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Frostbite in Oxfordshire: the impact of a severe winter on an unprepared civilian population
Injury
(1984)
15, 37S380
379
Printed in Great Britain
Frostbite in Oxfordshire: winter on an unprepared
the impact of a severe civilian population
H. M. Bishop, J. Collin, R. F. M. Wood and P. J. Morris Nuffield Department of Surgery, John Radcliffe Hospital, Oxford
Summary The winter of 1981-1982 in Oxfordshire was unusually cold. During this winter, 18 patients with frostbite were referred to the Peripheral Vascular Service of the Nuffield Department of Surgery. The age-range was 52-83 years. None was diabetic. Seven were smokers. All had frostbite of either feet or fingers, sometimes of both. Patients could be divided into 2 groups based on the severity of their injury. In the first group 10 patients had mild injuries and were managed as outpatients. One patient had terminal phalanges amputated as a day case. Patients in this group had adequate homes and no associated medical disease. Eight patients in the second group had severe frostbite. All were socially disadvantaged and 4 had significant medical disease (mitral valve disease, lymphoma, alcoholism and depression). Because of social circumstances and because it takes time to establish the line of demarcation between healthy and dead tissue, all patients in this group were in hospital for a minimum of 2 months (range 2-10 months). Four patients required skin grafting and 2 needed special shoes to enable them to walk. There needs to be greater public awareness of the dangers
and risks of cold injury. INTRODUCTlON THE winter of 1981-1982 was unusually severe through-
out the United Kingdom. In January 1982, the Radcliffe Meteorological Observer recorded the lowest daytime temperature ( - 16.6 “C) since records commenced 100 years previously. The mean daytime temperature in December 1981 was the lowest since 1890 and night temperatures were even lower. During the winter an unprecedented number of 18 patients with frostbite were referred to the Peripheral Vascular Service in Oxford. We report our experience in managing this group of patients. PATIENTS The mean age of the 18 patients
was 62 years, with a range of 52-83 years. None was diabetic. Seven were smokers. All had frostbite of either feet or fingers, sometimes both. The patients could be divided into 2 groups based on the severity of their injury. There were 15 men and 3 women. Group 1: minor cold injury There were 10 patients in this group; all had minor cold injuries and were managed as outpatients. One patient attended the Casualty Department but the remainder were referred to the routine outpatient clinic, usually
with a label of ‘atypical peripheral vascular disease’. None of the patients in this group was socially disadvantaged and none had important coexisting medical disease. Cold injury was sustained while engaged in activities such as snow clearing. In many instances the patients were unaware of just how cold the weather was and 2 were quite inadequately clad; for example, a professional man clearing snow in his bedroom slippers. Group 2: severe cold injury
The 8 people in this group had severe frostbite and were all admitted to hospital as emergencies. All were socially disadvantaged and 4 had important medical disease (mitral valve disease, lymphoma, alcoholism and depression). Patients sustained their injuries passively in the sense that they had no way of escaping from the cold. All were treated as hospital inpatients for a minimum of 2 months (range 2-10 months). There was 1 death, an 83year-old man with lymphoma and cold injury who died 3 months after admission. Four patients required skin grafting, and 2 of these needed special shoes to enable them to walk. TREATMENT Group 1
All the patients in this group were managed conservatively with dry dressings alone. One patient required amputation of 3 terminal phalanges 8 weeks after her injury when a line of demarcation had appeared. Antibiotics were not given routinely but 1 patient received a short course of antibiotics to control an area of superficial infection on a frostbitten toe. Group 2
Following rewarming and rehydration, the feet were elevated and nursed on sheepskins or water cushions. Frostbitten parts were initially exposed to the air under a bed cradle and later protected with dry dressings. Blisters were aspirated with a fine needle and the fluid sent for culture. Antibiotics (Magnapen) and tetanus toxoid were given to all patients on admission. Antibiotic treatment was stopped after 1 week and subsequently antibiotics were given only if superficial infection developed at the site of demarcation. Initially, hospital treatment was required because it took several weeks to establish the line of demarcation between living and dead tissue. Subsequently, the prolonged hospital stay was due to
380
difficulties in rehabilitation and poor social circumstances. Ward (1979) has stressed the importance of delaying surgical intervention until a clear line of demarcation has developed, and we followed this policy. None of our patients underwent sympathectomy. DISCUSSION
The pathophysiology of cold injury in the vascular system suggests that initial venous constriction leads to raised venous pressure and hence decreased capillary flow and capillary sludging (MacClean and EmslieSmith, 1977). For this reason some authors, for example Jarrett (1974), extol the use of low-molecular weight dextrans as anti-sludging agents. Whilst dextran may be successful in the experimental animal (Mundth et al., 1964), other studies (Penn and Schwartz, 1964), have failed to confirm any benefit in the human. For this reason low-molecular weight dextrans were not used in our series. Patients with severe frostbite will inevitably spend a long period in hospital and all authors stress the importance of maintaining morale, and the necessity of physiotherapy and a good diet. It cannot be stressed too strongly that early surgery is potentially disastrous. It is gratifying to both patients and their doctors to observe a line of demarcation forming some distance from where it was originally feared amputation would take place. Frostbite is rare in civilian practice, even in parts of the world that endure a particularly harsh climate. For example, in a recent review from Saskatoon, Canada, there were only 107 patients seen with cold injury in 10 years (Miller and Chasmar, 1980). The majority of these patients were either inebriated or stranded by automobile failure. Only 1 of our severely frostbitten patients was an alcoholic and no patient in this group owned a motor car. The Canadian patients were also much younger, the average age being 40 years in contrast to our mean age of 62. The majority of patients with frostbite seen in a Finnish winter occurred in what the author (KyGsola, 1979) describes as ‘skid-row types’. Our group 1 patients lived in reasonable accommodation and their mild injuries were sustained as a result of relatively brief exposure to cold weather. The majority of patients in this group were unaware how cold their toes were becoming. The group 2 patients with severe frostbite were all socially disadvantaged, though only 1 was a vagrant. Their prolonged hospital stay was necessary for a number of reasons: the lines of demarcation took a long time to appear; some patients needed skin grafting and 2 needed special shoes; 2 patients had no home to go to and there were inevitable delays while appropriate accommodation and support were arranged by the social services. There were other differences between the 2 groups. Patients in group 1 were referred as outpatients with a presumed diagnosis of peripheral vascular disease. Unlike patients with peripheral vascular disease, however, there were only 3 smokers in this
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 6
group. There was a surprising absence of diabetic patients. Patients with mild cold injury developed frostbite after periods of elective activity, such as clearing snow. Patients in group 2 developed frostbite because they had no escape from the cold; they were immobilized by disease or prisoners in their unheated homes. In this civilian series no young person was seen with frostbite. Frostbite is, however, a common injury in young soldiers during winter wars. In the recent campaign in the Falkland Islands, 9 per cent of all British casualties were caused by cold injury (Richards, 1983). Both civil and military patients with severe frostbite suffer their injuries because they have no opportunity of refuge and rewarming. By contrast the patients in group 1 with the milder injuries did have an opportunity to come in from the cold. That they did not do so is puzzling. Many patients were unaware of how cold they were becoming while others behaved foolishly. Snow is not unusual in the United Kingdom in winter, but extreme cold is rare. Education of the public on the dangers of exposure to cold, reinforced by new broadcasts when extreme cold threatens, may reduce the number of cases of minor frostbite. Some patients in group 1 were genuinely ignorant of the risks they were incurring. Prophylaxis in the case of group 2 patients is less straightforward. An awareness of cold injury by the social services might have helped, but it must be recognized that making practical provision for this group of individuals is difficult. The cost of treating these injuries is enormous. The average cost of an acute bed in the John Radcliffe Hospital is f 113 per day and patients in group 2,spent, between them, 990 days in hospital at a cost of almost f 120 000. For such a sum, warm shelter could have been provided for those most at risk during the critical months of December and January 1981-1982.
REFERENCES
Jarrett F. (1974) Frostbite: current concepts of pathogens and treatment. Rev. Surg. 31, 71. Kyiisola K. (1979) Clinical experience in the management of cold injuries: a study of 110 cases. J. Trauma 14, 32. MacClean D. and Emslie-Smith D. (1977) Accidental Hypethermia. Oxford Blackwell Scientific Publications, 237. Miller B. J. and Chasmar L. R. (1980) Frostbite in Saskatoon: a review of 10 winters. Can. J. Surg. 23, 423. Mundth E. D., Long D. M. and Brown R. B. (1964)Treatment of experimental frostbite with low molecular weight Dextran. J. Trauma 4, 246.
Penn I. and Schwartz S. I. (1964) Evaluation of low molecular weight dextran in the treatment of frostbite. J. Trauma 4, 784.
Richards T. (1983) Medical lessons from the Falklands. Br. Med. J. 286, 790.
Ward M. A.
(1974)
Frostbite. Br. Med. J. 1, 67.
Paper accepted 10 October 1983. Requests fir reprints should be addressed to: H. M. Bishop, Ntield Headington, Oxford OX3 9DU.
Department of Surgery, University of Oxford, John Radcliffe Hospital,
(1984)
15, 37S380
379
Printed in Great Britain
Frostbite in Oxfordshire: winter on an unprepared
the impact of a severe civilian population
H. M. Bishop, J. Collin, R. F. M. Wood and P. J. Morris Nuffield Department of Surgery, John Radcliffe Hospital, Oxford
Summary The winter of 1981-1982 in Oxfordshire was unusually cold. During this winter, 18 patients with frostbite were referred to the Peripheral Vascular Service of the Nuffield Department of Surgery. The age-range was 52-83 years. None was diabetic. Seven were smokers. All had frostbite of either feet or fingers, sometimes of both. Patients could be divided into 2 groups based on the severity of their injury. In the first group 10 patients had mild injuries and were managed as outpatients. One patient had terminal phalanges amputated as a day case. Patients in this group had adequate homes and no associated medical disease. Eight patients in the second group had severe frostbite. All were socially disadvantaged and 4 had significant medical disease (mitral valve disease, lymphoma, alcoholism and depression). Because of social circumstances and because it takes time to establish the line of demarcation between healthy and dead tissue, all patients in this group were in hospital for a minimum of 2 months (range 2-10 months). Four patients required skin grafting and 2 needed special shoes to enable them to walk. There needs to be greater public awareness of the dangers
and risks of cold injury. INTRODUCTlON THE winter of 1981-1982 was unusually severe through-
out the United Kingdom. In January 1982, the Radcliffe Meteorological Observer recorded the lowest daytime temperature ( - 16.6 “C) since records commenced 100 years previously. The mean daytime temperature in December 1981 was the lowest since 1890 and night temperatures were even lower. During the winter an unprecedented number of 18 patients with frostbite were referred to the Peripheral Vascular Service in Oxford. We report our experience in managing this group of patients. PATIENTS The mean age of the 18 patients
was 62 years, with a range of 52-83 years. None was diabetic. Seven were smokers. All had frostbite of either feet or fingers, sometimes both. The patients could be divided into 2 groups based on the severity of their injury. There were 15 men and 3 women. Group 1: minor cold injury There were 10 patients in this group; all had minor cold injuries and were managed as outpatients. One patient attended the Casualty Department but the remainder were referred to the routine outpatient clinic, usually
with a label of ‘atypical peripheral vascular disease’. None of the patients in this group was socially disadvantaged and none had important coexisting medical disease. Cold injury was sustained while engaged in activities such as snow clearing. In many instances the patients were unaware of just how cold the weather was and 2 were quite inadequately clad; for example, a professional man clearing snow in his bedroom slippers. Group 2: severe cold injury
The 8 people in this group had severe frostbite and were all admitted to hospital as emergencies. All were socially disadvantaged and 4 had important medical disease (mitral valve disease, lymphoma, alcoholism and depression). Patients sustained their injuries passively in the sense that they had no way of escaping from the cold. All were treated as hospital inpatients for a minimum of 2 months (range 2-10 months). There was 1 death, an 83year-old man with lymphoma and cold injury who died 3 months after admission. Four patients required skin grafting, and 2 of these needed special shoes to enable them to walk. TREATMENT Group 1
All the patients in this group were managed conservatively with dry dressings alone. One patient required amputation of 3 terminal phalanges 8 weeks after her injury when a line of demarcation had appeared. Antibiotics were not given routinely but 1 patient received a short course of antibiotics to control an area of superficial infection on a frostbitten toe. Group 2
Following rewarming and rehydration, the feet were elevated and nursed on sheepskins or water cushions. Frostbitten parts were initially exposed to the air under a bed cradle and later protected with dry dressings. Blisters were aspirated with a fine needle and the fluid sent for culture. Antibiotics (Magnapen) and tetanus toxoid were given to all patients on admission. Antibiotic treatment was stopped after 1 week and subsequently antibiotics were given only if superficial infection developed at the site of demarcation. Initially, hospital treatment was required because it took several weeks to establish the line of demarcation between living and dead tissue. Subsequently, the prolonged hospital stay was due to
380
difficulties in rehabilitation and poor social circumstances. Ward (1979) has stressed the importance of delaying surgical intervention until a clear line of demarcation has developed, and we followed this policy. None of our patients underwent sympathectomy. DISCUSSION
The pathophysiology of cold injury in the vascular system suggests that initial venous constriction leads to raised venous pressure and hence decreased capillary flow and capillary sludging (MacClean and EmslieSmith, 1977). For this reason some authors, for example Jarrett (1974), extol the use of low-molecular weight dextrans as anti-sludging agents. Whilst dextran may be successful in the experimental animal (Mundth et al., 1964), other studies (Penn and Schwartz, 1964), have failed to confirm any benefit in the human. For this reason low-molecular weight dextrans were not used in our series. Patients with severe frostbite will inevitably spend a long period in hospital and all authors stress the importance of maintaining morale, and the necessity of physiotherapy and a good diet. It cannot be stressed too strongly that early surgery is potentially disastrous. It is gratifying to both patients and their doctors to observe a line of demarcation forming some distance from where it was originally feared amputation would take place. Frostbite is rare in civilian practice, even in parts of the world that endure a particularly harsh climate. For example, in a recent review from Saskatoon, Canada, there were only 107 patients seen with cold injury in 10 years (Miller and Chasmar, 1980). The majority of these patients were either inebriated or stranded by automobile failure. Only 1 of our severely frostbitten patients was an alcoholic and no patient in this group owned a motor car. The Canadian patients were also much younger, the average age being 40 years in contrast to our mean age of 62. The majority of patients with frostbite seen in a Finnish winter occurred in what the author (KyGsola, 1979) describes as ‘skid-row types’. Our group 1 patients lived in reasonable accommodation and their mild injuries were sustained as a result of relatively brief exposure to cold weather. The majority of patients in this group were unaware how cold their toes were becoming. The group 2 patients with severe frostbite were all socially disadvantaged, though only 1 was a vagrant. Their prolonged hospital stay was necessary for a number of reasons: the lines of demarcation took a long time to appear; some patients needed skin grafting and 2 needed special shoes; 2 patients had no home to go to and there were inevitable delays while appropriate accommodation and support were arranged by the social services. There were other differences between the 2 groups. Patients in group 1 were referred as outpatients with a presumed diagnosis of peripheral vascular disease. Unlike patients with peripheral vascular disease, however, there were only 3 smokers in this
Injury: the British Journal of Accident Surgery Vol. 1 ~/NO. 6
group. There was a surprising absence of diabetic patients. Patients with mild cold injury developed frostbite after periods of elective activity, such as clearing snow. Patients in group 2 developed frostbite because they had no escape from the cold; they were immobilized by disease or prisoners in their unheated homes. In this civilian series no young person was seen with frostbite. Frostbite is, however, a common injury in young soldiers during winter wars. In the recent campaign in the Falkland Islands, 9 per cent of all British casualties were caused by cold injury (Richards, 1983). Both civil and military patients with severe frostbite suffer their injuries because they have no opportunity of refuge and rewarming. By contrast the patients in group 1 with the milder injuries did have an opportunity to come in from the cold. That they did not do so is puzzling. Many patients were unaware of how cold they were becoming while others behaved foolishly. Snow is not unusual in the United Kingdom in winter, but extreme cold is rare. Education of the public on the dangers of exposure to cold, reinforced by new broadcasts when extreme cold threatens, may reduce the number of cases of minor frostbite. Some patients in group 1 were genuinely ignorant of the risks they were incurring. Prophylaxis in the case of group 2 patients is less straightforward. An awareness of cold injury by the social services might have helped, but it must be recognized that making practical provision for this group of individuals is difficult. The cost of treating these injuries is enormous. The average cost of an acute bed in the John Radcliffe Hospital is f 113 per day and patients in group 2,spent, between them, 990 days in hospital at a cost of almost f 120 000. For such a sum, warm shelter could have been provided for those most at risk during the critical months of December and January 1981-1982.
REFERENCES
Jarrett F. (1974) Frostbite: current concepts of pathogens and treatment. Rev. Surg. 31, 71. Kyiisola K. (1979) Clinical experience in the management of cold injuries: a study of 110 cases. J. Trauma 14, 32. MacClean D. and Emslie-Smith D. (1977) Accidental Hypethermia. Oxford Blackwell Scientific Publications, 237. Miller B. J. and Chasmar L. R. (1980) Frostbite in Saskatoon: a review of 10 winters. Can. J. Surg. 23, 423. Mundth E. D., Long D. M. and Brown R. B. (1964)Treatment of experimental frostbite with low molecular weight Dextran. J. Trauma 4, 246.
Penn I. and Schwartz S. I. (1964) Evaluation of low molecular weight dextran in the treatment of frostbite. J. Trauma 4, 784.
Richards T. (1983) Medical lessons from the Falklands. Br. Med. J. 286, 790.
Ward M. A.
(1974)
Frostbite. Br. Med. J. 1, 67.
Paper accepted 10 October 1983. Requests fir reprints should be addressed to: H. M. Bishop, Ntield Headington, Oxford OX3 9DU.
Department of Surgery, University of Oxford, John Radcliffe Hospital,