation to the nearest
hospital are directly proportional to the degree of frostbite
and the better outcome. Prevention is through wearing proper
clothing, maintaining hydration and nutrition, avoiding low
temperatures, and staying active without becoming exhausted.
The present study results revealed a higher incidence of cases
among the younger age group (<30 years) and this is similar
to the observations of the other studies carried out among
military personnel. In a study among military personnel, it was
noted that the majority of the affected were females <20 years
old.[11] This could be because of the fact that individuals in
the armed forces who are deployed for tasks in such high
altitude areas are usually moung and healthy. However, it
is also noted that the higher prevalence among the general
public and mountaineers was found to be in the age group of
30–49 years.[12] A study among 637 mountaineers reported that
the mean age of their study population was 28.8 ± 1.1 years,
Figure 1: Distribution of the study participants based severity of frostbite
Table 1: Distribution of the study participants based on
the baseline characteristics (n=72)
Parameter Frequency (%)
Age (years)
18-20 4 (5.6)
21-30 48 (66.7)
31-40 18 (25)
41-50 2 (2.8)
Duration of exposure (h)
<6 57 (79.2)
6-12 10 (13.9)
>12 5 (6.9)
Evacuation time (h)
<6 27 (37.5)
6-12 39 (54.7)
>12 6 (8.3)
Height of place where deployed (feet)
12,000-17,000 42 (58.3)
17,000-21,000 27 (37.5)
>21,000 3 (4.2)
Incidence month
January 11 (15.28)
February 12 (16.67)
March 08 (11.11)
April 03 (4.17)
May 04 (5.56)
June 0 (0.00)
July 02 (2.78)
August 03 (4.17)
September 02 (2.78)
October 05 (6.94)
November 09 (12.50)
December 13 (18.06)
Total 72 (100.0)
Table 2: Distribution of the study patients based on the
type of management (n=72)
Type of management Frequency (%)
Conservative dressing 47 (65.3)
Wound debridement 5 (6.9)
Split skin grafting 3 (4.2)
Amputation
Amputation
All ngers at interphalangeal joints 1 (1.4)
Great toe 2 (2.8)
Middle nger at proximal interphalangeal joint 1 (1.4)
Index nger at distal proximal interphalangeal
joint
1 (1.4)
Autoamputation
Fore feet including toes 1 (1.4)
Middle nger right 2 (2.8)
Tip of little toe 1 (1.4)
Great toe 2 (2.8)
Four-quadrant fasciotomy 2 (2.8)
Hyperbaric oxygen 4 (5.6)
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Agrawal, et al.: Epidemiology of frostbite at high altitudes
Journal of Marine Medical Society ¦ Volume 22 ¦ Issue 2 ¦ July-December 2020 139
and the youngest among them was 16 years and the oldest
was 65 years.[13] Strohle et al. reported in their research work
that the mean patient’s age was 41.6 ± 17.5 years, ranging
from 20 to 90 years.[14] These demographic observations of
frostbite cases were concordant with that of the present study
ndings. After detailed epidemiological investigation, it was
noted that the most common risk factors were tight boots,
nonadherence to the instructions regarding self-examination,
not doing regular foot parade, use of wet socks, and exhaustion.
The foot parade consists of self-examination of feet, washing
them with lukewarm water, and jumping on feet which helps in
rewarming. In our study, among 23 cases (31.9%), hands were
affected which was also due to the use of single or wet glove.
All the study patients recovered without amputation except
four. Two cases required proximal phalanx amputation of one
nger, one required proximal phalanx amputation of left great
toe, and one required amputation of all ngers at the junction of
metacarpophalangeal joints. In a large review among the British
military personnel, it was reported that extremities (hands and
feet) accounted for the majority of cases (60.8%), only hands
in 28.9%, only feet in 23.7%, and 7% had both hands and
feet involvement. Face and neck involvement was recorded
in 1% of the study sample.[15] However, another study stated
that feet and the hands accounted for 90% of injuries while it
also affects the buttocks (sitting) and penis (joggers).[12] In a
study among Norwegian armed forces personnel, 96% suffered
frostbite on ngers/hands or toes/feet.[16] These results were
comparable to that of the present study ndings, in terms of
body part involved. The correlation of the independent effect of
height on the degree of frostbite showed that height adversely
affected the lesions beyond 17,000 feet. The decline beyond
21,000 feet was because of the fact that persons who went
and stayed at those heights were conned to their shelters
with very little movement. However, the study reported the
majority of the affected patients at altitude levels starting from
12,000 to 17,000 feet as compared to the higher altitude. This
could be explained by the fact that a relatively higher number
of personnel are deployed at this altitude range as compared
to the higher altitude, thereby increasing the number of
incident case, however not the incidence rate. Incidence rates
could not be estimated in our study because of constantly
mobile military population in the study area. Furthermore,
complacency in the prevention measures among these
personnel could be a potential explanation, which may not
be expected among individuals at greater altitude levels. An
Australian Alps study also reported that most of the frostbite
injuries occurred over 5000 feet (67.8%).[14] A prospective
study was conducted in four different geographical regions
of the Himalayas and reported that the rst-, second-, and
third-degree frostbite comprised 62.2%, 34.3%, and 3.49%
of patients, respectively.[17] These ndings were similar to
that of the present study reports. In the study on frostbite
cases in the Australian Alps, rescue of affected was mostly
terrestrial (32.3%), followed by helicopter (38.7%), and the
rest (22.6%) cases involved both.[14] The present study setting
involved a similar hilly terrain with restricted access by land;
however, most patients were evacuated by road when possible
while air evacuation to the hospital was also used based on
the prevailing weather conditions. The seasonal distribution
of frostbite shows the highest occurrence in January and
Table 3: Distribution of the study participants based on
sequelae after frostbite (n=25)
Sequelae Frequency (%)
Disgurement 4 (5.6)
Causalgia/chronic regional pain 6 (8.3)
Cold hypersensitivity 3 (4.2)
Numbness of the digits 4 (5.6)
Reduced sensitivity 3 (4.2)
Infection 5 (6.9)
None 47 (65.3)
Total 25 (100.0)
Figure 2: (a) Third degree frostbite in the healing phase.(b) Fourth degree frostbite with dry gangrene of the fingers.(c) Four th degree frostbite
with dry gangrene of toes.(d) Fourth degree frostbite with dry gangrene of great toe.(e) Second degree frostbite having bullae filled with clear fluid.
(f) Third degree frostbite of the hand
d
c
b
f
a
e
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Agrawal, et al.: Epidemiology of frostbite at high altitudes
Journal of Marine Medical Society ¦ Volume 22 ¦ Issue 2 ¦ July-December 2020
140
February (with at least three times as many injuries as in other
months), with another less striking rise in the incidence during
summer months when large-scale expeditions to high peaks
are scheduled. Inappropriate clothing was believed by the
mountaineers to be the main cause of the injury followed by
the lack or incorrect use of equipment and lack of knowledge
about dealing with cold and severe cold weather.[13]
The principles of treatment in frostbite include prevention
of refreezing, aspirin and ibuprofen can be given to prevent
clotting and inammation, managing coexisting hypothermia,
antibiotics are added if there is trauma, skin infection (cellulitis),
or severe injury, and debridement or amputation of necrotic
tissue should be delayed. Early hyperbaric oxygen therapy
is also documented to curb amputations.[18] Tissue loss and
autoamputation are the potential consequences of frostbite. In
a retrospective study of 265 frostbite injuries in Canada, it was
noted that 35% of patients with deep frostbite had operative
interventions and autoamputations occurred in 28% of them.[19]
Although the present study did not evaluate the proportion
of adjunctive procedures among the subclasses of frostbite,
because of relatively smaller sample size, these proportions
observed in the above study are comparable to that of the
present study. Treatment is usually conservative. If the part
becomes gangrenous, it should be left to autoamputate. Surgical
amputation should be done if the patient has intolerable pain or
wound gets infected. The use of hyperbaric oxygen, medical
sympathectomy using intraarterial reserpine, and recombinant
tissue plasminogen activator have also been attempted with
limited success.[7,8,20-22] More randomized control studies
are required to establish their role in the management. The
limitations of the study include that the study involved only
personnel of the armed forces who are in most occasions young
and healthy, which makes the study population not easily
comparable with that of the general population.
Timely prehospital and denitive hospital management are
important to minimize the nal tissue loss and maximize the
functionality of the affected limb. Frostbite can result in a wide
spectrum of injury, ranging from complete resolution without
signicant sequelae to major limb amputation and its functional
consequences. The rst- and second-degree frostbite was the
most common, predominantly noticed in young individuals
during peaks winter months of December and January. The
higher proportion of adjunct operative procedures is required
as the severity of frostbite increases. Once in the hospital
setting, the best outcomes will be achieved for the patient
when a multidisciplinary approach is utilized.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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frostbite injury. J Burn Care Res 2017;38:e877-81.
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... Similar finding was observed in a study done by Vishnuprasad et al. in a similar setting where more than 75% cases were of first and second grade. [17] However, as compared to a previous study where feet were the most commonly affected part; in this study hands (65%) were more commonly involved than feet (35%). More than 50% of severe cases (second-and third-grade injury) of frostbite had a history of direct exposure to both snow and cold winds while the rest have either snow or cold winds. ...
Article
Objectives The objective of the study was to study the clinico-epidemiological profile of frostbite cases in high altitude region of Northern India. Study Design This study involves a descriptive study. Materials and Methods A descriptive study was undertaken in service hospitals situated in the northernmost region of India receiving frostbite cases from December 1, 2019, to Mar 30, 2020, to assess their clinico-epidemiological profile. A semi-structured questionnaire was designed comprising demographic characteristics and clinical and epidemiological characteristics of the frostbite cases. Frostbite cases were classified based on grades of injury and were studied for any association with age, physical activity, and temperature extremes. Results A total of 29 cases of frostbite were reported during the study period with the majority of cases being <25 years of age. All cases were reported at altitudes of above 12,000 ft. and maximum cases gave a history of direct exposure to extreme weather conditions or other predisposing factors. The most common complaint at the onset of the symptoms was discoloration of the skin followed by swelling of digits and pain with most of the cases falling under first and second grade of injury. Protective clothing and footwear were adequate during induction/de-induction/stay in extreme climate regions. Conclusions Exposure to extreme cold climates, high altitude, personal clothing, and physical exertion plays an essential role in the occurrence of frostbite cases as well as their severity. With the rising number of cases of frostbite, understanding of multiple factors which predisposes to frostbite injury is essential.
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Introduction: Frostbite is a common debilitating condition seen in travelers and residents at high altitudes. Emergent on-site management is warranted in the absence of institutionalized care and compromised evacuation facilities. This prospective, observational study assessed the outcome of on-site emergent management in low-resource, high altitude healthcare setups in the field, applicable in situations of delayed evacuation.Methods: This is a prospective cohort study. All frostbite patients presenting at 4 Himalayan regions were included. Patients were diagnosed, assessed clinically, and evaluated for causation. On-site emergent management was given in situations of delayed evacuation, and responses were monitored. Further prevention was advised for all patients.Results: Frostbite presented in 172 healthy, acclimatized patients having knowledge of frostbite. A total of 158 (91.86%) males and 14 (8.14%) females with a mean age of 27.8 ± 7 years sustained frostbite at altitudes between 9000-24000 feet with a mean of 14575 ± 3848 feet. First-, second-, and third-degree frostbite comprised 62.2%, 34.3%, and 3.49% of cases, respectively. Fingertips were most frequently affected, followed by toe tips. Of the frostbite cases treated on-site, 57.94% were first-degree and 34.29% were second-degree.Conclusion: Frostbite can occur in people who are cold-experienced and knowledgeable. Therapeutic and preventive rewarming can be attempted in limited-resource setups outside the hospital. Frostbite up to second-degree can be treated under high altitude field conditions; however, this is advisable only in situations of delayed evacuation.
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The start of World War II (WWII) led to the deployment of combat troops in several continents. Destruction and many casualties among both the military and civilians became an inevitable consequence. A large amount of people injured were in need of life-saving treatment and a speedy return to duty. Intensive studies of the specific issues of diagnosis and treatment of thermal injury were conducted in the Soviet Union before the war. The first special units for patients with burn injuries were created, and the first specialists received their first clinical experience. The contributions of famous Soviet scientists in the development of the treatment of burns and frostbite in WWII are studied in this article. The structure of thermal injuries among military personnel and the results of their treatment are shown. Treatment, classification and quantity frostbite in the structure of sanitary losses during the WWII are studied in this article.
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Despite advances in outdoor clothing and medical management of frostbite, individuals still experience catastrophic amputations. This is a particular risk for those in austere environments, due to resource limitations and delayed definitive treatment. The emerging best therapies for severe frostbite are thrombolytics and iloprost. However, they must be started within 24 hours after rewarming for recombinant tissue plasminogen activator (rt-PA) and within 48 hours for iloprost. Evacuation of individuals experiencing frostbite from remote environments within 24 to 48 hours is often impossible. To date, use of these agents has been confined to hospitals, thus depriving most individuals in the austere environment of the best treatment. We propose that thrombolytics and iloprost be considered for field treatment to maximize chances for recovery and reduce amputations. Given the small but potentially serious risk of complications, rt-PA should only be used for grade 4 frostbite where amputation is inevitable, and within 24 hours of rewarming. Prostacyclin has less risk and can be used for grades 2 to 4 frostbite within 48 hours of rewarming. Until more field experience is reported with these agents, their use should probably be restricted to experienced physicians. Other modalities, such as local nerve blocks and improving oxygenation at high altitude may also be considered. We submit that it remains possible to improve frostbite outcomes despite delayed evacuation using resource-limited treatment strategies. We present 2 cases of frostbite treated with rt-PA at K2 basecamp to illustrate feasibility and important considerations.
Article
The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the guidelines published in 2014.
Article
Ströhle, Mathias, Simon Rauch, Philipp Lastei, Monika Brodmann Maeder, Hermann Brugger, and Peter Paal. Frostbite injuries in the Austrian Alps: a retrospective 11-year national registry study. High Alt Med Biol 00:000-000, 2018. Objectives: Frostbite is a cold injury mostly affecting the extremities. The objective of this study was to reveal the incidence of frostbite injuries in the Austrian Alps, to search for frostbite risk factors, and thereby optimize prevention and treatment. Methods: Out-of-hospital data in the National Registry of Alpine Accidents from January 1, 2005, to December 31, 2015, were screened for frostbite injuries. Cases in the registry were merged with clinical data from the major trauma center in western Austria, Innsbruck Medical University Hospital, and statistically analyzed. Results: Documented in the National Registry are 114,595 injured persons in the 11-year study period. Thirty-one frostbite cases were documented nationwide, 18 (58%) of which occurred in the western states of Austria and were therefore potentially referred to the Innsbruck Medical University Hospital. Six (19.6%) patients were female. Frostbite was almost exclusively related to fingers and toes (90% of cases). Conclusions: Frostbite injuries in the Austrian Alps are rare. With an incidence of 0.07/100,000, three to four clinically relevant frostbite injuries occur annually. Men are at greater risk for frostbite injuries than women. Fingers and toes are at greatest risk. Proper preparation of outdoor activities and cold-protective gear can help prevent frostbite injuries.
Article
Introduction Humans have suffered frostbite at all times when exposed to cold surroundings. The oldest known case of frostbite is a 5000-year-old Chilean mummy. Most Norwegian military personnel are exposed to temperatures below the freezing point during a part of their service period, and a portion of the soldiers will suffer frostbite each year. Frostbite may cause chronic sequela, with symptoms such as cold-hypersensitivity, chronic pain, hyperhidrosis and paresthesia with an electric-shock feeling. The Norwegian Armed Forces Health Registry (NAFHR) was established in 2005 to supervise the health of Norwegian soldiers, and to produce statistics and research to get new knowledge about the health of military personnel. Norwegian soldiers who experience a frostbite during military service, and consult a military medical doctor for this injury, are registered in the NAFHR. In this study, we assessed the incidence of frostbite among conscripts in the Norwegian Armed Forces during a five-year period (2010–2014). We also report on self-reported long-term sequela following a frostbite injury during service in the Armed Forces in the same period. Methods To calculate the incidence of frostbites, we identified all conscripts suffering a frostbite (ICD-codes T34, T35) during service at the garrisons in Northern Norway in the period January 1st, 2010 to December 31st, 2014, registered in the NAFHR. The Norwegian Armed Forces Personnel Register supplied us with an estimate of the total number of conscripts doing their military service at the same garrisons during the same period. To assess long-term sequela after frostbite, all military personnel diagnosed with frostbite during the same period received a questionnaire via the internet-based tool Confirmit, asking them to confirm their frostbite-diagnosis. We also asked if they had any sequela from the frostbite injury, and if so, the degree of symptoms from the sequela. Results A total of 563 conscripts serving in Northern Norway were diagnosed with frostbite during the observation period. In total, approximately 2700 conscripts served in Northern Norway each year during the observation period. Based on these numbers, the yearly incidence of frostbite is approximately 2,5% among Norwegian conscripts serving in Northern Norway. When including all types of military personnel, we identified 810 soldiers with a frostbite-diagnosis during the five-year period. We sent all of them a questionnaire via e-mail. Eighty-six questionnaires were not delivered due to faulty e-mail addresses; hence, 724 persons received the questionnaire. Of the 478 persons that returned the questionnaire, 18 persons did not want to participate in the survey. Hence, 460 persons answered the questionnaire, a response-rate of 66%. Of these persons, 397 confirmed that they had experienced a frostbite during military service. The majority were men (80%), and median age was 20 years. Three hundred and twenty-two persons (81%) reported that they suffered frostbite during military winter training, and almost everyone had suffered frostbite on fingers/hands or toes/feet (96%). Seventy percent reported that they had sequela, and 20% reported sequela with serious symptoms affecting their daily life more than two years after the frostbite. Conclusion Frostbite is a significant health problem among Norwegian military personnel. In our study, seventy percent of the persons who suffered frostbite during military service reported sequela, and one fifth reported chronic sequela with serious symptoms affecting their daily living more than two years after the frostbite.
Article
Deep frostbite is a thermal injury associated with significant morbidity. Historically, this has been associated with military personnel; however, increasingly it is becoming an injury that afflicts the civilian population. The use of intravenous iloprost or intra-arterial thrombolytics has led to promising tissue salvage. This article provides an up-to-date understanding of frostbite pathophysiology, classification, prevention, and management. It also highlights the role of telemedicine in optimizing patient outcomes. To further the understanding of optimal frostbite management, larger, likely multicenter, high-quality trials are required. An international frostbite register would facilitate data gathering.
Article
Frostbite can lead to severe consequences including loss of digits and limbs. One of the mechanisms of frostbite includes vascular thrombosis. The use of tissue plasminogen activator (tPA) in frostbite has been shown to be effective in case reports and small prospective studies. A retrospective chart review was performed on all patients admitted for frostbite between January 2008 and April 2015, and six patients were identified as having received treatment with intravenous tPA. Patients received an initial bolus dose followed by a 6-hour infusion of tPA. Five patients (83.3%) were treated with continuous infusion heparin following tPA administration. Three patients (50%) were discharged on aspirin 325 mg daily for 30 days and two patients (33.3%) were discharged on warfarin for 28 days. There were no serious complications noted with tPA. In this case series, there were 65 digits at risk for amputation in six patients. Only 16 digits (24.6%) were partially or completely amputated in three (50%) of the patients. After rapid rewarming, the use of tPA is safe and effective at reducing the number of digits amputated. Patients who had less of a response to tPA were those who had an unknown duration of cold exposure along with drug or alcohol intoxication at presentation. Utilizing a guideline with clear criteria will help facilitate determining appropriate patients to safely treat with tPA for frostbite injury.
Article
Background: Frostbite is a common yet challenging injury to both diagnose and treat. McCauley's frostbite treatment protocol consists of 12 treatments that might well represent the standard of care. However, its effectiveness in preventing operative intervention has yet to be examined. Our objectives were to characterize frostbite injuries in Eastern Ontario, identify risk factors for deep injuries, and assess the protocol's efficacy in preventing operative outcomes. Methods: This cohort study examined patients with frostbite over ten years at a tertiary care hospital. Demographics and predisposing factors were recorded. Frostbite severity was categorized into superficial or deep. Treatments were recorded, including adherence to protocol and operative outcome. Results: Of the 265 frostbite patients identified, deep frostbite accounted for 56 (21.1%, 95% CI: 16.2-26.1%), of whom 20 (35.7%) had an operative outcome. Amputation occurred in 16 (28.6%) of deep injuries and debridement in 5 (8.9%). Risk factors for deep frostbite were older age (p =0.002), smoking (p <0.001), male sex (p =0.056) and alcohol abuse (p =0.056). None of the patients with deep frostbite had all 12 treatments performed. Adherence to protocol ranged from 0.0% to 48.2% per treatment. The rate of operative intervention was 7.7% in patients with deep frostbite who did not have any McCauley's frostbite treatments and ranged from 0.0% to 100.0% per treatment in those who did receive treatments. Conclusions: The frostbite protocol was not regularly followed and therefore its efficacy in preventing operative intervention could not be determined. Further, none of the individual treatments in the protocol were associated with preventing operative intervention. We recommend that future research focus on identifying effective individual treatments.
Article
Introduction: Cold injuries have been a recurrent feature of warfare for millennia and continue to present during British Military operations today. Those affecting the peripheries are divided into freezing cold injury (FCI) and non-FCI. FCI occurs when tissue fluids freeze at around -0.5°C and is commonly referred to as frostnip or frostbite. Method: All FMED7 notes held at the Institute of Naval Medicine's Cold Weather Injury Clinic (CIC) from 2002 to 2014 were searched for the terms 'frostbite' and 'frostnip' and then analysed to identify common themes. Results: In total 245 results were found and from these, 149 patients with a positive FCI diagnosis were identified and formed the cohort of this study. Royal Marines (RM) represented over 50% of patients and Arctic training in Norway accounted for over two thirds of the total cases. The extremities were almost always those areas which were affected by FCI. Further analysis of the RM cases showed the majority of those injured were of the most junior rank (Marine/Private or Lance Corporal). Conclusions: A lack of supporting climatic and activity data meant that it was difficult to draw additional conclusions from the data collected. In future, a greater emphasis should be placed on collection of climatic and additional data when FCIs are diagnosed. These data should be collated at the end of each deployment and published as was regularly done historically. It is hoped that these data could then be used as the starting point for an annual climatic study day, where issues related to FCIs could be discussed in a Tri-Service environment and lessons learned disseminated around all British Forces personnel.