ELDER TIP The following risk factors put elderly people at increased risk for cold injuries: cardiovascular disease, alcohol abuse, malnutrition, diabetes, skin diseases, scarring from major burns, inadequate fluid intake, working outdoors, wearing inappropriate clothing, and living in poor environmental conditions. The use of anticholinergics, phenothiazines, diuretics, antihistamines, antidepressants, or beta-adrenergic blockers also increases the risk.
Signs and symptoms
Frostbite may be deep or superficial. Superficial frostbite affects skin and subcutaneous tissue, especially of the face, ears, extremities, and other exposed areas. Although it may go unnoticed at first, frostbite produces burning, tingling, numbness, swelling, and a mottled, blue-gray skin color when the person returns to a warm place.
Deep frostbite extends beyond subcutaneous tissue and usually affects the hands or feet. The skin becomes white until it’s thawed; then it turns purplish blue. Deep frostbite also produces pain, skin blisters, tissue necrosis, and gangrene. (See Recognizing frostbite.)
Indications of hypothermia (a core body temperature below 957 F [357 C]) vary with severity:
❑ mild hypothermia — temperature of 89.67 to 957 F (327 to 357 C), severe shivering, slurred speech, and amnesia
❑ moderate hypothermia — temperature of 867 to 89.67 F (307 to 327 C), unresponsiveness or confusion, muscle rigidity, peripheral cyanosis and, with improper rewarming, signs of shock
❑ severe hypothermia — temperature of 777 to 867 F (257 to 307 C), loss of deep tendon reflexes, and ventricular fibrillation. The patient may appear dead (in a state of rigor mortis), with no palpable pulse or audible heart sounds. His pupils may be dilated. A temperature drop below 777 F causes cardiopulmonary arrest and death.
Diagnosis
A history of severe and prolonged exposure to cold may make this diagnosis obvious. Nevertheless, hypothermia can be overlooked if outdoor temperatures are above freezing or if the patient is comatose.
Treatment
In a localized cold injury, treatment consists of rewarming the injured part, supportive measures and, sometimes, a fasciotomy to increase circulation by lowering edematous tissue pressure. However, if gangrene occurs, amputation may be necessary. In hypothermia, therapy consists of immediate resuscitative measures, careful monitoring, and gradual rewarming of the body. If cold injuries in children suggest neglect or abuse, a thorough history should be performed.
Treat localized cold injuries as follows:
❑ Remove constrictive clothing and jewelry and slowly rewarm the affected part in tepid water (1007 to 1087 F [37.87 to 42.27 C]). Give the patient warm fluids to drink. Never rub the injured area — this aggravates tissue damage.
❑ When the affected part begins to rewarm, the patient will feel pain, so give analgesics as ordered. Check for a pulse. Be careful not to rupture any blebs. If the injury is on the foot, place cotton or gauze sponges between the toes to prevent maceration. Instruct the patient not to walk.
❑ If the injury has caused an open skin wound, give antibiotics and tetanus prophylaxis as ordered.
❑ If a pulse fails to return, the patient may develop compartment syndrome and need a fasciotomy to restore circulation. (See Recognizing compartment syndrome, page 304.) If gangrene occurs, prepare the patient for amputation.
❑ Before discharge, teach the patient about possible long-term effects: increased sensitivity to cold, burning and tingling, and increased sweating. Warn him against smoking, which causes vasoconstriction and slows healing.
Systemic hypothermia is treated as follows:
❑ If you detect no pulse or respiration, begin cardiopulmonary resuscitation (CPR) immediately and, if necessary, continue it for 2 to 3 hours. (Remember that hypothermia helps protect the brain from anoxia, which normally accompanies prolonged cardiopulmonary arrest. Therefore, even after the patient has been unresponsive for a long time, resuscitation may be possible, especially after cold-water near drownings.) Perform CPR until the patient is adequately rewarmed.
❑ Move the patient to a warm area, remove wet clothing, and keep him dry. If he’s conscious, give warm fluids with a high sugar content such as tea with sugar. If the patient’s core temperature is above 89.67 F (327 C), use external warming techniques. Bathe him in water that is 1047 F (407 C), cover him with a heating blanket set at 97.97 to 99.97 F (36.67 to 37.77 C), and cautiously apply hot water bottles at 1047 F to the groin and axillae, guarding against burns.
❑ If the patient’s core temperature is below 89.67 F (327 C), use internal and external warming methods. Rewarm his body core and surface 17 to 27 F (–0.57 to –1.17 C) per hour concurrently. (If you rewarm the surface first, rewarming shock could cause potentially fatal ventricular fibrillation.) To warm inhalations, provide oxygen heated to 107.67 to 114.87 F (427 to 467 C). Infuse I.V. solutions that have been warmed to 98.67 F (377 C) and perform nasogastric lavage with normal saline solution that has been warmed to the same temperature. Assist with peritoneal lavage, using normal saline solution (full or half-strength) warmed to 1047 to 1137 F (407 to 457 C); in severe hypothermia, assist with heart and lung bypass at controlled temperatures and thoracotomy with direct cardiac warm saline bath.
Special considerations
❑ Throughout treatment, monitor arterial blood gas levels, intake and output, central venous pressure, temperature, and cardiac and neurologic status every 30 minutes. Also monitor laboratory test results, such as complete blood count, blood urea nitrogen and electrolyte levels, prothrombin time, and partial thromboplastin time.
❑ If the patient has developed a cold injury because of inadequate clothes or housing, refer him to a community social service agency, if appropriate.
Cold injuries can be prevented:
❑ Tell the patient to wear mittens (not gloves); windproof, water-resistant, multi-layered clothing; two pairs of socks (cotton next to skin, then wool); and a scarf and hat that cover the ears (to avoid substantial heat loss through the head).
❑ Advise the patient not to drink alcohol or smoke and to get adequate food and rest before prolonged exposure.
❑ Caution the patient to find shelter early or to increase physical activity if he’s caught in a severe snowstorm.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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