Emergency War Surgery NATO Handbook: Part I: Types of Wounds and Injuries: Chapter IV: Cold Injury

Management

United States Department of Defense

A major deterrent to evaluation of therapy has been the inability to predict the outcome in any given cold injury early in the post-thaw period. Because of this, nuances of clinical management have been very difficult to evaluate. Since the extent of injury to the tissue is related to temperature and the duration of exposure, rapid rewarming is of primary importance. Other therapeutic programs, including anticoagulant therapy, administration of low molecular weight dextran or similar agents, or surgical or pharmacologic sympathectomy, while theoretically sound and supported in some instances by experimental data, have not had controlled clinical trials sufficient to encourage their general use.

In the light of most clinical experience, it should be emphasized that meddlesome manipulations, rubbing, application of unguents, or exposure to excessive temperatures should be guarded against carefully. As soon as cold injury is recognized, every effort should be made to avoid compounding the effects of cold with physical injury.

In military operations, the treatment of cold injuries is influenced by (1) the tactical situation, (2) the availability of evacuation to a fixed facility, and (3) the fact that most cold injuries are encountered in large numbers, during periods of intense combat, at the same time that many other wounded casualties are generated. Highly individualized treatment under these circumstances may be impossible. Examination and treatment of more life-endangering wounds must take precedence over this injury (lives versus limbs).

As a practical matter, any specific therapy designed to modify the physiologic changes in cold injuries must be instituted very early after thawing. Since, in many cases, the injury is not seen until some time after thawing, contemplation of therapy is purely academic and the major emphasis must be on protection from further injury, avoidance of premature surgery that might sacrifice otherwise viable tissue, early identification and control of infections, attention to maintenance of extremity function through early physiotherapy, and generalized nutritional support.

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Operational Medicine 2001

Health Care in Military Settings

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