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

Later Management

United States Department of Defense
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When the casualty reaches a definitive care facility, the following treatment should be employed

1. Continued diligence to avoid injury of already compromised tissue should be maintained. In general, for lower extremity injuries, this is accomplished by keeping the patient at bed rest, with the part elevated on surgically clean sheets under a foot cradle and with sterile pledgets of cotton separating the toes. Bearing weight on injured feet should not be allowed until mature epithelial tissue has developed over the affected areas. In upper extremity injuries, elevation is also desirable on sterile towels, with special care to avoid injury to bullae.
2. In an effort to reduce superficial bacterial contamination, the affected part is treated by whirlpool bath at 98.6°F (37°C), with povidone iodine or hexachlorophine added, on a twice-daily basis, encouraging active motion on the part of the patient during the whirlpool treatment. Whirlpool baths assist in superficial debridement and make active range of motion exercises more tolerable to the patient and less traumatic to the tissues.
3. Analgesics may be required in the early post-thaw days, but a continued requirement for analgesics in uncomplicated injuries is uncommon.
4. The patient should be encouraged to take a nutritious diet with adequate fluids to maintain hydration.
5. Patients should be placed on surgically clean sheets and all lesions should be exposed to the air at the normal room temperature.
6. Superficial debridement of ruptured blebs should be performed, and suppurative eschars and partially detached nails should be removed. Close attention should be paid to circumferential eschars or eschars where vascular compromise could be a problem. Such eschars at least should be bivalved, although complete debridement is occasionally necessary. Early amputation has no place in the management of cold injury. Surgical intervention should be deferred until a distinct line of demarcation has developed. There is usually healthy granulation tissue under an eschar at the line of demarcation. Delay of surgical procedures, especially in upper extremity injuries, will enhance the potential for a functional result. Rarely, generalized sepsis from large areas of necrotic and infected tissue will necessitate amputation. Skin grafting, while not a function of forward facilities, is occasionally indicated to protect denuded areas over vital structures.
7. Active physiotherapy should be instituted during daily whirlpool as soon as possible.
8. Newly epithelialized areas are susceptible to minor trauma, as in walking, and are especially sensitive to cold. Therefore, continued protection must be offered until normal keratinization has occurred. Subsequently, special skin care may be required to deal with residual hyperhydrotic states.

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