Drill of the Month Developed by Gloria Bizjak Recognizing and Managing Cold Emergencies: Frostbite and Hypothermia Frostbite and Hypothermia

Drill of the MonthDrill of the MonthDeveloped by Gloria BizjakDeveloped by Gloria Bizjak

Recognizing and Managing Recognizing and Managing Cold Emergencies:Cold Emergencies:

Frostbite and HypothermiaFrostbite and Hypothermia

Drill of the MonthDrill of the Month 22

Recognizing and Managing Recognizing and Managing Cold Emergencies: Frostbite Cold Emergencies: Frostbite

and Hypothermiaand Hypothermia

Student Performance Objective:Student Performance Objective:Given information, resources, and Given information, resources, and opportunity for discussion and practice, EMTs opportunity for discussion and practice, EMTs will be able to:will be able to:• Describe types of frostbite and hypothermiaDescribe types of frostbite and hypothermia• Describe signs and symptomsDescribe signs and symptoms• Demonstrate patient assessment and careDemonstrate patient assessment and careEMTs will follow acceptable Maryland medical EMTs will follow acceptable Maryland medical practice and Maryland Medical Protocols for practice and Maryland Medical Protocols for Emergency Medical Providers.Emergency Medical Providers.


Altered Mental Status: Altered Mental Status: Assessing and Managing Assessing and Managing

Seizure PatientsSeizure PatientsOverviewOverview Frostbite description and classificationsFrostbite description and classifications Frostbite signs and symptomsFrostbite signs and symptoms Frostbite assessment and emergency careFrostbite assessment and emergency care Hypothermia description and classificationsHypothermia description and classifications Hypothermia signs and symptomsHypothermia signs and symptoms Hypothermia assessment and emergency Hypothermia assessment and emergency

carecare Practice assessment and carePractice assessment and care


FrostbiteFrostbite DescriptionDescription

– Freezing of a distal or small body part Freezing of a distal or small body part from prolonged cold exposurefrom prolonged cold exposure Cold airCold air Contact with a cold objectContact with a cold object Wind and/or water chillWind and/or water chill


FrostbiteFrostbite

DescriptionDescription– Local cooling injuries to extremitiesLocal cooling injuries to extremities

Feet and toesFeet and toes Hands and fingersHands and fingers Face: nose and cheeksFace: nose and cheeks EarsEars



– Known by several namesKnown by several names FrostnipFrostnip Immersion foot (trench foot): Injury to skin, Immersion foot (trench foot): Injury to skin,

blood vessels, and nerves of the feet from blood vessels, and nerves of the feet from continuous immersion in water, even in continuous immersion in water, even in above freezing conditionsabove freezing conditions

Chilblains (pernio): Inflammation of the Chilblains (pernio): Inflammation of the hands and feet from repeated exposure to hands and feet from repeated exposure to cold and moisturecold and moisture



– A result of prolonged cold exposure, A result of prolonged cold exposure, outdoors as well as indoors, outdoors as well as indoors, constricting blood vessels in the constricting blood vessels in the extremities, which diverts warm blood extremities, which diverts warm blood flow and oxygen to central vital organsflow and oxygen to central vital organs Constriction cycles with dilation to Constriction cycles with dilation to

preserve functions of extremitiespreserve functions of extremities



– As the body temperature continues to As the body temperature continues to drop, the brain permanently constricts drop, the brain permanently constricts vessels in extremities to maintain vessels in extremities to maintain warmth in vital organs: frostbite beginswarmth in vital organs: frostbite begins

– Cell death due to exposure Cell death due to exposure Ice crystals form in the space outside cellsIce crystals form in the space outside cells Cells become dehydratedCells become dehydrated



– Cell deterioration from of lack of Cell deterioration from of lack of oxygen and wateroxygen and water Lining of blood vessels is damagedLining of blood vessels is damaged Blood leaks from vessels on rewarmingBlood leaks from vessels on rewarming Small clots form causing blood flow Small clots form causing blood flow

problems and inflammationproblems and inflammation Inflammation causes further tissue damageInflammation causes further tissue damage


FrostbiteFrostbite ClassificationsClassifications

– Superficial (early stage)Superficial (early stage) Blood flow is restricted to body partsBlood flow is restricted to body parts Body parts freezeBody parts freeze Ice crystals form inside tissuesIce crystals form inside tissues

– Deep (late stage)Deep (late stage) Gangrene sets in due to cell dehydration and Gangrene sets in due to cell dehydration and

oxygen lossoxygen loss The part may have to be amputated, even The part may have to be amputated, even

after months of trying to healafter months of trying to heal


Frostbite Signs and Frostbite Signs and SymptomsSymptoms

Superficial (early stage)Superficial (early stage)– Patient may complain of burning, Patient may complain of burning,

numbness, tingling, itching, or cold in numbness, tingling, itching, or cold in affected areasaffected areas

– Affected part first appears red, then turns Affected part first appears red, then turns mottled, bluish, white, or grey as the flesh mottled, bluish, white, or grey as the flesh continues to freezecontinues to freeze

– Dark skin: the skin color lightens, then Dark skin: the skin color lightens, then blanches and will quickly turn bluish or greyblanches and will quickly turn bluish or grey

– Skin feels frozen/stiff/rigid; has some Skin feels frozen/stiff/rigid; has some pliability when pressedpliability when pressed



Deep (late stage)Deep (late stage)– Patient may complain of decreased Patient may complain of decreased

sensation, then lose all sensation or sensation, then lose all sensation or feelingfeeling

– Affected part swells, develops blood-filled Affected part swells, develops blood-filled blisters over white/yellowish waxy-looking blisters over white/yellowish waxy-looking skinskin

– Skin feels hard with no pliability when Skin feels hard with no pliability when pressedpressed

– Affected part may appear blackAffected part may appear black



Deep (late stage)Deep (late stage)– On rewarmingOn rewarming

Affected part turns purplish-blueAffected part turns purplish-blue Painful aching as blood flow returns to Painful aching as blood flow returns to

tissuestissues Throbbing begins in 2 – 3 days; may last Throbbing begins in 2 – 3 days; may last

monthsmonths Part may never heal and may require Part may never heal and may require

amputationamputation


Frostbite Assessment and Frostbite Assessment and CareCare

Assessment: Perform General Patient Assessment: Perform General Patient Care (Maryland Protocols)Care (Maryland Protocols)– Size up the scene; gather info on approachSize up the scene; gather info on approach– Perform initial assessmentPerform initial assessment

SuperficialSuperficial– Look for color changes: light skin reddens; dark skin Look for color changes: light skin reddens; dark skin

lightens; both blanch followed by color changeslightens; both blanch followed by color changes– Feel area for pliabilityFeel area for pliability– Ask patient how it feels: patient may report Ask patient how it feels: patient may report

numbness, tingling, burning, etc.numbness, tingling, burning, etc.



Assessment: Perform General Patient Assessment: Perform General Patient Care (Maryland Protocols)Care (Maryland Protocols)– Size up the scene; gather info on approachSize up the scene; gather info on approach– Perform initial assessmentPerform initial assessment

DeepDeep– Check skin appearance: white, waxy skin turns Check skin appearance: white, waxy skin turns

mottled or blotchy, then to grayish yellow to grayish mottled or blotchy, then to grayish yellow to grayish blueblue

– Look for swelling and blisteringLook for swelling and blistering– Gently palpate: Does surface feel frozen w/no Gently palpate: Does surface feel frozen w/no

pliability in underlying tissue? Do not squeeze pliability in underlying tissue? Do not squeeze affected partaffected part

– Ask patient how it feelsAsk patient how it feels



Assessment: Perform General Patient Assessment: Perform General Patient Care (Maryland Protocols)Care (Maryland Protocols)– Perform focused history and physical Perform focused history and physical

examexam– Follow treatment protocolsFollow treatment protocols– Communicate with hospital or other Communicate with hospital or other

response personnelresponse personnel– Disposition: determine priority and Disposition: determine priority and

mode of transportmode of transport



Emergency care (adults or peds)Emergency care (adults or peds)– Remove patient from cold environmentRemove patient from cold environment

Outside: Place patient in heated ambulance, Outside: Place patient in heated ambulance, wrap in blanketswrap in blankets

Inside: Turn up heat while working in Inside: Turn up heat while working in patient’s home, wrap in blankets, move to patient’s home, wrap in blankets, move to heated ambulanceheated ambulance



Emergency care (adults or peds)Emergency care (adults or peds)– Gently handle frostbitten areasGently handle frostbitten areas

Do not rub affected areasDo not rub affected areas Ice crystals in tissues cause further damageIce crystals in tissues cause further damage

– Wrap affected area gently, loosely with Wrap affected area gently, loosely with gauzegauze Patient may complain of tingling/burning: Patient may complain of tingling/burning:

these are normal sensationsthese are normal sensations



Emergency care (adults or peds)Emergency care (adults or peds)– If patient does not respond to simple If patient does not respond to simple

treatment, begin care for deep frostbitetreatment, begin care for deep frostbite Provide high-concentration oxygenProvide high-concentration oxygen Provide rapid transportProvide rapid transport If transport is delayed, re-warm affected part If transport is delayed, re-warm affected part

only only on medical directionon medical direction Do not allow patient to smoke or consume Do not allow patient to smoke or consume

caffeine or alcohol (vasoconstrictors, raise caffeine or alcohol (vasoconstrictors, raise blood pressure)blood pressure)

Do not allow patient to use affected part or Do not allow patient to use affected part or walk on affected feetwalk on affected feet



Emergency care (adults or peds)Emergency care (adults or peds)– Maintain a warm environment: do not Maintain a warm environment: do not

re-expose patient to a cold environmentre-expose patient to a cold environment– Reassess: recheck vital signs, recheck Reassess: recheck vital signs, recheck

injury treatments and medical statusinjury treatments and medical status– Transport/transfer/transition patient and Transport/transfer/transition patient and

informationinformation


HypothermiaHypothermia DescriptionDescription

– Generalized body cooling as a result of Generalized body cooling as a result of prolonged cold exposureprolonged cold exposure Reduces body heatReduces body heat Prevents body from maintaining proper core Prevents body from maintaining proper core

body temperaturebody temperature Can be life-threatening Can be life-threatening



– Loss of body heat through several Loss of body heat through several methodsmethods Radiation: heat lost to environment from Radiation: heat lost to environment from

what body gives off (radiates)what body gives off (radiates) Conduction: heat lost by contact with or Conduction: heat lost by contact with or

immersion in cold water or snowimmersion in cold water or snow Convection: heat lost by cold water flow or Convection: heat lost by cold water flow or

air currentsair currents Evaporation: heat lost through perspiration Evaporation: heat lost through perspiration

or wet skinor wet skin Respiration: heat lost through expired Respiration: heat lost through expired

breaths—warm air to cooler environmentbreaths—warm air to cooler environment



– Abnormally low core body temperatureAbnormally low core body temperature 95°F or below95°F or below Life-threatening at 90°F and belowLife-threatening at 90°F and below

– Core body measurementsCore body measurements Oral measurement: 96.8 to 98.6 °F (affected Oral measurement: 96.8 to 98.6 °F (affected

by liquid and food intake and breathing)by liquid and food intake and breathing) Rectal temperature: 0.9 °F higher than oralRectal temperature: 0.9 °F higher than oral Axillary temperature: 0.9 °F lower than oralAxillary temperature: 0.9 °F lower than oral Tympanic temperature: very close to oral Tympanic temperature: very close to oral

measurementmeasurement


HypothermiaHypothermia Classifications: Mild to moderate — Classifications: Mild to moderate —

95°F to 90°F core body temperater: 95°F to 90°F core body temperater: Caused by a cold environment Caused by a cold environment

– Affects healthy individuals with Affects healthy individuals with prolonged exposureprolonged exposure

– Can quickly affect at-risk individualsCan quickly affect at-risk individuals Patients with major trauma and shock, Patients with major trauma and shock,

chronic illness, circulatory disorders, chronic illness, circulatory disorders, infection, burns, and diabetes infection, burns, and diabetes


HypothermiaHypothermia Classifications: Mild to moderate — Classifications: Mild to moderate —

95°F to 90°F core body 95°F to 90°F core body temperature: Caused by a cold temperature: Caused by a cold environmentenvironment

– Can quickly affect at-risk individualsCan quickly affect at-risk individuals Elderly persons in an environment with Elderly persons in an environment with

cool ambient temperature (low thermostat cool ambient temperature (low thermostat in winter), diet, illnesses, medications, in winter), diet, illnesses, medications, sedentary livingsedentary living


HypothermiaHypothermia Classifications: Mild to moderate—Classifications: Mild to moderate—

95°F to 90°F core body 95°F to 90°F core body temperature: Caused by a cold temperature: Caused by a cold environmentenvironment

– Can quickly affect at-risk individualsCan quickly affect at-risk individuals Infants and children with their large skin Infants and children with their large skin

surface to body mass ratio, little fat, and surface to body mass ratio, little fat, and small muscle mass (resulting in no small muscle mass (resulting in no shivering, a typical early warning sign)shivering, a typical early warning sign)


HypothermiaHypothermia Classifications: Severe, or extremeClassifications: Severe, or extreme

– Body temperature below 90°F Body temperature below 90°F – Presents an unconscious cold patient Presents an unconscious cold patient

in a cold environment with no apparent in a cold environment with no apparent vital signs (heart rate <10 beats per vital signs (heart rate <10 beats per minute) minute) Patients will not reach biological death for Patients will not reach biological death for

at least 30 minutes: resuscitate at least 30 minutes: resuscitate Do not assume death based on body Do not assume death based on body

temperature and no vital signs temperature and no vital signs


Hypothermia Signs and Hypothermia Signs and SymptomsSymptoms

GeneralGeneral– Vary with patient factors, length of Vary with patient factors, length of

exposure exposure Shivering, becomes intense; ceases in Shivering, becomes intense; ceases in

severe hypothermiasevere hypothermia Dizziness and confusionDizziness and confusion Numbness, stiffness, rigidity in posture, Numbness, stiffness, rigidity in posture,

weaknessweakness Impaired judgment, speech, and vision, Impaired judgment, speech, and vision,

glassy stareglassy stare



GeneralGeneral– Vary with patient factors, length of Vary with patient factors, length of

exposure exposure Drowsiness, decrease in consciousness to Drowsiness, decrease in consciousness to

unconsciousnessunconsciousness Cool abdominal skin temperature to your Cool abdominal skin temperature to your

touch (back of your hand)touch (back of your hand) Reddened skin turning to pale and cyanotic Reddened skin turning to pale and cyanotic

with prolonged exposure (dark skin initially with prolonged exposure (dark skin initially white turning cyanotic)white turning cyanotic)



SpecificSpecific– Mild to moderate (core body temperature Mild to moderate (core body temperature

90 to 95°F 90 to 95°F Shivering, which becomes intense (generates Shivering, which becomes intense (generates

body heat until muscles are fatigued)body heat until muscles are fatigued) Pulse and breathing rates and blood pressure Pulse and breathing rates and blood pressure

initially increase initially increase Vital signs drop as body temperature dropsVital signs drop as body temperature drops Apathy: patient becomes clumsy, apathetic, Apathy: patient becomes clumsy, apathetic,

confused, and has slurred speech (as if confused, and has slurred speech (as if drunk)drunk)



SpecificSpecific– Severe (core body temperature less Severe (core body temperature less

than 95°F) than 95°F) Loss of consciousnessLoss of consciousness

– Shivering stopsShivering stops– Oxygen intake dropsOxygen intake drops– Heart rhythm becomes irregularHeart rhythm becomes irregular– Patient loses consciousnessPatient loses consciousness



SpecificSpecific– Severe (core body temperature less Severe (core body temperature less

than 95°F than 95°F Continued decrease of pulse and breathing Continued decrease of pulse and breathing

ratesrates Appearance of death, close to deathAppearance of death, close to death

– No reflexesNo reflexes– Brain activity slowsBrain activity slows– Pupils dilatePupils dilate– Risk of lethal irregular heart rhythm increasesRisk of lethal irregular heart rhythm increases– Patient appears dead at 82°F Patient appears dead at 82°F


HypothermiaHypothermiaAssessment and Emergency Assessment and Emergency

CareCare Assessment: Perform General Patient Assessment: Perform General Patient Care (Maryland Protocols)Care (Maryland Protocols)– Size up the scene and gather info on Size up the scene and gather info on

approachapproach– Perform initial assessmentPerform initial assessment

Assess mental status: check patient’s Assess mental status: check patient’s orientation to person, place, timeorientation to person, place, time

Check airway, breathing, circulationCheck airway, breathing, circulation



CareCare Assessment: Consider the followingAssessment: Consider the following

Air temperature, wind chill or water chillAir temperature, wind chill or water chill Patient’s agePatient’s age Clothing worn by patientClothing worn by patient Patient’s general health, illnesses and Patient’s general health, illnesses and

medications, or injuriesmedications, or injuries Activity at time of incidentActivity at time of incident Use of alcohol or drugsUse of alcohol or drugs Mental status and motor function, which Mental status and motor function, which

decreases with degree of hypothermiadecreases with degree of hypothermia



CareCare AssessmentAssessment

– Perform focused history and physical Perform focused history and physical examexam

– Follow treatment protocolsFollow treatment protocols– Communicate with hospital or other Communicate with hospital or other

response personnelresponse personnel– Disposition: determine priority and Disposition: determine priority and

mode of transportmode of transport



CareCare Emergency care (adults or peds)Emergency care (adults or peds)– Quickly remove patient from cold Quickly remove patient from cold

environmentenvironment– Handle gently—rough handling may Handle gently—rough handling may

cause cardiac arrestcause cardiac arrest– Resuscitate as necessaryResuscitate as necessary

Assess pulse for 30 – 45 secondsAssess pulse for 30 – 45 seconds No pulse, start CPRNo pulse, start CPR Prepare to use AED if indicatedPrepare to use AED if indicated



CareCare Emergency care (adults or peds)Emergency care (adults or peds)– Use passive rewarming methods to Use passive rewarming methods to

prevent further heat lossprevent further heat loss Remove wet or frozen clothingRemove wet or frozen clothing Wrap patient in thermal blankets and other Wrap patient in thermal blankets and other

insulating materialinsulating material Cover the patient’s headCover the patient’s head Administer warmed oxygen, if Administer warmed oxygen, if

possible/availablepossible/available



CareCare Emergency care (adults or peds)Emergency care (adults or peds)– Maintain a warm environment: do not Maintain a warm environment: do not

re-expose to cold environmentre-expose to cold environment– Reassess patientReassess patient

Recheck vital signsRecheck vital signs Recheck injuries and treatmentRecheck injuries and treatment Recheck medical statusRecheck medical status Transport/transfer/transition patient and Transport/transfer/transition patient and

informationinformation


PracticePractice Demonstrate assessment and care of Demonstrate assessment and care of

patients exposed to cold environments patients exposed to cold environments based on Maryland Medical Protocolsbased on Maryland Medical Protocols– General patient care steps for superficial General patient care steps for superficial

and deep frostbite patientsand deep frostbite patients– General patient care steps for mild to General patient care steps for mild to

moderate hypothermia patientsmoderate hypothermia patients– General patient care steps for severe General patient care steps for severe

hypothermia patients, including hypothermia patients, including resuscitation and AEDresuscitation and AED


Recognizing and Managing Recognizing and Managing Cold Emergencies: Frostbite Cold Emergencies: Frostbite

and Hypothermiaand Hypothermia

Student Performance Objective:Student Performance Objective:Given information, resources, and Given information, resources, and opportunity for discussion and practice, EMTs opportunity for discussion and practice, EMTs will be able to:will be able to:• Describe types of frostbite and hypothermiaDescribe types of frostbite and hypothermia• Describe signs and symptomsDescribe signs and symptoms• Demonstrate patient assessment and careDemonstrate patient assessment and careEMTs will follow acceptable Maryland medical EMTs will follow acceptable Maryland medical practice and Maryland Medical Protocols for practice and Maryland Medical Protocols for Emergency Medical Providers.Emergency Medical Providers.


Altered Mental Status: Altered Mental Status: Assessing and Managing Assessing and Managing

Seizure PatientsSeizure PatientsOverviewOverview Frostbite description and classificationsFrostbite description and classifications Frostbite signs and symptomsFrostbite signs and symptoms Frostbite assessment and emergency careFrostbite assessment and emergency care Hypothermia description and classificationsHypothermia description and classifications Hypothermia signs and symptomsHypothermia signs and symptoms Hypothermia assessment and emergency Hypothermia assessment and emergency

carecare Practice assessment and carePractice assessment and care

Documents

Drill of the Month Developed by Gloria Bizjak Recognizing and Managing Cold Emergencies: Frostbite and Hypothermia Frostbite and Hypothermia