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.

Borrasca Filomena: pie de trinchera en España en tiempos de paz / Storm «Philomena»: trench foot in peacetime in Spain

El pie de trinchera es considerada la lesión militar más frecuente no relacionada con el combate y conocemos de su existencia desde tiempos de Napoleón. Sin embargo, esta vasoneuropatía sigue siendo una condición poco conocida y, por ende, un desafío diagnóstico. Con la presentación de dos casos clínicos atendidos en nuestro hospital durante la borrasca Filomena, ocurrida en España en enero del 2021, con Madrid como una de las zonas más afectadas, pretendemos aportar un poco más de conocimiento, en aras de mejorar la identificación de los casos y el correcto manejo terapeútico que, a buen seguro, mejorará el pronóstico de nuestros pacientes, sin olvidar las medidas preventivas. En nuestra experiencia ha sido determinante un riguroso estudio diagnóstico (vascular y electroneurofisiológico) y el tratamiento vasodilatador con bloqueo ciático poplíteo, inhibidores de la 5 fosfodiesterasa y calcioantagonistas dihidropiridínicos.(AU)

Trench foot is considered the most common non-combat related military injury and we have known of its existance since Napoleon’s time. However, this vasoneuropathy remains a poorly understood condition and, therefore, a diagnostic challenge. With the report of 2 clinical cases treated in our hospital during Filomena storm, which occurred in Spain in January 2021, with Madrid as one of the most affected areas, we intend to contribute a little more knowledge, in order to improve cases identification and the correct management that, surely will improve our patients prognosis, without forgetting preventive measures. In our experience, a rigorous diagnostic study (vascular and electroneurophysiological) and a vasodilatador treatment with sciatic popliteal block, 5-phosphodiesterase inhibitors and dihydropyridine calcium antagonists have been decisive.(AU)

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.

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.

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.

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.

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.

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.

Cold-associated skin disorders

The human capacity for physiologic adaptation to cold is minimal. A cold environment can be a threat to the skin, leading to a subsequent fall in core body temperature. Many physiologic, behavioral, and environmental factors predispose to the global effects of cold injuries. Physical injuries caused by cold have two forms: systemic forms such as hypothermia and localized forms such as frostbite. Reduced temperature directly damages the tissue, as in frostbite and cold immersion foot. Vasospasm of vessels perfusing the skin induces chilblain, acrocyanosis, and frostbite. The degree of damage caused by cold is related to four factors: temperature, exposure time, wind intensity (temperature sensation), and high altitude.

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.

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.

Pés de imersão em água morna entre trabalhadores de lavagem de automóveis / Warm-water immersion feet among car wash workers

Introdução: O quadro clínico de pés de imersão em água morna (PIAM) está relacionado ao contato prolongado com água em temperaturas elevadas. Uma categoria profissional com possibilidade de exposição frequente à umidade é a dos prestadores de serviço de lavagem de automóveis (lava a jato). Não foram encontrados estudos científicos sobre doenças que acometam os trabalhadores dessa área. Objetivo: Avaliar a frequência de quadros de PIAM entre trabalhadores de um lava a jato. Métodos: O estudo foi realizado em um lava a jato na cidade de Jundiaí (SP), em 2013. Um grupo de 30 trabalhadores foi submetido a anamnese e exame físico dermatológico. Foram realizados testes estatísticos para avaliar associação entre quadros de PIAM e variáveis independentes. Resultados: Todos os participantes eram do sexo masculino, com idade média de 23 anos, e a maioria (60%) trabalhava na empresa há mais de um ano. Sessenta por cento dos participantes apresentaram lesões compatíveis com PIAM. A faixa etária e o tempo de trabalho estiveram associados ao quadro. Havia exposição frequente e permanente à umidade durante o trabalho, sem uso de vestuário impermeável. Conclusão: A maioria dos trabalhadores que fizeram parte da pesquisa tinha diagnóstico de PIAM; os com idade superior a 30 anos e que trabalhavam há menos de 1 ano na função tiveram maior probabilidade de apresentar o quadro clínico por exposição ocupacional à umidade.

Introduction: The diagnosis of warm-water immersion foot (WWIF) is related to prolonged contact with water at high temperatures. Car wash workers are exposed to humidity, but there are not studies about diseases that affect workers in this area. Objective: To evaluate the frequency of WWIF among car wash workers and associated factors. Methods: The study was carried out in a car wash service in the city of Jundiaí, in the state of São Paulo, Brazil, in 2013. A group of 30 workers was submitted to an interview and skin medical examination. Statistical tests were performed to evaluate the association between WWIF and independent variables. Results: All participants were males, average 23 years old, and the majority (60%) have worked in the company for over a year. Sixty percent of the participants presented injuries similar to WWIF. Age and working time were associated with the outcome. There was frequent and permanent exposure to humidity in the working hours, without the use of impermeable clothes. Conclusion: Most of the participants had diagnosis of WWIF; those over 30 years old and who had been working less than 1 year were more likely to have the diagnosis due to occupational exposure to humidity.

Update: Cold weather injuries, active and reserve components, U.S. Armed Forces, July 2010-June 2015.

From July 2014 through June 2015, the number of active and reserve component service members treated for cold injuries (n=603) was much lower than the 719 cases diagnosed during the previous, unusually cold winter of 2013- 2014. Army personnel accounted for the majority (51%) of cold injuries. Frostbite was the most common type of cold injury in each of the services except the Marine Corps for which immersion foot was unusually common. Consistent with trends from previous cold seasons, service members who were female, younger than 20 years old, or of black, non-Hispanic race/ethnicity tended to have higher cold injury rates than their respective counterparts. Numbers of cases in the combat zone have decreased in the past 3 years, most likely the result of declining numbers of personnel exposed and the changing nature of operations. It is important that awareness, policies, and procedures continue to be emphasized to reduce the toll of cold injuries among U.S. service members.

The Infectious and Noninfectious Dermatological Consequences of Flooding: A Field Manual for the Responding Provider.

Meteorological data show that disastrous floods are increasingly frequent and more severe in recent years, perhaps due to climatic changes such as global warming. During and after a flood disaster, traumatic injuries, communicable diseases, chemical exposures, malnutrition, decreased access to care, and even mental health disorders dramatically increase, and many of these have dermatological manifestations. Numerous case reports document typical and atypical cutaneous infections, percutaneous trauma, immersion injuries, noninfectious contact exposures, exposure to wildlife, and exacerbation of underlying skin diseases after such disasters as the 2004 Asian tsunami, Hurricane Katrina in 2005, and the 2010 Pakistan floods. This review attempts to provide a basic field manual of sorts to providers who are engaged in care after a flooding event, with particular focus on the infectious consequences. Bacterial pathogens such as Staphylococcus and Streptococcus are still common causes of skin infections after floods, with atypical bacteria also greatly increased. Vibrio vulnificus is classically associated with exposure to saltwater or brackish water. It may present as necrotizing fasciitis with hemorrhagic bullae, and treatment consists of doxycycline or a quinolone, plus a third-generation cephalosporin and surgical debridement. Atypical mycobacterial infections typically produce indolent cutaneous infections, possibly showing sporotrichoid spread. A unique nontuberculous infection called spam has recently been identified in Satowan Pacific Islanders; combination antibiotic therapy is recommended. Aeromonas infection is typically associated with freshwater exposure and, like Vibrio infections, immunocompromised or cirrhotic patients are at highest risk for severe disease, such as necrotizing fasciitis and sepsis. Various antibiotics can be used to treat Aeromonas infections. Melioidosis is seen mainly in Southeast Asia and Australia, particularly in rice farmers, and can remain latent for many years before presenting as the host's immunocompetence wanes. It can present with a variety of skin findings or as a nonspecific febrile illness, and preferred treatment consists of ceftazidime or a carbapenem with trimethoprim/sulfamethoxazole (TMP/SMX) for 2 weeks, then continuing TMP/SMX for at least 3 months. Leptospirosis is a waterborne zoonosis that is often prevalent after heavy rains or flooding. Different forms exist, including Fort Bragg fever, which produces a distinctive erythematous papular rash on the shins. Doxycycline is often sufficient; however, volume and potassium repletion may be necessary if renal involvement exists. Chromobacterium violaceum infection may occur after open skin is exposed to stagnant or muddy water. Cultured colonies produce a unique violacein pigment, and treatment typically consists of a carbapenem. Both typical and atypical fungal infections are increased in the flooding disaster scenario, such as dermatophytosis, chromoblastomycosis, blastomycosis, and mucormycosis. Appropriate antifungals should be used. In addition, land inundated with water expands the habitat for parasites and/or vectors, thus increased vigilance for regional parasitic infections is necessary after a flood. Lastly, noninfectious consequences of a flooding disaster are also common and include miliaria, immersion foot syndromes, irritant and allergic contact dermatitis, traumatic wounds and animal bites, and arthropod assault, as well as exacerbation of existing skin conditions such as atopic dermatitis, psoriasis, and alopecia areata due to increased stress or nonavailability of daily medications.