[The forensic medical assessment of the causes and conditions of the formation of the chilling injury]. / Sudebno-meditsinskaia otsenka prichin i uslovii vozniknoveniia kholodovoi travmy.

The authors present the data of the literature publications and theoretical considerations concerning the causes and conditions behind the formation of the chilling injury. It is demonstrated that the chilling injury develops as a consequence of a disturbance in the relationship between the hypothermic protection of the organism and the cooling potential of its environment. The thermal balance of the human organism depends not only on the natural mechanisms of physical and chemical thermoregulation but also on the character of artificial thermoregulation including the man-made means of cold protection. The critical evaluation of all the available data on chilling injuries to the human body gave evidence that the causes and conditions of their development can be highly multivarious which does not however exclude the possibility of their systematization.

Frostbite injuries treated in the Helsinki area from 1995 to 2002.

BACKGROUND: : Exposure to cold results in frostbite, superficial or deeper tissue damage. In severe frostbites, amputations are life-saving but diminish quality of life (QOL). METHODS: : Retrospective study was performed. RAND 36- questionnaire was administered to assess QOL. Our aim was to investigate risk factors and adjustment to everyday life of hospitalized patients. RESULTS: : 92 frostbites in 42 patients were recorded. One third of the patients were chronic alcoholics. Age and temperature were statistically significant factors for unfavorable outcome. 20% of patients required secondary reconstructive procedures. One-third reported their emotional well-being very poor. Half had limitations in social life. CONCLUSIONS: : Hospitalized cases of frostbite are rare. Anti-social behavior increases the risk in general, and patients present with complicated problems similar to those encountered in burns victims. We recommend that frostbite patients requiring hospital attendance are treated in specialized units, where sufficient expertise for acute as well as reconstructive surgery is available.

Surgical management and strategies in the treatment of hypothermia and cold injury.

Increased participation in outdoor activities and the epidemic of homelessness have caused the incidence of cold injuries in the civilian population to rise dramatically over the last 20 years. Knowledge of the treatment is crucial for emergency physicians in rural and urban areas. Recent developments have significantly advanced the understanding of the pathophysiology of hypothermic and frostbite injuries. Together with improved rewarming techniques and use of radiological assessment of tissue viability, future advancements should allow for a more aggressive and active approach to the management of these injuries.

Some aspects on death in the cold and concomitant frostbites.

The most important risk factors and findings of acute accidental hypothermia and concomitant local frostbites are reviewed. Both external and internal risk factors are usually present when exposure to cold is leading to death. The external factors are alcohol and psychic drugs, too light a clothing for the circumstances and wetness. Important internal factors are leanness, physical exhaustion and traumas in young persons and illnesses and degeneration of physiological heat conserving and production responses at old age. The signs caused by cold on the body are variable. In immersion hypothermia cases there are almost no changes, since the death occurs rapidly, most frequently from drowning. On the victims of dry frost first degree congelations, showing up as purple oedematic skin areas or spots, can be observed on the face and extremities. Stress ulcerations or haemorrhages in the stomach mucosa develop in ca. 70% of dry hypothermia cases. In long lasting exposures to cool temperature haemorrhagic pancreatitis, lung oedema and myxomatous skin oedema have been the characteristic signs. Frostbites developing concomitantly with fatal hypothermia show only oedema and hyperaemia, but no blisters or inflammation in the skin, which are the most conspicious vital reactions of frostbites after thawing.

Increased lethality of endotoxemia in murine frostbite.

Because frostbite (FB) is associated with increased intravascular coagulability, it is reasonable to assume that endotoxin, by enhancing platelet aggregation, will adversely affect FB. Swiss mice (25 +/- 2 g) were anesthetized, and the tails of the animals totally immersed in a freezing solution of equal volumes of ethylene glycol and water (-18 C) for 8 min. The tails were then thawed at room temperature (24 C). Half an hour after removal from the freezing solution, the animals were given either (Group A) 0.1 cc saline I.P. or (Group B) 0.1 mg E. coli endotoxin (055:B5; 1/3 LD50 dose) in 0.1 cc saline IP. A third group (Group C), was given the same dose of endotoxin but was not subjected to frostbite. Survivals in each group at 2 weeks were as follows: (A) 14/14 (100%), (B) 4/20 (20%), (C) 13/14 (93%). Using Fisher's exact test, A versus B P less than .001; B versus C P less than .001; A versus C NS. The data presented here emphasize the increased lethality of endotoxemia in murine FB.

Detrimental effects of ethanol on murine frostbite.

Many references have been made concerning the adverse effects of ethanol in human frostbite. The lack of experimental evidence to support this belief prompted the authors to undertake this investigation. Nineteen Swiss-Webster mice (25 +/- 2 gm) were given intraperitoneal injections of 0.2 cm3 of 50 per cent ethanol (group A) or 0.2 cm3 saline (group B). Thirty minutes later, the animals were anesthetized with pentobarbital (group A 30 mg/kg; group B 50 mg/kg). Lower barbiturate dose was used in group A because of the synergistic central nervous system depressant effect when combined with alcohol. Tail lengths of all animals were measured. The tails were immersed in a 50 per cent ethylene glycol solution (-18 C) for 6 min and then thawed at room temperature (24 C). At 24 hrs, tail circulation was assessed by length of tail perfused with the vital dye alphazurine 2 gm given intraperitoneally. Mortality to 14 days was recorded. All animals survived the initial anesthetic and/or alcohol administration. Group A had a statistically significant (P less than 0.001 Students t test) decrease in length of tail perfused compared with group B at 24 hours (0.98 +/- 0.19 cm versus 2.58 +/- 0.23 cm). Fourteen day survival was 10 per cent in group A compared with 89 per cent in group B (P less than 0.001, chi-square test). We conclude that ethanol has significant adverse effects on tissue perfusion and mortality associated with severe murine frostbite.