Page 84 - JSOM Spring 2023

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thermal injury from the sides of the vessel. The tissue has joint or metacarpophalangeal/metatarsophalangeal joints. These
completed rewarming when it appears red or purple and is joints have amputation rates of 60% and 100%, respectively,
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malleable. There is no current evidence that the rewarming without the use of iloprost. Iloprost represents a potential key
solution requires any antiseptic solution added to the water in the future of cold weather injury.
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bath. Medical providers should also consult telehealth if
available, ranging from the unit medical director to a cold This case raises the importance of proper protective gear, im-
weather/burn consultation. Additional efforts should be taken mediate action when layers are compromised, frequent cold
in the prehospital environment to optimize the patient’s hydra- weather checks, conservative treatments, and management of
tion status with ideally oral fluids. If the medical situation does hemorrhagic blisters without debridement. While extremity
not permit, providers should initiate intravenous with warmed cold weather injuries may be viewed as minor, they have the
fluids if available. potential to rapidly degrade dexterity, short- and long-term
digit function, and combat effectiveness.
Pain control is a crucial portion of management, including ibu-
profen due to its effects on prostaglandin and thromboxane, Conclusion
with aspirin as a secondary choice. Especially in considering
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aspirin, medical providers should consider the platelet inhib- The arctic environment poses a unique problem set for tactical
itory effects for hemostasis in a combat environment versus leaders and medical providers. Proper planning and issue and
treatment of the cold weather injury. Ibuprofen should be ad- wear of cold weather gear can allow the Special Operations
ministered daily at 12mg/kg split into two doses with a maxi- community to mitigate cold weather injury and operational
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mum dose of 2400mg daily. The affected extremity should be disruption. Prevention and early recognition of cold weather
dressed with bulky, clean, sterile dressing, with the fingers and injuries place a high importance on the unit’s medical provider
toes separated if possible. If the tactical situation permits, an to continually assess their teammates, maintaining mission
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extremity with cold weather injury should not be used or am- capability. This article stresses the importance of Special Op-
bulated on. However if unavoidable, case reports demonstrate erations providers rapidly recognizing cold weather injuries
minimal long term deleterious effects from prolonged ambula- and taking the initial proper steps of management to prevent
tion on cold weather injuries. Blisters should not be debrided more harm. The medical decision to rewarm injuries should
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in the prehospital environment, though aloe vera application be made in the context of potential risk of refreezing injury.
improves outcomes in both human and animal studies with Recognizing the severity of the injury can help medical provid-
very minimal risk. 12,13 There are no indications for prophylac- ers in the field make the early determination of evacuation if
tic antibiotics, as cold weather injury is a sterile injury. How- needed. Additionally, debriding hemorrhagic blisters can lead
ever, in the subacute phase, edematous dermal layer incurs an to negative patient outcomes and increased loss of tissue, while
increased risk of gram-positive infections from the patient’s early pain control with ibuprofen and application of aloe vera
own flora. 14 can improve early healing. As arctic warfare emerges as a key
battle space, this cold weather injury pattern will become more
Considerations for hospital care include active rewarming and common, stressing the critical nature of these medical lessons.
cold injury care, localized thrombolytic therapy, and vasodila-
tors. 15,16 If able, medical providers should rewarm the affected Disclosure
extremity in the prehospital setting. However, if there is a None.
risk of refreezing, rewarming should be delayed until defini-
tive care can be obtained. Unlike thermal or friction blisters, Disclaimer
blisters from cold weather injury are often managed more con- The view(s) expressed herein are those of the author(s) and do
servatively. The drainage of serous blisters can be considered not reflect the official policy or position of Brooke Army Med-
in consultation with surgical and cold weather experts. In con- ical Center, the US Army Medical Department, United States
trast, hemorrhagic blisters should not be unroofed. Army Special Operations Command, the US Army Office of
the Surgeon General, the Department of the Army, the Depart-
The use of tissue plasminogen activator (tPA) within a critical ment of the Air Force and Department of Defense or the US
care setting has reduced digital amputation rates, and this is Government.
recommended for deep tissue injury proximal to proximal in-
terphalangeal joints. 18–21 However, clinicians must consider the Funding
risks versus benefits with the patient’s overall condition and None.
comorbidities, as systemic bleeding presents a life-threatening
adverse effect. While not yet adopted in the US, intra-arterial Author Contributions
iloprost, a synthetic prostacyclin analogue originally used for SC, NC, and RB saw the patient and generated the manuscript.
pulmonary hypertension and Raynaud’s phenomenon, vaso- DT provided care for the patient as well as provided addi-
dilates and reduces platelet aggregation. This can mitigate mi- tional comments and figures for the manuscript. BL edited the
cro-vascular occlusion. 22,23 It is available across Europe for cold initial first draft with multiple rounds of editing. All authors
weather injury as well as Canada through Health Canada’s approved the final draft.
Special Access Program. 24,25 Based on European and Canadian
data, the recommended dosing regimen is a six-hour intrave- References
nous Iloprost infusion for five days in patients with deep cold 1. O’Donnell FL, Taubman SB. Update: Cold weather injuries, active
weather injury that would otherwise be at risk of amputation and reserve components, U.S. Armed Forces, July 2011–June 2016.
MSMR. 2016;23(10):12–20.
and presenting within 72 hours of rewarming. 5,24–26 Iloprost 2. Armed Forces Health Surveillance Division. Update: Cold weather
infusion may reduce the need for amputation in patients with injuries, active and reserve components, U.S. Armed Forces, July
frostbite extending proximal to the proximal interphalangeal 2015–June 2020. MSMR. 22AD;27(11):15–24.

82 | JSOM Volume 23, Edition 1 / Spring 2023