Prevention and Treatment of Nonfreezing Cold Injuries and Warm Water Immersion Tissue Injuries: Supplement to Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite.

We convened an expert panel to develop evidence-based guidelines for the evaluation, treatment, and prevention of nonfreezing cold injuries (NFCIs; trench foot and immersion foot) and warm water immersion injuries (warm water immersion foot and tropical immersion foot) in prehospital and hospital settings. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according to the criteria published by the American College of Chest Physicians. Treatment is more difficult with NFCIs than with warm water immersion injuries. In contrast to warm water immersion injuries that usually resolve without sequelae, NFCIs may cause prolonged debilitating symptoms, including neuropathic pain and cold sensitivity.

[Analysis of 15 cases of trench foot in peacetime].

Trench foot was first seen in World War Ⅰ and was one of the reasons for non combat attrition. We reviewed and analyzed 15 cases of trench foot admitted from 2010 to 2021, summarized clinical treatment methods and experiences, analyzed the causes, population characteristics, treatment methods, and treatment experiences of trench foot during peacetime, strengthened attention to high-risk groups, and improved the success rate of clinical treatment.

Contact allergy mimicking trench foot infection: a case study.

Hard-to-heal wounds are a major cause of morbidity and/or mortality. Multiple aetiologies can be identified and wounds can be treated according to their aetiology and macroscopic appearance. However, evidence behind the wide range of locally applied treatments is weak, without clear guidelines available to treat a variety of wound aetiologies. We present the case of a 63-year-old male with hard-to-heal wounds not responding to standard topical treatment. No clear underlying aetiology could be found. Extensive contact allergies were diagnosed after multiple topical and systemic treatments had been applied. A full recovery was observed after stopping topical agents and treating the wounds with an alternative treatment based on epicutaneous test results.

A review of trench foot: a disease of the past in the present.

From the French Invasion of Russia in 1812, to Glastonbury festival in 2007, trench foot has been reported, yet the exact nature of the condition remains unclear. This review explores the pathogenesis and treatment of trench foot. Trench foot is considered to be a nonfreezing cold injury often complicated by infection, in which exposure to cold temperatures just above freezing, combined with moisture, results in a peripheral vasoneuropathy. The presence of physical trauma, bacterial or fungal infections, malnutrition, venous hypertension and lymphoedema mean that some individuals are at greater risk of trench foot. Trench foot may be prevented by warming the feet, changing socks, staying active, rubbing the skin with oil and regularly inspecting the feet. Avoiding risk factors may help prevent the condition. The management of trench foot is less clear. Vasodilators such as iloprost and nicotinyl tartrate or sympathectomy may help. Trench foot may lead to necrosis, cellulitis, sepsis and amputation. It remains a poorly understood condition.

Immersion Foot Syndrome in 6 Equids Exposed to Hurricane Floodwaters.

Prolonged exposure to water, known as immersion foot syndrome in humans, is a phenomenon first described in soldiers during World War I and characterized by dermal ischemic necrosis. In this report, we describe the pathologic findings of a condition resembling immersion foot syndrome in 5 horses and 1 donkey with prolonged floodwater exposure during Hurricane Harvey. At necropsy, all animals had dermal defects ventral to a sharply demarcated "water line" along the lateral trunk. In 5 animals, histologic examination revealed moderate to severe perivascular dermatitis with vasculitis and coagulative necrosis consistent with ischemia. The severity of the lesions progressed from ventral trunk to distal limbs and became more pronounced in the chronic cases. The pathophysiology of immersion foot syndrome is multifactorial and results from changes in the dermal microvasculature leading to thrombosis and ischemia. Prompt recognition of this disease may lead to appropriate patient management and decreased morbidity.

Tolio: Foot Rot in Grand Canyon River Runners.

Treating skin disorders in wilderness settings is often challenging. In this report we describe common skin conditions affecting the feet of river runners on the Colorado River in Grand Canyon National Park. These conditions are frequently referred to by river runners with a catchall term, "tolio." Several skin disorders have been identified as components of tolio, with the most prevalent currently being pitted keratolysis. We present a case of pitted keratolysis in a river guide occurring during a multiday river trip, where treatment can be difficult. Prevention is often more important.

Hypothermia and Cold Weather Injuries.

Hypothermia, frostbite, and nonfreezing cold injuries predominantly affect older adults, homeless or intoxicated people, adventurers, and military personnel. Prevention begins with clothing that is clean, layered, and loose to promote circulation. Base layers made of moisture-wicking materials are favored over wool or cotton. Wool or fleece garments are ideal for middle layers, whereas outer layers should repel moisture. Hypothermia occurs when core body temperature drops below 95°F and can be staged by clinical symptoms when core temperature measurement is unavailable. Initial treatment includes external and internal rewarming. Warmed normal saline is favored over lactated Ringer solution. Frostbite is a freezing injury that usually affects the extremities. After rapid rewarming, prognosis is best determined with technetium 99mTc pyrophosphate scintigraphy or magnetic resonance angiography. Initial treatment includes protecting tissue from further trauma, preventing refreezing, and avoiding dry heat sources. Ideally, patients should be transported to facilities where rapid rewarming, imaging, and thrombolytic treatment are available. Tissue plasminogen activator significantly decreases amputation rates for severe injuries if started within 24 hours of rewarming. Immersion foot occurs during damp nonfreezing conditions. Rapid rewarming should be avoided, and amitriptyline should be considered for pain control.

Preventing and treating trench foot: validation of an educational manual for military personnel.

OBJECTIVE:: To develop and validate an educational manual on the prevention and treatment of trench foot for military personnel. METHOD:: This is a prospective, descriptive, observational study. A manual was developed based on a literature review of books, theses and articles published in the last 10 years. The manual was evaluated by an expert committee of the Brazilian Army, and tested and validated by military students from an Army Sargent School in Brazil. Students evaluated the following parameters: definition of trench foot, risk of trench foot development among the military, risk factors, identification of trench foot, preventive measures, treatment of trench foot, and final considerations. RESULTS:: A total of 99 military students participated in the testing. Some parameters were exclusively evaluated by the experts, 12 physicians and 11 nurses, and rated as 'good or very good' as follows: thematic content (100%), graphic display (100%), topic sequence (100%), clarity of language and comprehension of information (91.3%) and illustrations (95.6%). Other parameters were rated as 'good or very good' by both the experts and military students, as follows: definition of trench foot (100% and 85.8%), risk of trench foot among the military (95.6% and 86.8%), risk factors (100% and 82.8%), identification of trench foot (100% and 86.8%), preventive measures (100% and 81.8%), treatment (95.6% and 84.8%) and final considerations (95.6% and 81.82 %), respectively. Cronbach's alpha was 0.891 for consistency and 0.854 for reliability. CONCLUSION:: The educational manual was validated by health professionals, tested by military students, and showed to be a consistent, reliable and valid educational instrument for the prevention and treatment of trench foot.

Immersion Foot: A Case Report.

BACKGROUND: Immersion foot (commonly called "trench foot") was originally described in the military literature during World War I. Since that time, the emergency department (ED) has become a common setting where this injury presents. However, this topic is neglected in the emergency medicine literature. The purpose of this case report is to present trench foot in a way that is relevant to emergency physicians and to provide an up-to-date summary of the history, case reports, physiology, clinical presentation, and treatment of this injury. CASE REPORT: Here we present the case of a homeless, schizophrenic patient who presented to one Midwestern ED in January for immersion foot. Photos of the actual patient are shown to illustrate the case. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Due to unfamiliarity, immersion foot can go undiagnosed during assessment of patients exposed to moist environments. In addition, patients at increased risk for developing immersion foot are frequently encountered in EDs. Most importantly, the appropriate treatment for immersion foot is different than the treatment for other freezing cold injuries.

Cold weather issues in sideline and event management.

Exercise in cold environments exerts a unique physiologic stress on the human body, which, under certain conditions, may result in a cold-related injury. Environmental factors are the most important risk factors for the development of hypothermia in athletes. Frostbite occurs as a result of direct cold injury to peripheral tissues. The biggest risk for frostbite is temperature. Trench foot is a result of repeated and constant immersion in cold water. Chilblains are local erythematous or cyanotic skin lesions that develop at ambient air temperatures of 32°F to 60°F after an exposure time of about 1 to 5 h. Cold urticaria is, essentially, an allergic reaction to a cold exposure and can be controlled with avoidance of the cold. There are a number of risk factors and conditions that predispose athletes to cold injury, but exercise in the cold can be done safely with proper education and planning.

Nonfreezing Cold Injury (Trench Foot).

Nonfreezing cold injury (NFCI) is a modern term for trench foot or immersion foot. Moisture is required to produce a NFCI. NFCI seldom, if ever, results in loss of tissue unless there is also pressure necrosis or infection. Much of the published material regarding management of NFCIs has been erroneously borrowed from the literature on warm water immersion injuries. NFCI is a clinical diagnosis. Most patients with NFCI have a history of losing feeling for at least 30 min and having pain or abnormal sensation on rewarming. Limbs with NFCI usually pass through four 'stages.' cold exposure, post-exposure (prehyperaemic), hyperaemic, and posthyperaemic. Limbs with NFCI should be cooled gradually and kept cool. Amitriptyline is likely the most effective medication for pain relief. If prolonged exposure to wet, cold conditions cannot be avoided, the most effective measures to prevent NFCI are to stay active, wear adequate clothing, stay well-nourished, and change into dry socks at least daily.

Cutaneous Cold Weather Injuries in the US Military.

Service members of the US Military are at risk for cutaneous cold weather injuries due to the demands of military training, combat operations, and peacekeeping missions. In this article, we review common cutaneous cold weather injuries likely to be encountered in the military, including frostbite, immersion foot, pernio, Raynaud phenomenon (RP), and cold urticaria. We aim to bring awareness to these specific injuries to improve diagnostic and treatment outcomes, both in service members and civilians.

Frostbite and Immersion Foot Care.

Historically, cold injury, hypothermia, and frostbite have been severe problems for military units on the battlefield. Kenneth D. Orr and David C. Fainer captured these difficulties in their book, Cold Injuries in Korea During Winter of 1950-51, still cited in military medical readiness training. While not common in modern conflicts, the potential exists for large numbers of these casualties in war and during training.

Military cold injury during the war in the Falkland Islands 1982: an evaluation of possible risk factors.

Throughout the history of war, there have been many instances when the cold has ravaged armies more effectively than their enemies. Delineated risk factors are restricted to negro origins, previous cold injury, moderate but not heavy smoking and the possession of blood group O. No attention has been directed to the possibility that abnormal blood constituents could feasibly predispose to the development of local cold injury. This study considers this possibility and investigates the potential contribution of certain components of the circulating blood which might do so. Three groups of soldiers from two of the battalions who served during the war in the Falklands Islands in 1982 were investigated. The risk factors which were sought included the presence or absence of asymptomatic cryoglobulinaemia, abnormal total protein, albumin, individual gamma globulin or complement C3 or C4 levels, plasma hyperviscosity or evidence of chronic alcoholism manifesting as high haemoglobin, PCV, RBC, MCV or gamma glutamyl transpeptidase (GGT). No cases of cryoglobulinaemia were isolated and there was no haematological evidence to suggest that any of those men who had developed cold injury, one year before this study was performed, had abnormal circulating proteins, plasma hyperviscosity or indicators of alcohol abuse. Individual blood groups were not incriminated as a predisposing factor although the small numbers of negroes in this series fared badly. Although this investigation has excluded a range of potential risk factors which could contribute to the development of cold injury, the problem persists. Two areas of further study are needed: the first involves research into the production of better protective clothing in the form of effective cold weather boots and gloves and the second requires the delineation of those dietary and ethnic factors which allow certain communities to adapt successfully to the cold. A review of the literature in this latter area is presented.

[Diagnostic image (272). A boy with discoloured, painful hands]. / Diagnose in beeld (272). Een jongen met verkleurde, pijnlijke handen.

A 6-year-old boy was admittted because of dark discoloured and painful finger tips of both hands, which had developed 2 weeks after playing with bare hands in a ditch with cold water still containing parts of ice. Trench foot of the hands was diagnosed.

Immersion foot. A problem of the homeless in the 1990s.

The syndrome of immersion foot is being seen with increasing frequency among the homeless population. It represents the effects of injury by water absorption in the stratum corneum of the skin of the feet. The taxonomy of this disorder is confusing and the many colorful pseudonyms should probably be dropped in favor of a simple classification based on the temperature of the water and the duration of exposure. When uncomplicated by infection or ischemic injury, immersion foot will quickly resolve with conservative measures only. More complicated cases may require antibiotics and surgical treatment. This syndrome may be exacerbated by disturbances of cognition, peripheral neuropathy, peripheral vascular disease, or the use of tobacco or vasoconstrictor drugs such as cocaine. A major contributing factor seems to be lack of shelter in the homeless population. Attention to foot care problems among the homeless and education concerning preventive measures are incumbent on physicians who care for the indigent.