Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Frostbite

Tat-CIRP Peptide Facilitates Frozen Wound Healing by Ameliorating Inflammation and Promoting Angiogenesis

Background

Frostbite is a chemia resulting from cold-induced skin damage. The process of frostbite is often accompanied by inflammation, and the therapeutic strategies focusing on anti-inflammation are the main direction to data. Tat-CIRP is a 15 amino acid peptide containing HIV protein and cold-inducible RNA-binding protein (CIRP), which is believed to compete with endogenous CIRP for myeloid differentiation 2 (MD2) binding. This study aims to investigate the efficacy of Tat-CIRP in the treatment of frostbite.

Methods

A mouse model of frostbite was established, and on the first day after frostbite occurrence, Tat-CIRP peptide was administered intravenously via the tail with a dosage interval of one day for a total of three doses. Frozen mouse skin sections were subjected to histological analysis, including hematoxylin-eosin (HE) staining, Masson staining, and immunohistochemical examination. Western blotting was performed to detect the expression level of Ki-67 in mouse skin tissue.

Results

One day after frostbite, mice exhibited skin swelling and a solid appearance. From day 1 to 5 after frostbite, MD2 expression was significantly upregulated, while CIRP expression was downregulated. Compared to the frostbite group, mice treated with Tat-CIRP showed accelerated frostbite recovery, reduced levels of inflammatory factors and MD2. Furthermore, the expression of cell proliferation-associated protein Ki-67 and angiogenesis-related protein CD31 was upregulated.

Conclusion

Tat-CIRP promotes frozen wound healing via inhibiting inflammation and promoting angiogenesis in frostbitten mice.

The Effects of Recombinant Human Granulocyte-Macrophage Colony-Stimulating Factor Gel on Third-Degree Frostbite Wounds in Northeastern China: A Randomized Controlled Trial

The aim of the study was to investigate the effects of the rhGM-CSF gel on third-degree frostbite wounds. Sixty-two patients who had suffered third-degree frostbite on their hand or foot (91 wounds in total) were selected using a convenience sampling method and randomly allocated to two groups: the rhGM-CSF group(31patients,45 frostbite wounds) received the rhGM-CSF gel when wound dressing change daily; however, the control group (31patients, 46 frostbite wounds) received aloe glue. The wound healing time, the score of inflammation about the wound and the positive bacterial culture of wound secretions were used to measure outcomes, respectively. Data were analyzed using SPSS (25.0), Student's t test or Mann-Whitney U test and chi-square test or Fisher exact test were selected, as appropriate. The healing time of the rhGM-CSF group was (12.2 ± 5.0) days, which was significantly shorter than that of the control group (15.5 ± 4.7) days (P < .0001). The rhGM-CSF group's wound inflammation scores on the 7th and 14th day of treatment were (0.96 ± 0.21) and (1.88 ± 0.29), respectively, which were better than those of the control group (1.12 ± 0.24) and (1.38 ± 0.15) (both P < .0001). The positive bacterial culture of wound secretions in the rhGM-CSF group was also better than that in the control group on the 3rd, 7th, and 14th day after treatment (P = .027, .004, .030, respectively). According to the results, using rhGM-CSF gel considerably increases the speed of frostbite wounds healing, and have an effect on protecting third-degree frostbite wounds regarding the positive effects. Trial Registration: This trial was registered in the Chinese Clinical Trial Register, ChiCTR1900021299.

Increased cold injuries and the effect of body mass index in patients with peripheral vascular disease

Background

Exposure to extremely or moderate low temperatures is associated with increased morbidity and mortality risk. Peripheral vascular disease (PVD) is a slow and progressive circulation disorder. Given that cold temperature causes constriction of the small arteries and veins in the skin, patients who suffer from peripheral circulation problems, like PVD, may be vulnerable to cold injuries. This study aimed to investigate the association between PVD and cold-induced injuries in the winter among Korean adults. We further analyzed the association stratified by body mass index (BMI) classification.

Methods

We used the 2002–2015 National Health Insurance Service-National Sample Cohort data and included a total of 535,186 adults as the study population. Patients with underlying PVD were identified by ICD-10 code I73. Cold-related illnesses were defined by ICD-10 codes (T690, T691, T698, T699, T330 ~ T339, T340 ~ T349, and T350 ~ T357). Body mass index (BMI) was categorized into underweight, normal weight, overweight, and obese.

Results

A total of 23.21% (n = 124,224) were PVD patients, and 0.59% (n = 3154) had cold-induced injuries. PVD patients were more likely to be diagnosed with cold injuries, but it was valid only in the underweight or normal weight groups. After adjusting for age, sex, income, cigarette smoking, alcohol consumption, regular exercise, high blood pressure, and hyperglycemia, PVD patients had a significantly increased odds ratio (OR) for cold injuries [adjusted OR = 1.11; 95% confidence intervals (95% CI): 1.01–1.21]. Increased OR for cold injuries in PVD patients was also observed in adults (adjusted OR = 1.14; 95% CI: 1.03–1.25 in Model 2), but not in the elderly. When we classified study subjects into the four BMI groups, the adjusted OR of cold injuries in PVD patients was significant in the underweight group (OR = 1.83; 95% CI, 1.26–2.66) and normal weight group (OR = 1.15; 95% CI, 1.03–1.27), not in those with overweight and obese. In adults, a consistent result was found in adults in the underweight group (OR = 1.63; 95% CI, 1.08–2.47 in Model 2) and normal weight group (OR = 1.19; 95% CI, 1.07–1.33 in Model 2). In the elderly, the adjusted OR for cold injuries was only significant in the underweight group (OR = 3.37; 95% CI, 1.08–10.53 in Model 2).

Conclusions

We found a significant association between PVD and cold-induced injuries in the general population. BMI modified the association. Thus, the association observed appears to be clinically applicable to PVD patients being low to normal BMI.

Expert consensus on the prevention, diagnosis and treatment of cold injury in China, 2020

Cold injury refers to local or systemic injury caused by a rapid, massive loss of body heat in a cold environment. The incidence of cold injury is high. However, the current situation regarding the diagnosis and treatment of cold injury in our country is not ideal. To standardize and improve the level of clinical diagnosis and treatment of cold injury in China, it is necessary to make a consensus that is practical and adapted to the conditions in China. We used the latest population-level epidemiological and clinical research data, combined with relevant literature from China and foreign countries. The consensus was developed by a joint committee of multidisciplinary experts. This expert consensus addresses the epidemiology, diagnosis, on-site emergency procedures, in-hospital treatment, and prevention of cold injury.

The Use of tPA in the Treatment of Frostbite: A Systematic Review

BACKGROUND

The use of tissue plasminogen activator (tPA) for the treatment of frostbite has been reported and advocated, but its efficacy has not been well established. We conducted a systematic review to guide physicians on the role of tPA in the treatment of frostbite. Our hypothesis was that the use of tPA improves clinical outcomes, as measured by amputation rate.

METHODS

We searched MEDLINE (PubMed) and EMBASE for primary research articles on the use of tPA for the treatment of extremity frostbite. Information related to study design, outcomes, and complications was extracted. A total of 204 citations were screened, and then 35 abstracts and 24 reports were reviewed. Fifteen studies met the standard for final review.

RESULTS

One randomized, prospective study; 3 cohort studies; 8 case series; and 3 case reports were found. A total of 208 patients were treated. Differences in protocols, inclusion criteria, and outcomes measures prevented combining the study results. In all the studies, the authors reported that the use of tPA was or may have been useful in reducing amputation rates or increasing tissue salvage. Complication rates ranged from 0% to 100%, with a combined rate of 13%. The quality of the evidence was low.

CONCLUSIONS

Due to the low scientific quality of the studies, the efficacy of tPA in reducing amputation rates cannot currently be established. Randomized, prospective trials or well-controlled cohort studies are needed to better assess the role of tPA. Consideration should be given to limiting its use to research protocols.

A New Proposal for Management of Severe Frostbite in the Austere Environment

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.

The Triaging and Treatment of Cold-Induced Injuries

BACKGROUND

In Central Europe, cold-induced injuries are much less common than burns. In a burn center in western Germany, the mean ratio of these two types of injury over the past 10 years was 1 to 35. Because cold-induced injuries are so rare, physicians often do not know how to deal with them.

METHODS

This article is based on a review of publications (up to December 2014) retrieved by a selective search in PubMed using the terms "freezing," "frostbite injury," "non-freezing cold injury," and "frostbite review," as well as on the authors' clinical experience.

RESULTS

Freezing and cold-induced trauma are part of the treatment spectrum in burn centers. The treatment of cold-induced injuries is not standardized and is based largely on case reports and observations of use. distinction is drawn between non-freezing injuries, in which there is a slow temperature drop in tissue without freezing, and freezing injuries in which ice crystals form in tissue. In all cases of cold-induced injury, the patient should be slowly warmed to 22°-27°C to prevent reperfusion injury. Freezing injuries are treated with warming of the body's core temperature and with the bathing of the affected body parts in warm water with added antiseptic agents. Any large or open vesicles that are already apparent should be debrided. To inhibit prostaglandin-mediated thrombosis, ibuprofen is given (12 mg/kg body weight b.i.d.).

CONCLUSION

The treatment of cold-induced injuries is based on their type, severity, and timing. The recommendations above are grade C recommendations. The current approach to reperfusion has yielded promising initial results and should be further investigated in prospective studies.

Cold burn injuries in the UK: the 11-year experience of a tertiary burns centre

Background

Guidance for the management of thermal injuries has evolved with improved understanding of burn pathophysiology. Guidance for the management of cold burn injuries is not widely available. The management of these burns differs from the standard management of thermal injuries. This study aimed to review the etiology and management of all cold burns presenting to a large regional burn centre in the UK and to provide a simplified management pathway for cold burns.

Methods

An 11-year retrospective  analysis (1 January 2003–31 December 2014)  of all cold injuries presenting to a regional burns centre in the UK was conducted. Patient case notes were reviewed for injury mechanism, first aid administered, treatment outcomes and time to healing. An anonymized nationwide survey on aspects of management of cold burns was disseminated between 13 July 2015–5 October 2015 to British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) and Plastic Surgery Trainees Association (PLASTA) members in the UK. Electronic searches of MEDLINE, EMBASE and the Cochrane Library were performed to identify relevant literature to provide evidence for a management pathway for cold burn injuries.

Results

Twenty-three patients were identified. Age range was 8 months–69 years. Total body surface area (TBSA) burn ranged from 0.25 to 5 %. Twenty cases involved peripheral limbs. Seventeen (73.9 %)cases were accidental, with the remaining six (26.1 %) cases being deliberate self-inflicted injuries. Only eight patients received first aid. All except one patient were managed conservatively. One case required skin graft application due to delayed healing. We received 52 responses from a total of 200 questionaires. Ninety percent of responders think clearer guidelines should exist. We present a simplified management pathway based on evidence identified in our literature search. 

Conclusions

Cold burns are uncommon in comparison to other types of burn injuries. In the UK, a disproportionate number of cold burn injuries are deliberately self-inflicted, especially in the younger patient population. Our findings reflect a gap in clinical knowledge and experience. We proposed a simplified management pathway for managing cold burn injuries, consisting of adequate first aid using warm water, oral prostaglandin inhibitors, deroofing of blisters and topical antithromboxane therapy.

Electronic supplementary material

The online version of this article (doi:10.1186/s41038-016-0060-x) contains supplementary material, which is available to authorized users.

Dull Brains and Frozen Feet: A Historical Essay on Cold

This essay will review historical and medical aspects of cold exposure, hypothermia, and frostbite during the Napoleonic era. The 19th century writings of Dominique Jean Larrey, Pierre Jean Moricheau-Beaupré, and others are used to provide an evocative supporting narrative to illustrate some of the cold illnesses, physiology, and theory of both an earlier era and the present time. Medical care for over a century followed the how but not the why of treating frostbite and hypothermia slowly with snow or cold water rather than heat. There were 2 main reasons: First was a practical attempt to limit gangrene. Less known, and long forgotten, is a major rationale based on the erroneous theory of heat called "the caloric." Because of these 2 reasons, the slow method of "cold warming" remained standard medical practice well into the 20th century. Although these recommendations are now known to be flawed, some of the reasons behind them will be discussed, along with early but correct observations on afterdrop and circumrescue collapse. There is a long backstory of treatment from 1812 to the present.

Pathophysiologic Determination of Frostbite Under High Altitude Environment Simulation in Sprague-Dawley Rats

OBJECTIVES

Pathophysiologic changes of frostbite have been postulated but rarely understood, especially the changes caused by chilly high altitude environment. Therefore, we investigated the pathophysiologic changes of high altitude frostbite (HAF) caused by cold and hypoxia.

METHODS

Forty Sprague-Dawley rats were randomly divided into 5 equal groups, namely, control, superficial HAF (S-HAF), partial-thickness HAF (PT-HAF), full-thickness HAF (FT-HAF), and partial-thickness normal frostbite (PT-NF) groups. The S-HAF, PT-HAF, and FT-HAF groups were fed under hypobaric hypoxic conditions simulating an altitude of 5000 m. Then, the PT-NF, S-HAF, PT-HAF, and FT-HAF models were constructed by controlling the duration of the direct freezing by liquid nitrogen. Animal vital signs were measured after the operation, and histopathologic changes were observed after routine hematoxylin and eosin staining. In addition, the microcirculation of frostbite tissues was monitored and compared by contrast ultrasonography during wound healing.

RESULTS

The S-HAF, PT-HAF, and FT-HAF groups showed significant differences in the microcirculatory and histopathologic changes in the various tissue layers (P < .05). In addition, combined cold and hypoxia caused more damage to frostbite tissue than pure cold. The circulation recovery of HAF models was significantly slower relative to NF models (P < .05).

CONCLUSIONS

A safe and reproducible HAF model was proposed. More important, pathophysiologic determination of HAF provided the foundation and potential for developing novel and effective frostbite therapies.

Freezing and non-freezing cold weather injuries: a systematic review

INTRODUCTION

The debilitating impact of cold weather on the human body is one of the world's oldest recorded injuries. The severe and life-changing damage which can be caused is now more commonly seen recreationally in extreme outdoor sports rather than in occupational settings such as the military. The diagnosis and treatment of these injuries need to be completed carefully but quickly to reduce the risk of loss of limb and possibly life. Therefore, we have conducted a systematic review of the literature surrounding cold weather injuries (CWIs) to ascertain the epidemiology and current management strategies.

SOURCES OF DATA

Medline (PubMED), EMBASE, CINHAL, Cochrane Collaboration Database, Web of Science, Scopus and Google Scholar.

AREAS OF AGREEMENT IMMEDIATE FIELD TREATMENT

The risk of freeze thaw freeze injuries. Delayed surgical intervention when possible. Different epidemiology of freezing and non-freezing injuries.

AREAS OF CONTROVERSY

Prophylatic use of antibiotics; the use of vasodilators surgical and medical.

GROWING POINTS

The use of ilioprost and PFG2a for the treatment of deep frostbite.

AREAS TIMELY FOR DEVELOPING RESEARCH

The treatment of non-freezing CWIs with their long-term follow-up.

Counseling for the Wilderness Athlete and Adventurer During a Preparticipation Evaluation for Preparation, Safety, and Injury Prevention

Wilderness sports and adventures continue to increase in popularity. Counseling is an essential element of the preparticipation evaluation (PPE) for athletes in traditional sports. This approach can be applied to and augmented for the wilderness athlete and adventurer. The authors reviewed the literature on counseling during PPEs and gathered expert opinion from medical professionals who perform such PPEs for wilderness sports enthusiasts. The objective was to present findings of this review and make recommendations on the counseling component of a wilderness sports/adventure PPE. The counseling component of a PPE for wilderness sports/adventures should take place after a basic medical evaluation, and include a discussion on sport or activity-specific injury prevention, personal health, travel recommendations, and emergency event planning. Counseling should be individualized and thorough, and involve shared decision making. This should take place early enough to allow ample time for the athlete or adventurer to further prepare as needed based on the recommendations. Resources may be recommended for individuals desiring more information on selected topics.

Sunburn, Thermal, and Chemical Injuries to the Skin

Sunburn, thermal, and chemical injuries to the skin are common in the United States and worldwide. Initial management is determined by type and extent of injury with special care to early management of airway, breathing, and circulation. Fluid management has typically been guided by the Parkland formula, whereas some experts now question this. Each type of skin injury has its own pathophysiology and resultant complications. All primary care physicians should have at least a basic knowledge of management of acute and chronic skin injuries.

Counseling for the Wilderness Athlete and Adventurer During a Preparticipation Evaluation for Preparation, Safety, and Injury Prevention

Wilderness sports and adventures continue to increase in popularity. Counseling is an essential element of the preparticipation evaluation (PPE) for athletes in traditional sports. This approach can be applied to and augmented for the wilderness athlete and adventurer. The authors reviewed the literature on counseling during PPEs and gathered expert opinion from medical professionals who perform such PPEs for wilderness sports enthusiasts. The objective was to present findings of this review and make recommendations on the counseling component of a wilderness sports/adventure PPE. The counseling component of a PPE for wilderness sports/adventures should take place after a basic medical evaluation, and include a discussion on sport or activity-specific injury prevention, personal health, travel recommendations, and emergency event planning. Counseling should be individualized and thorough, and involve shared decision making. This should take place early enough to allow ample time for the athlete or adventurer to further prepare as needed based on the recommendations. Resources may be recommended for individuals desiring more information on selected topics.

Medical Evaluation for Exposure Extremes: Cold

Risk of injury in cold environments is related to a combination of athlete preparedness, preexisting medical conditions, and the body's physiologic response to environmental factors, including ambient temperature, windchill, and wetness. The goal of this section is to decrease the risk of hypothermia, frostbite, and nonfreezing cold injuries as well as to prevent worsening of preexisting conditions in cold environments using a preparticipation screening history, examination, and counseling. Cold weather exercise can be done safely with education, proper preparation, and appropriate response to changing weather conditions.

Special problems in burns

Burn units provide a unique set of resources to patients with complex wounds, sepsis, and organ failures. This resource set is useful in a number of traumatic, infectious, and medical conditions as well. Further, many burn patients have sustained simultaneous non-burn trauma which will be managed in burn programs.

Frostbite of the hand

Frostbite is damage caused by the freezing of tissue owing to exposure to extreme cold. Clinically, it is often difficult to identify the severity of frostbite injury. There may be a wide discrepancy between the extent of damage to the skin versus that to the deeper structures. The initial clinical impression is usually worse than actual tissue damage. In addition to physical examination, diagnostic imaging, especially triple-phase bone scan, has been proposed to help differentiate between superficial and deep damage. Principles of treatment involve rapid rewarming to thaw the tissues and halt direct cellular damage, methods to minimize progressive dermal ischemia, and active wound care to promote timely healing. Pharmacological adjuncts, such as fibrinolytics, have been proposed to minimize tissue damage. Surgical therapy is postponed until there is clear demarcation between healthy and necrotic tissue.

Frostbite: a practical approach to hospital management

Frostbite presentation to hospital is relatively infrequent, and the optimal management of the more severely injured patient requires a multidisciplinary integration of specialist care. Clinicians with an interest in wilderness medicine/freezing cold injury have the awareness of specific potential interventions but may lack the skill or experience to implement the knowledge. The on-call specialist clinician (vascular, general surgery, orthopaedic, plastic surgeon or interventional radiologist), who is likely to receive these patients, may have the skill and knowledge to administer potentially limb-saving intervention but may be unaware of the available treatment options for frostbite. Over the last 10 years, frostbite management has improved with clear guidelines and management protocols available for both the medically trained and winter sports enthusiasts. Many specialist surgeons are unaware that patients with severe frostbite injuries presenting within 24 h of the injury may be good candidates for treatment with either TPA or iloprost. In this review, we aim to give a brief overview of field frostbite care and a practical guide to the hospital management of frostbite with a stepwise approach to thrombolysis and prostacyclin administration for clinicians.

Wilderness medicine

BACKGROUND

Human activity in wilderness areas has increased globally in recent decades, leading to increased risk of injury and illness. Wilderness medicine has developed in response to both need and interest.

METHODS

The field of wilderness medicine encompasses many areas of interest. Some focus on special circumstances (such as avalanches) while others have a broader scope (such as trauma care). Several core areas of key interest within wilderness medicine are discussed in this study.

RESULTS

Wilderness medicine is characterized by remote and improvised care of patients with routine or exotic illnesses or trauma, limited resources and manpower, and delayed evacuation to definitive care. Wilderness medicine is developing rapidly and draws from the breadth of medical and surgical subspecialties as well as the technical fields of mountaineering, climbing, and diving. Research, epidemiology, and evidence-based guidelines are evolving. A hallmark of this field is injury prevention and risk mitigation. The range of topics encompasses high-altitude cerebral edema, decompression sickness, snake envenomation, lightning injury, extremity trauma, and gastroenteritis. Several professional societies, academic fellowships, and training organizations offer education and resources for laypeople and health care professionals.

CONCLUSIONS

THE FUTURE OF WILDERNESS MEDICINE IS UNFOLDING ON MULTIPLE FRONTS: education, research, training, technology, communications, and environment. Although wilderness medicine research is technically difficult to perform, it is essential to deepening our understanding of the contribution of specific techniques in achieving improvements in clinical outcomes.

Frostbite: prevention and initial management

Frostbite is a local freezing injury that can cause tissue loss. Historically, it has been a disease of wars, but it is a hazard for anyone who ventures outdoors in cold weather. Frozen tissue is damaged both during freezing and rewarming. Frozen tissue is numb. Rewarming causes hyperemia and is often painful. Blisters and edema develop after rewarming. Hard eschar may form with healthy tissue deep to the eschar. Frostbite can be classified as superficial, without permanent tissue loss, or deep, with varying degrees of permanent tissue loss, often less than appearances suggest. It can be difficult to predict the amount of tissue loss at the time of presentation and early in the subsequent course. Prevention is better than treatment. It may be advisable not to rewarm frozen extremities in the field, but spontaneous thawing is often unavoidable. Extremities that have thawed should be protected from refreezing at all costs. Once in a protected environment, extremities that are still frozen should be rapidly thawed in warm water. Therapy with aspirin or ibuprofen may be helpful, but evidence is limited. Thrombolytic treatment within the first 24 hours after rewarming seems to be beneficial in some cases of severe frostbite. Prostacyclin therapy is very promising.

Mountaineering medical events and trauma on Denali, 1992-2011

Denali (Mt. McKinley) is the tallest mountain in North America and a popular climbing destination for high altitude mountaineering expeditions. National Park Service (NPS) personnel care for and manage medical incidences and traumatic injuries for mountaineers each year. We retrospectively examined NPS medical reports from the climbing seasons of 1992-2011. Medical complaints, diagnoses, treatment, provider training, and overall numbers of injuries and illness were analyzed. Fatalities were included only if they were cared for by NPS medical personnel prior to death. Of the 24,079 climbers on Denali during this period, 831 (3.5%) required medical assistance from the NPS. There were 819 diagnoses; 502 were due to medical illness and 317 were traumatic injuries. Patient encounters occurred most frequently (71%) at the 4328 m camp. Frostbite was the most common individual diagnosis (18.1%), while altitude-related syndromes were the most common illness category (29%). Most patients (84%) were treated and released to descend without additional intervention, whereas 11% needed air evacuation, and 4% needed another type of NPS assistance to descend. The only fatality in this series was caused by traumatic brain injury due to a climbing fall. A broad variety of medical complaints were evaluated and treated by NPS personnel, most commonly altitude related problems and frostbite. The results of the study will enhance the awareness of potential illness and injuries encountered by medical providers participating in high altitude mountaineering expeditions. Additionally, providers responsible for evaluating mountaineers prior to their expeditions can educate them on the spectrum of physical and environmental conditions that increase the chances of illness or injury. This ideally will decrease the incidence of morbidity on both Denali and other high altitude mountaineering destinations.

Critical care for frostbite

Frostbite, a preventable cold-weather injury, occurs when the skin temperature cools to below 0°C with the formation of extracellular ice crystals. On rewarming, an inflammatory response develops, contributing to ischemia and tissue loss. The severity of injury depends on the temperature, duration of exposure, and amount and depth of frozen tissue. Environmental, individual, behavioral, and physiologic factors increase susceptibility to cold. Rapid rewarming and watchful waiting remains the mainstay of treatment. Prevention can be accomplished through increasing public awareness of the adverse effects of cold exposure, and recognizing and mitigating the risks associated with the development of frostbite.

Morbidity pattern of the 27th Indian Indian Scientific Expedition to Antarctica

OBJECTIVE

To evaluate morbidity prototype of 27th Indian Scientific Expedition to Antarctica (ISEA).

METHODS

Twenty-six team members of 27th ISEA wintered over at the Indian Antarctic Station, Maitri, from February 2008 to January 2009. The morbidity pattern was sourced from the medical records. Preexisting illnesses were also considered in this analysis.

RESULTS

The team consisted of men between 27 and 59 years of age (mean age, 43 years). Nine team members had preexisting illnesses. A total of 93 illness incidents were recorded during the stay in Antarctica. Most of these (27) were musculoskeletal injuries, bruises, and lacerations. Thirty-two (34%) incidents of illness were noted under the purview of medicine; 26 (28%), surgery; 15 (16%), orthopedics; 9 (10%), otorhinolaryngology; 8 (9%), ophthalmology; 2 (2%), dentistry; and 3 (3%), psychiatry. Oral ulcers were noted in 8 (8%) participants primarily during early wintering.

CONCLUSIONS

Injuries continue to be the most common cause of morbidity in Antarctica. Nutritional deficiencies and cold-related injuries are relatively less common.

Frostbite and other cold injuries in the heroic age of Antarctic exploration

Frostbite and other cold injuries on the early polar expeditions were common. This paper explains how frostbite was described, prevented, and treated on the Antarctic expeditions of the heroic age, comparing them with modern recommendations. Nonfreezing cold injury probably also occurred but was not differentiated from frostbite, and chilblains were also described.

Frostbites in circumpolar areas

Circumpolar areas are associated with prolonged cold exposure where wind, precipitation, and darkness further aggravate the environmental conditions and the associated risks. Despite the climate warming, cold climatic conditions will prevail in circumpolar areas and contribute to adverse health effects. Frostbite is a freezing injury where localized damage affects the skin and other tissues. It occurs during occupational or leisure-time activities and is common in the general population among men and women of various ages. Industries of the circumpolar areas where frostbite occurs frequently include transportation, mining, oil, and gas industry, construction, agriculture, and military operations. Cold injuries may also occur during leisure-time activities involving substantial cold exposure, such as mountaineering, skiing, and snowmobiling. Accidental situations (occupational, leisure time) often contribute to adverse cooling and cold injuries. Several environmental (temperature, wind, wetness, cold objects, and altitude) and individual (behavior, health, and physiology) predisposing factors are connected with frostbite injuries. Vulnerable populations include those having a chronic disease (cardiovascular, diabetes, and depression), children and the elderly, or homeless people. Frostbite results in sequelae causing different types of discomfort and functional limitations that may persist for years. A frostbite injury is preventable, and hence, unacceptable from a public health perspective. Appropriate cold risk management includes awareness of the adverse effects of cold, individual adjustment of cold exposure and clothing, or in occupational context different organizational and technical measures. In addition, vulnerable population groups need customized information and care for proper prevention of frostbites.