Cold Injuries in Children | Types, Features and Treatment

1. Types of cold Injuries
2. Pathophysiology •  Mechanism
3. Clinical features based on the type of cold Exposure
4. Treatment General Principles •  Specific
5. Outcomes
6. Pearls

1. Cold Injury (June/2007) Marks - 10
2. Cold injury may produce either local tissue damage, with the injury pattern depending on exposure to the type of cold

Types of cold injuries

Type of cold	Injury
Damp cold	Frostnip, immersion foot, or trench foot
Dry cold	leads to local frostbite
Generalized systemic effects	hypothermia
Others	Chill blains, Panniculitis

Pathophysiology:

Clinical manifestations

Frostnip

Firm, cold, white areas on the face, ears, or extremities. Blistering and peeling may occur.

Immersion Foot (Trench Foot):

Immersion foot occurs in cold weather when the feet remain in damp or wet, poorly ventilated boots.

The feet become cold, numb, pale, edematous, and clammy. Tissue maceration and infection are likely.

Frostbite

Initial stinging or aching of the skin progresses to cold, hard, white aesthetic, and numb areas. On rewarming, the area becomes blotchy, itchy, and often red, swollen, and painful.

Chilblain (Pernio)

Chilblain (pernio) is a form of cold injury in which erythematous, vesicular, or ulcerative lesions occur. They are often itchy, may be painful, and result in swelling and scabbing.

The lesions are most often found on the ears, the tips of the fingers and toes, and exposed areas of the legs.

Cold-Induced Fat Necrosis (Panniculitis)

It is a common and usually benign cold injury. Cold-induced fat necrosis occurs upon exposure to cold air, snow, or ice and manifests in exposed or, less often, covered surfaces.

Looks red or, less often, purple to blue macular, papular, or nodular lesions.

Treatment of various cold injuries in Children

General Principles

1. Airway Breathing and circulation takes priority.
2. Move to a safer and warmer area.
3. Identify type and severity of Injury, and act accordingly.
4. Avoid activities on the injured part like walking in case legs are affected.
5. Sometimes removal of dead tissues may be necessary to prevent infection.

Treatment of Frostnip

Treatment consists of warming the area with an unaffected hand or a warm object.

Treatment of Trench Foot

is largely prophylactic and consists of using well-fitting, insulated, waterproof, nonconstricting footwear.

Treatment of frostbite

1. Warming the affected area.
2. Anti-inflammatory agents and analgesia are necessary.
3. Freeze and rethaw cycles are most likely to cause permanent tissue injury.
4. The affected area should be immersed in warm water (approximately 42⁰C), with care taken not to burn the anesthetized skin.
5. Vasodilating agents, such as prazosin and phenoxybenzamine, may be helpful.
6. Surgical sympathectomy has also been tried with equivocal results.

Treatment of Chilblain

Treatment consists of prophylaxis - Avoiding prolonged chilling and protecting potentially susceptible areas with a cap, gloves, and stockings. Prazosin and phenoxybenzamine have been tried.

For significant itching, local corticosteroid preparations may be helpful.

Treatment of Panniculitis

Treatment is with nonsteroidal anti-inflammatory agents. The lesions may last 10 days to 3 wk.

Prognosis

The outcomes of cold injury depend on the 

1. The severity of exposure and 
2. Duration of exposure to the cold.

1. Often the pain is ignored, especially the rewarming can be quite painful. Use adequate analgesia including opiates where necessary.
2. Tetanus Prophylaxis where necessary.
3. Assessment of dehydration and use of a proper rehydration regime.
4. Make sure the parents and children ( if older) receive advice on the prevention of future incidents.

Frostbite and Frostnip in Children - Stanford guide

1. Headache in Children
2. Breath Holding spells
3. Congenital Adrenal Hyperplasia

Sources - Image [1] - Winky from Oxford, UK, CC BY 2.0, via Wikimedia Commons

Author

Vasu Burli | DNB (Pediatrics) Fellowship in Pediatric Critical Care

Vasu completed his Pediatrics residency at Kanchi KamaKoti Childs Trust Hospital, Chennai and received further training in Pediatric Intensive care in India and UK