Cold injury - types, degrees, stages of frostbite in the medical classification. What is a cold burn: classification and features Need help learning a topic

It is the main damaging factor. Cold injury is divided into categories: straight and indirect contact, as well as local and general. The direct one occurs during direct contact with a cold object, work with cryogenic liquids, etc., and indirect during frostbite, cold air, etc. With a general cold injury, the entire body suffers, and with a local one, only the affected part of it. Most often, cold injuries affect the hands.

In terms of its damaging effect, cold injury is in many ways similar to a burn. In winter, especially in cold weather, you should not touch metal objects with your bare hands - you can easily get a cold injury or even freeze to metal, in which case the cold injury will be even harder than a burn from hot metal, in which a person instinctively pulls back the affected part.

Severe and extremely severe cold injuries occur rarely, mainly in people who work with cryogenic fluids and materials or live in places where extremely low temperatures are observed. It is worth noting that the same cryogenic liquids that have fallen on a person, such as liquid nitrogen, often cannot instantly cause severe cold injury (unless, of course, one does not stick one's hands into them) due to their low thermal conductivity.

The degree of influence of cold injury on the body

In mild cases, a cold burn is possible, like a simple burn, there is no threat to health and life;
In severe cases, there is a deep lesion of the limbs, up to their complete destruction, severe hypothermia of the whole organism, shock and a threat to life and health are possible.

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See what "Cold injury" is in other dictionaries:

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Cold injury (general cooling, freezing, frostbite)
When cold is applied to the entire surface of the body, when its temperature drops below 35 ° C, a general cooling of the body occurs. Prolonged exposure to low temperatures leads to freezing: the functions of the body are inhibited, up to their complete disappearance.

Resistance to cooling decreases with significant starvation, after an injury, blood loss, in persons in a state of shock, alcohol intoxication, when exposed to cold water. Hypothermia occurs faster with high humidity, strong winds, especially if the person is wearing light, tight or wet clothes.

Excitation, chills, cyanosis of the lips, pallor and coldness of the skin, goosebumps, shortness of breath, increased heart rate testify to the beginning of general cooling. Then there is a feeling of fatigue, stiffness, drowsiness, indifference, general weakness. If cooling continues, fainting occurs, loss of consciousness, respiratory and circulatory arrest.

Types of frostbite and their signs

For rendering it is necessary: to transfer the victim from the cooling zone to a calm place, a room with room temperature;
remove wet clothes from the victim, wrap him in a blanket;
ensure peace, do not allow movement. Do not massage the limbs;
observe the pulse, breathing.

When breathing stops, carry out artificial ventilation of the lungs;
in the presence of consciousness, give hot drinks (, coffee, milk). Do not drink alcohol!

A gradual general warming of the body is necessary. Attempts to quickly warm the victim, especially by covering him with heating pads or intensively rubbing the limbs, due to the redistribution of cold blood from the peripheral vessels to the heart, can be disastrous for a person!

Local tissue damage as a result of local exposure to cold is called frostbite. The reasons are prolonged exposure to wind, tight wet shoes, prolonged forced immobility. More often fingers and toes, nose, cheeks, ears are frozen. Initially, there is a feeling of cold, then numbness with the disappearance of pain, and later - all kinds of sensitivity.

When providing first aid, you must:
move the victim to a warm room;
remove tight clothing and shoes;
to warm frostbitten parts of the body with your own warmth (hands or in the armpit); give hot drinks (not alcohol!).

In case of deep extensive frostbite, urgently call an ambulance, control breathing, in case of loss of consciousness, give the victim a stable lateral position, and if breathing stops, carry out artificial ventilation of the lungs.

You can not lubricate the affected areas of the body with fat or ointments, rub them with snow, so as not to aggravate the cooling and not to injure the outer layer of the skin with ice.

When frostbite is combined with body cooling, it is first necessary to direct efforts towards general warming of the victim.

frostbite- tissue damage caused by prolonged exposure to low temperatures. During the Second World War, frostbite in the Soviet Army amounted to 1-3%, and in the German fascist - 10% of sanitary losses (Gamov V.S.). In the 16th German Army, which blockaded Leningrad in the winter (1941-1942), 19,694 people suffered from the cold. In peacetime, frostbite is incomparably more rare, and the most common factor contributing to frostbite is alcohol intoxication. The loss of a real assessment of one's own condition and weather conditions, and in some cases falling into a coma in cold weather, plus a simultaneous increase in heat transfer due to vasodilation caused by alcohol, contribute to the rapid development of frostbite and general freezing.

In most cases, peripheral parts of the body (face, feet, ears, nose, etc.) are subject to frostbite. The first place in the frequency of frostbite is occupied by the 1st toe, the fingers are in the second place. From exposure to low negative temperatures during dry frost, mainly open or peripheral parts of the body suffer. Cellular protoplasm is directly damaged, followed by tissue necrosis or degeneration. With prolonged intermittent exposure to damp cold, often occurring in spring, heat transfer increases. This leads to the development of the so-called "trench foot", which is a classic example of grade IV frostbite at above freezing temperatures. As a result of vasomotor and neurotrophic disorders, destructive changes can develop up to tissue necrosis, wet gangrene and sepsis.

Contact frostbite occurs when bare parts of the body (usually hands) come into direct contact with sharply cooled metal objects. Such frostbites are more often observed in wartime among tankmen, rocketmen, pilots, etc.

Chilliness is a kind of chronic frostbite of predominantly open parts of the body (hands, face, ears, etc.), often arising under the influence of systematic, but unsharp and short-term cooling. People who have experienced frostbite in the past are most susceptible to chills. Clinically, chilliness is relieved by edema, cyanosis, itching and paresthesia of the affected skin. In more severe cases, cracks and ulcers in the skin, secondary dermatoses and dermatitis may develop.

In the occurrence of various forms of frostbite and their severity, not only the duration of the cold effect is of great importance, but also numerous concomitant factors: increased air humidity and windy weather in the cold season, impaired blood circulation in the limbs from squeezing with tight shoes, clothing, constriction of the limb with a hemostatic tourniquet, increased sweating of the feet, wet clothes and shoes, neuropsychic depression, physical fatigue, exhaustion, blood loss, shock, etc.

To date, several classifications of local cold injury or frostbite have been proposed. So, T.Ya. Ariev (1943; 1966) proposes to distinguish between:

1) frostbite from dry frost;

2) contact frostbite that occurs at subcritical tissue temperature;

3) "trench foot";

4) chill.

One of the most consistent classifications, built on an etiological basis, in our opinion, is the classification proposed by B.S. Vikhriev et al. (1991), distinguishing between frostbite that occurs:

1) from the action of cold air.

2) with prolonged periodic cooling in a humid environment ("trench foot").

3) when immersed in cold water (immersion foot).

4) from contact with objects cooled to a low temperature (-40 °C).

When cold is applied to tissues, afferent impulses that occur in thermoreceptors enter through the conductive nerve pathways to the thermoregulation centers located in the hypothalamus. There is a response neurohumoral adaptive reaction aimed at maintaining temperature homeostasis. The resulting spasm of peripheral vessels leads to a decrease in heat loss from the body surface and maintenance of blood supply to vital internal organs: the heart, brain, kidneys, liver, etc. The occurrence of muscle tremors and other adaptive reactions aimed at maintaining the required temperature of the internal organs is characteristic. With the continuation of the action of cold, blood stasis occurs, aggregation of formed elements in the capillaries of the cooled zones. Microthrombosis in capillaries and, under unfavorable conditions, ascending thrombosis of arterioles and stem arteries are more typical for the moment of warming and in the first hours after it. In some cases, there is damage to the walls of blood vessels. Meanwhile, the cells of tissues that are in a state of cooling reduce their metabolic processes. After warming, the need for cells to increase metabolism increases dramatically, however, adequate delivery of oxygen and essential nutrients in unfavorable cases can be significantly hindered due to the resulting circulatory disorder. As a result, it is tissue ischemia that occurs at the time of warming and the first hours after it, which becomes the main cause of the development of subsequent necrosis.

The mechanism of tissue damage occurrence largely determines the clinical course of cold injury. Therefore, with the development of frostbite, and with a general cold injury, a pre-reactive period (before warming) and a reactive period (after warming) are distinguished.

Pre-reactive period with local cold injury, it is usually poor in its clinical symptoms. There is blanching and cooling of the skin, loss of sensitivity or paresthesia in the form of tingling, burning, etc. Determining the depth of damage during the cooling period is extremely difficult.

After warming up the clinical picture becomes much more diverse. Swelling of the skin develops, after a while blisters appear, with deep frostbite, tissue necrosis occurs. One of the early beneficent signs of superficial injury is warming and recovery of sensation after rewarming. Increased pain and lack of sensitivity after warming are characteristic of deep frostbite.

The depth and area of tissue damage during frostbite in the reactive period often becomes clear not immediately, but only after some time. Considering the difficulty of accurate clinical determination of the depth and spread of frostbite in the initial period, special research methods are used for diagnosis that determine the state of blood circulation in frostbite areas: thermal imaging thermography, scintigraphy, angiography. If muscle death is suspected, a biochemical test for creatinine kinase, an enzyme that enters the bloodstream during the breakdown of muscle tissue, can be informative.

The reactive period with deep frostbite is often divided into early and late, characterized by the development of necrotic processes. It should be noted that with the development of necrosis, the clinical course of local changes corresponds to the course of the wound process, which is characteristic of all necrotic wounds. Therefore, a number of authors (V.P. Kotelnikov, 1988; B.S. Vikhriev et al., 1991, etc.) distinguish during this period the phase of inflammation, the phase of development of necrosis and its limitation, the phase of scarring and epithelialization of wounds.

According to the depth of the lesion, frostbite, according to the classification adopted in our country (Ariev T.Ya., 1940), is divided into four degrees. I-II degree refers to superficial frostbite, III-IV degree - to deep.

At I degree superficial layers of the skin are affected. Signs of necrosis are not microscopically determined. After warming, pale skin becomes red or bluish for a while, peeling may be noted. Normalization of the skin condition occurs within one week.

At II degree part of the epidermis dies, which leads to its exfoliation and the formation of blisters filled with exudate, often light. The border of necrosis does not go deeper than the papillary-epithelial layer of the skin. After about a week, such blisters subside, and after about two to three weeks, the skin is completely restored.

With III degree the border of tissue necrosis passes in the lower layers of the dermis or at the level of subcutaneous fatty tissue. The resulting blisters often contain hemorrhagic exudate, their bottom is necrotic, often blue-purple in color, insensitive to pain irritations. After rejection of dead tissue, granulating wounds are formed.

With frostbite IV degree the underlying soft tissues are also necrotized, often with the involvement of the osteoarticular apparatus. With deep injuries, frostbite is often accompanied by a general reaction of the body, the affected part of the body swells sharply, becomes dark, with an unfavorable course, gangrene may develop.

It should be noted that the differentiation of tissues in deep frostbite into damaged ones - the actual zone of necrosis and into healthy ones adjacent to them, does not quite correspond to reality. With deep frostbite T.Ya. Ariev proposes to distinguish 4 affected zones. The first zone is the area of necrosis. He characterized the zone adjacent to it as the second zone of irreversible degenerative changes, where the surviving cells have an insufficient ability to regenerate, which manifests itself during the spontaneous healing of frostbite by the formation of long-term non-healing wounds and trophic ulcers. The third zone is the zone of reversible degenerative changes, where cells restore their regenerative potential, and where healing occurs without any problems. The fourth zone of late ascending processes is an area of late pathological changes that occur in ascending anatomical and physiological formations (endarteritis, thrombophlebitis, osteoporosis, etc.). This division largely predicts the clinical course of deep local cold injury and determines the tactics of treatment (the possibility of developing trophic ulcers, etc.).

With deep frostbite, the course of the wound process is often complicated by the development of abscesses, phlegmon and purulent streaks. Given that frostbite is most often localized in the area of the feet and hands, which have a large number of joints covered with a relatively thin skin-fat layer, frostbite IV degree often develop lesions of the osteoarticular apparatus in the form of purulent arthritis, osteomyelitis, etc. Lymphangitis may develop , lymphadenitis, erysipelas, thrombophlebitis, etc. General complications - shock, toxemia, purulent-resorptive fever and sepsis - most often occur with relatively extensive deep frostbite, spreading above the ankle, wrist joints, or, in cases of simultaneous damage, several parts of the body .

Frequent consequences of deep frostbite are joint contractures, arthrosis, osteoporosis, chronic osteomyelitis, neuritis, obliterating endarteritis, etc. The social and medical prognosis for IV degree frostbite depends on the presence of complications, the extent of the lesion and the level of amputation.

Immersion (immersed) foot. The defeat occurs as a result of intensive cooling of the limb in a highly thermally conductive medium - cold water. It is observed mainly in the conduct of hostilities at sea. Already during the stay in the water, a feeling of numbness quickly sets in, finger movements are difficult, cramps of the calf muscles appear, and swelling of the distal extremities. After the cessation of the action of cold, marbling of the skin is noted, swelling increases (it is not possible to remove shoes). The severity of the developed changes can be judged in the reactive stage (after 2-5 hours). With the defeat of the I degree, pathological changes (edema, hyperemia, pain) are eliminated after 10-12 days. Degree II lesions are characterized by the spread of edema to the level of the knee joints, the appearance of multiple blisters on the bluish-red skin, and weakening of muscle strength. These disturbances last from 2 to 5 months. With the defeat of the III degree, the edema lasts for a long time, the skin acquires a blue-green color, wet necrosis appears. The final diagnosis of the depth and prevalence of dead tissue is possible only after the demarcation of necrosis. The phenomena of the general intoxication are noted. In later periods, neurovasculitis often develops with degenerative changes and cicatricial degeneration of muscles, vascular lesions of the type of endarteritis.

Cold injury - damage to body tissues due to exposure to low ambient temperatures. The protruding parts of the body are more often affected: fingers, auricles, chin, nose. Such injuries are often combined with general hypothermia of the body and require urgent assistance.

Acute and chronic types of cold injuries - degrees of general frostbite

There are several different classifications of cold injuries, depending on the etiology, the depth of tissue damage, the development of the pathological process, and other factors.

Necessary to prevent the progression of pathological processes.

Cold injuries are acute and chronic:

Acute cold injury

Freezing (general hypothermia) is distinguished when the internal organs and systems of the body, and frostbite or frostbite (local hypothermia) - the development of tissue necrosis with secondary changes.

Chronic cold injury

Distinguish between cold neurovasculitis and cooling or chilliness.

General hypothermia has three degrees of severity:

Light degree

It is characterized by pallor and cyanosis of the skin, chills, difficulty in speech. Blood pressure is slightly elevated or normal, heart rate slows to 60 beats per minute. Local injuries of I-II degree are possible.

Average degree

The skin is pale, sometimes with a marble color, blood pressure is slightly reduced, the pulse is weak filling, reduced to 50 beats per minute. Body temperature is reduced to 32°C. Breathing is shallow, rare, drowsiness, impaired consciousness are noted. Frostbite of I-IV degree is possible.

Severe degree

Consciousness is absent, convulsions are possible. The body temperature is below 31 ° C, the pulse is low, 30-40 beats per minute, the blood pressure is sharply reduced. Breathing is weak, shallow, 3-4 times per minute. Severe and numerous frostbites are noted.

Types of frostbite according to the mechanism of development of cold injury

Frostbite may occur:

From exposure to cold air, most often develops at temperatures below -10 ° C and high humidity. The fingers of the feet and hands, protruding parts of the face (nose, ears, cheeks, chin) are affected.
From contact with environmental objects with a low temperature(up to -40 ° C and below) - contact frostbite. They are distinguished by a sharp decrease in temperature in the tissues.

Degrees of frostbite according to the depth of tissue damage

Depending on the depth of tissue damage, there are:

Frostbite I degree

It develops after a short exposure to cold. It is characterized by tingling of the affected area, then its numbness. The skin is pale with a marble color, after warming, edema develops, the skin turns red, peeling is noted.

Frostbite II degree

Appears with prolonged exposure to cold, partial
death of skin cells to the germ layer. The formation of blisters with transparent contents in the first days after injury is a hallmark of II degree frostbite. In the future, after warming, itching, burning, prolonged pain are noted.

Frostbite III degree

It develops after a long period of exposure to low temperatures, necrosis of all layers of the skin occurs. Bubbles with hemorrhagic contents are formed. Subsequently, granulations and scars appear on the damaged areas. After warming - intense prolonged pain.

Frostbite IV degree

There is damage to the skin and muscle tissue, bone tissue is often affected. Bubbles are absent, after warming, severe edema develops.

Rate -

Introduction

Losses from the cold in the troops were noted throughout almost the entire history of wars. Sometimes they reached very impressive numbers. So, Hannibal, when crossing the Alps, lost about 30,000 people, some of whom died of cold, and the rest lost their legs due to frostbite. During the defeat of Charles XII in Ukraine in 1709, 2000 Swedish soldiers died from the cold in one crossing. In 1719, during the siege of Trondheim, the Swedish army lost 7,000 frozen soldiers. Many authors note that during the Napoleonic campaign of 1812, frostbite and freezing were widespread. Although there is no exact data, but individual descriptions testify to this. So, Dr. Roussy saw 300 frozen soldiers near Smolensk near an extinct fire.

In the Crimean War of 1854-1855. the French had 5215 cases of frostbite, of which 22.7% died, the British - 2398 (23.8% died). In the Russian-Turkish war of 1877-1878. in the Russian army there were 5403 frostbites.

The absolute number of victims of frostbite during a long war is very large. During the First World War 1914-1918. frostbite numbered in the hundreds of thousands:

Italian army - 300.000 frostbite

French army - 150.000

English army - 84.000.

Often, sanitary losses from the cold were massive.

So, when crossing the Balkans in 1878 in the column of General Gurko, losses from frostbite in 2 days amounted to 813 people, and 53 people completely froze (6.1%).

In the Sarakamysh operation in December 1914 (Caucasus), the 9th Turkish Corps lost half of its strength, and in the 10th Corps more than 10,000 people froze to death in one night.

In 1942, at 75-78 km from Murmansk in the direction of Pechenga, during positional battles in the autumn-winter period, it rained for 2 days, and then frost hit at night. 2 divisions froze, one of them was ours. Now this place is called the "road of death." In 1974, I was there at the exercises - the deployment of the Front PGB.

In the besieged Leningrad in the winter of 1941/1942, about 900,000 people froze to death, however, they were hungry, emaciated people, dystrophics who froze either on the street or in houses.

In Korea (1949-1952), Americans suffered from frostbite up to 25% of all sanitary losses.

Thus, among the combat losses, frostbite occupied a significant place. In a combat situation at the front, conditions can be created for the occurrence of frostbite, and it is not possible to eliminate or reduce their harmful effects in the vast majority of cases. Unfavorable factors depend on the specific combat situation that arises on one or another small sector of the front, on the nature of hostilities, the power of enemy fire, meteorological conditions, and so on. and are not subject to active regulation for individual fighters. Therefore, frostbite should be considered as a special type of combat defeat.

1. Statistics

Localization and frequency of frostbite. In wartime, according to both domestic and foreign authors, over 90% of frostbite occurs in the lower limbs, 5-6% in the upper limbs, less than 1% in the face, 0.1% in other areas. In almost 5%, the upper and lower extremities are affected.

In the pathogenesis of frostbite, the duration of the action of cold plays an important role. In a combat situation, it is not easy to dry or change wet shoes, dry footcloths, while taking measures to warm hands is much more accessible, even in conditions of forced immobility. In addition, the lower extremities are constantly in close contact with the cooling medium in the form of snow, ice, cold mud, while the rest of the body is cooled mainly through the air.

The side of the lesion (right - left) has no difference.

Bilateral lesions were quite common (from 39 to 63%). Frostbite of 4 limbs is the most severe lesions, their frequency varied from 1.4 to 7.3% (according to different authors).

Frostbite of the genital organs in men are quite rare and do not exceed a few fractions of a percent.

Frostbite of unusual localization. This includes frostbite in the region of various protruding areas: the outer ankle of the tibia, the patella, the condyle of the radius, the inner condyle of the shoulder, the region of the costal arch, the scapula, the anterior-superior spine of the pelvis, the sacrum, the buttocks, and the heels. Frostbite of protruding areas usually occurs either when stationary, often due to injury, or during prolonged crawling in the snow, when the snow is stuffed into the sleeves or the tops of the boots.

A special place is occupied by frostbite of the proximal interphalangeal joints of the hands. When clenching the hand into a fist in order to warm the fingers, the nail phalanges come into contact with the palm, and the area of the interphalangeal joints becomes the most peripheral and therefore undergoes the greatest cooling.

Often there is a so-called sandal-shaped form of frostbite, in which, due to wet shoes, the plantar surface of the foot is affected.

Among frostbite, combined with injuries, frostbite of the wounded limb was observed in 32.2%.

2. Types of frostbite

1 - Frostbite resulting from the action of dry frost, i.e. at T below 00. Such frostbites make up the vast majority of peacetime frostbites. During the Second World War, they were often observed among pilots. These frostbites are localized almost exclusively in the most peripheral areas of the body (ears, nose, brow ridges, fingertips and toes). In most cases, the process is limited to soft tissues, but if it captures the bones, then mainly the terminal phalanges. The whitening of the skin constantly observed in such cases was, apparently, the basis for the assumption that the tissue fluid during frostbite of this form freezes and, thus, the temperature of the tissues falls below zero. This view is met with a number of objections:

1. Glaciation of tissue fluid can occur only as a result of a complete cessation of biological processes in tissues, in particular, with a complete cessation of blood circulation, innervation, cellular metabolism, i.e. when tissues become not a biological, but a physical object of cold action. Natural thermoregulation in these cases is excluded. But still, the physical properties of the skin and subcutaneous tissue (their poor thermal conductivity) are an obstacle to the penetration of cold into tissues.

2. The capillarity of the tissue structure and the high content of mineral salts in the tissue fluid cause a decrease in the freezing temperature of warm-blooded tissues to at least - 5 - 10 degrees. Thus, tissue freezing occurs only in severe frost.

3. For tissue damage as a result of freezing of tissue fluid, a long period is required, since short-term glaciation does not cause cell death. For example, freezing with chloroethyl.

4. As experimental data have shown, metabolic, circulatory and cellular nutrition disorders begin at tissue temperatures much higher than zero. If we take into account that the drop in tissue temperature occurs slowly and is accompanied by biological “resistance” of tissues, then severe pathological processes and cell death occur before glaciation and, thus, already dead tissues are subjected to glaciation. In any case, this is true for the whole organism, since the death of a warm-blooded one occurs at a body temperature of +220, +230, and the corpse is subjected to glaciation.

2 - "Trench foot" - frostbite that develops at T0 above zero, but in conditions of dampness, immobility, and difficulty in blood circulation. Cold exposure is repeated and prolonged. Suddenly, after the last warming, gangrene is found. The process, as a rule, is symmetrical on both feet - wet gangrene, accompanied by high fever and general severe condition.

Experimental studies (G.L. Frenkel) showed that complete cessation of blood circulation in tissues occurs at +10 tissue temperature, and its significant disorder is observed even at +19. Thus, it becomes clear that circulatory disorders lead to necrosis and tissue degeneration.

The pure form of the trench foot occurs, as a rule, during positional warfare, in autumn and spring. But varieties of the trench foot are also possible in dry frost, and during maneuver warfare, in particular, during reconnaissance, during military operations on the ice of lakes and rivers.

3 - Frostbite as a result of the action of a critically low temperature within 450-500 below zero (contact frostbite) in contact with metal objects. Therefore, more often such frostbite was observed in pilots, tankers.

4 - Chill - a chronic form of frostbite. The feet, hands, face, ears are mainly affected. Considered as chronic frostbite 1 tbsp. Most often occurs in people who have suffered frostbite 1 tbsp. With repeated cooling, edema, cyanosis, and various paresthesias occur.

3. Factors contributing to frostbite

I- Meteorological factors:

a). Increased air humidity (dampness) - contributes to the rapid action of cold, prevents clothes from drying out and leads to conditions conducive to increased heat transfer. The thermal conductivity of moist air is also increased, and therefore the body's heat loss increases significantly.

b) wind. First of all, exposed parts of the body suffer: ears, nose and other parts of the face, as well as those that are not sufficiently protected by windproof clothing (fingers, genitals), for example, in skiers making long transitions in open areas.

c) A sharp change in air temperature, especially a rapid transition from low temperatures (-10-15) to the point of melting snow (Larrey, the battle of Preussisch-Eylau, 02/10/1807) or from high temperatures to low ones.

As a rule, several factors act simultaneously. So, V.S. Gamov describes mass frostbite in a military unit that spent the night on January 10, 1934 in the steppe in Kazakhstan (Dzhungar pass). During the day a blizzard raged with sleet, by night the temperature dropped, the clothes were covered with an ice crust, the wind of great strength blew all night. The next day it turned out that half of the personnel of the unit received frostbite.

Mass frostbite was observed in February among a group of athletes who skied and hiked along the Gulf of Finland (D.G. Golman and V.K. Lubo), when during the day at a wind speed of 3 to 5 m / s the temperature dropped from -8 down to -22 with a simultaneous increase in humidity up to 90% and the formation of fog.

II - Factors that mechanically impede the blood circulation of the limbs:

a) tight shoes, compression of the feet by ski bindings, tight clothing;

b) hemostatic tourniquet;

c) transport immobilization.

III - Factors that reduce tissue resistance:

a) previous frostbite (according to Mignon, 2/3 patients with frostbite, who suffered in 1914/1915, received frostbite again in 1915/1916).

b) excessive and prolonged flexion of the limbs (forced posture or position);

c) local diseases of the extremities: endarteritis, varicose veins, hyperhidrosis.

IY - Factors that reduce the overall resistance of the body:

a) injuries (forced immobility), blood loss (hypoxia), shock (decrease in temperature);

b) poor physical development;

c) exhaustion and fatigue (according to DeBakay, 1958, 70% of frostbitten with a "trench foot" were in combat for 8 or more days);

e) disorder of consciousness (mental disorder, epilepsy attack);

f) the state of alcoholic intoxication (heat production and heat release are faster), as well as excessive smoking (vasospasm).

g) the morale of the troops (those who retreat are more likely to experience frostbite and freezing).

4. Etiology and pathogenesis of frostbite

Freezing of liquid in capillaries (and interstitial spaces are similar to them) occurs at T much below 00. In this regard, it is believed that the formation of ice in tissues for the first time occurs at a tissue temperature of -5 (Nogelsbach).

1). The first group of theories considers frostbite as a consequence of the direct action of low temperatures, which leads to icing of cells, causing their degeneration and death (Lewis, Green, Lay).

However, it is rather not ice formation that occurs (as a factor corroding, tearing, squeezing the protoplasmic body), but the cells suffer from the loss of the water they contain, dehydration associated with the formation of ice crystals in them (lyophilization of tissues) (E.V. Maistrakh, 1964) .

In clinical practice, there is no indisputable glaciation of tissues. The drop in temperature of tissues to -5-100 C, necessary for glaciation of tissues, even at the periphery of the body, can occur in a period only in a situation of lethal hypothermia. Frostbite is not freezing. Frostbite occurs more often precisely at temperatures above 00, especially during a thaw, which completely eliminates tissue glaciation (as with a “trench foot”). It is not a person that freezes, but a corpse.

"Biological zero" (Beleradek, 1935) - the temperature level at which the specific activity of one or another type of animal tissue stops.

This justifies the effect of "cold" anesthesia (reversible suppression of sensitivity and movements) (E.V. Maistrakh):

in a rat at T +150 C,

rabbit + 200

dogs + 280

person 31-250.

Fatal hypothermia occurs with T in the rectum:

in a rat + 13-150 C,

dogs 18-200,

person 24-260.

Maistrakh E.V.: the higher the organism is located on the phylogenetic ladder, the lower the amount of hypothermia necessary to suppress certain types of nervous activity.

Shade: the main effect of cold on tissues is to change the tissue colloidal state, the transition of the tissue protoplasm hydrosol into a hydrogel.

Ischemic theory (Marchand) - tissue hypoxia occurs due to vascular spasm.

Neuroparalytic theory (Wieting, 1913) - damage to the vascular innervation leads to vascular paralysis, and then erythrocyte stasis occurs.

The theory of thrombosis (Kriege, Hodara) - the cause of changes in frostbite is thrombosis. T.Ya.Ariev - conglomerates of agglutinated erythrocytes.

In fact, each of these theories explains a separate stage in the continuous action of cold.

Morphological changes are reduced to aseptic necrosis and inflammation.

Frostbite zones (T.Ya. Ariev, 1940):

1 - zone of total necrosis;

2 - zone of irreversible degenerative changes;

3 - zone of reversible degenerative changes;

4 - zone of ascending pathological processes (ascending endarteritis, neuritis, osteoporosis).

5. Biological features of the action of low temperatures

The more complex the organism is built, the more sensitive it is to the action of low temperatures.

Incomparably greater resistance of tissues, cells and protein in general to cold than to heat. In this regard, a rather significant duration of low temperatures is required, and the time factor in most cases is decisive for the occurrence of irreversible tissue changes. WhayneetDeBakey (1958): "Massive cold injury occurs only in wartime, only in cold or cold-damp weather, and only in combat tension."

Slowdown of biochemical and biological processes in a cooled area occurs after local thermoregulation begins to deplete, and tissue temperature drops (van't Hoff's law of slowing down chemical processes in the cold: at T = 00 in tissues, oxygen demand decreases by 760 times).

The latent nature of damage during the cooling period and the manifestation of these damages only after a certain period after the cessation of low temperatures. Cold, as it were, “preserves” tissues for the entire duration of its action. In the pathology of frostbite, therefore, 2 periods are distinguished:

Pre-reactive (hidden), which is characterized by blanching of the skin, cooling, loss of sensitivity;

Reactive (after warming).

The latent period is more correctly referred to as the period of general and local hypothermia.

6. Reversibility of tissue processes

Under the influence of low temperatures, tissue death most often does not occur: freezing of erythrocytes, and after all they are then used after thawing, although a certain percentage dies, therefore it is necessary to wash them first, i.e. remove hemolyzed (destroyed) red blood cells; freezing fruits (T = -12-180), and in fact they remain edible; recently, in 1999, a mammoth was discovered on the Taimyr Peninsula, frozen in ice, which had lain for many millennia, and nevertheless, French scientists were going to get sperm from it, and live ones, because they decided to impregnate an elephant with it and breed some new animal.

Thus, the cold has a preservative, not a destructive effect! Let's reverse the process! Moreover, A.Ya. Golomidov declared as early as 1955: “Frostbite IY Art. can not be. Frostbite IY Art. - the result of our wrong treatment!

7. Classification and diagnosis of frostbite

The classification was proposed by T.Ya. Ariev (1940), which is based on 2 principles:

1 - diagnosis of frostbite according to severity is possible only after tissue warming;

2 - the vast majority of frostbite captures muscleless areas of the body, mainly fingers and toes.

According to the depth of the lesion, 4 degrees of frostbite are distinguished.

Frostbite I degree.

Two features:

1 - with frostbite I st. in military conditions, the vast majority of the victims remain at the combat post;

2 - objective symptoms in most cases do not allow to decide whether there is a first stage of a more severe process or stable mild frostbite of the 1st stage.

Clinic: unbearable itching, stabbing and burning pains, aching joints, paresthesia; skin color is often dark blue, sometimes marble pattern. Edema is permanent, with deeper lesions the edema progresses. Unlike frostbite I st. with deeper lesions, the severity of objective changes increases towards the periphery. Signs of necrosis are not macroscopically determined.

Frostbite II degree.

The duration of tissue hypothermia is longer.

The border of skin necrosis passes in the horny, granular or in the uppermost zones of the papillary-epithelial layer. The pains are more intense, appear in the time preceding the development of the "latent" period, disappear in the latent period and reappear with the development of edema (2-3 days).

Clinic. Bubbles appear during the first two days, their contents are jelly-like, transparent, sometimes hemorrhagic. The bottom of the bladder is a pink epithelial cover, sensitive to mechanical irritation and alcohol application. The skin around the bladder is changed, as with frostbite I st. The phenomena of necrosis are absent, the structure of the skin does not change significantly. Granulations and scars do not occur, the nails grow again. Two stages of the disease can be distinguished: the stage of blisters and the stage of skin regeneration.

Frostbite III degree.

The duration of the period of tissue hypothermia and the drop in tissue temperature increase accordingly. The border of tissue necrosis passes in the lower layers of the dermis or at the level of adipose tissue. The pain is longer and more intense.

The development of the pathological process goes through 3 stages:

1 - stage of necrosis and blisters;

2 - stage of tissue resorption and development of granulations;

3 - stage of scarring and epithelialization.

Clinic. The skin is bluish, cold, dark or deathly pale. Blisters with hemorrhagic contents. The bottom of their blue-purple color, is not sensitive to mechanical irritation or to the application of alcohol.

After 5-7 days, when the first signs of demarcation appear, it becomes possible to establish frostbite with bone damage, i.e. IV degree. Reception for early definition of demarcation (Billroth): 1) establishment of the border of full anesthesia; 2) establishing the boundary of the difference in skin temperature.

Rejection of dead tissues begins on the 5th-7th day, more often with suppuration (less often under a scab). By 9-10 days, granulations appear. Scar healing (epithelialization in uncomplicated cases ends within 1 to 2 months). Descended nails do not grow at all or grow deformed.

Frostbite IV degree.

The boundaries of tissue necrosis pass at the level of the bones and joints of the limbs. Distal from these boundaries, total necrosis of all tissues occurs, incl. and bone. In the future, mummification or gangrene develops. If the border passes at the level of the diaphysis, then the final demarcation is delayed for many months.

Clinic. The affected area is pale or cyanotic, cold, covered with dark blisters, the bottom of which is purple in color and has a typical vascular pattern. The border of necrosis can be determined on the basis of the persistent disappearance of pain, thermal and deep muscle sensitivity within 3-5 days. A distinct demarcation furrow is formed, on average, on the 12th day.

4 stages of the process:

1 - formation of a distinct demarcation furrow;

2 - stage of rejection of dead tissues;

3 - stage of development of granulations;

4 - stage of scarring and epithelialization of the scar.

With a significant spread of frostbite IYst. severe general symptoms develop: high fever, blood leukocytosis, colds, kidney irritation (protein in the urine).

The outcome of frostbite IYst. in all cases is the rejection of dead tissue and the formation of a stump.

A special type of frostbite IYst. is the "trench foot". There are light (anesthesia, pain, swelling, redness), medium (bubbles, limited scabs) and severe forms (gangrene and the development of septic complications).

Frostbite complications.

group 1 - purulent complications of damaged tissues (6%), lymphangitis (12%), lymphadenitis (8%), tetanus (4% of all cases of tetanus), sepsis;

Group II - acute infections without suppuration (neuritis, arthritis);

Group III - metabolic disorders: pigmentation (melanosis), calcification, elephantiasis, endarteritis, ulcers of the extremities;

Group IY - endocrine disorders, the formation of subcutaneous connective tissue nodes.

General diseases (rather not complications, but companions): bronchitis, otitis, laryngitis, rhinitis, pneumonia, diarrhea, sorbut.

8. Prevention and treatment of frostbite

frostbite limb treatment

Prevention. Regular drying of shoes, provision of warm clothing, timely greasing of shoes, appropriate socks, wearing comfortable non-compressive shoes, changing wet clothes. General hardening. Rapid evacuation of the wounded from the battlefield (on Damansky Island, the wounded lay on the snow for 12 or more hours, even 18-20).

Treatment in wartime.

Persons with frostbite 1 tbsp. treated in KV Omedb.

Persons with frostbite II degree, who have retained the ability to move, are subject to referral to the GLR.

Persons with frostbite III-IYst. are subject to referral to a general surgical hospital or to a specialized hospital intended for the treatment of thermal injury and called SVHG for burned patients.

However, the difficulty lies in the fact that the depth of the lesion can be determined only after a few days.

The fundamental question remains, what is the provision of assistance to the affected, who arrived in the latent period: to warm the actively affected part of the body (limb) or not? It is fundamental because the provision of first and first medical aid in the latent period predetermines the outcome.

The difficulty lies in the fact that both in the "Instructions on military field surgery", and in textbooks and manuals, even the latest editions, there is a lot of confusion - an attempt to combine two opposing methods: active warming of the limb (as a tribute to the past), and isolation her from external heat and warming her from the inside (modern approach). Therefore, we will have to consider both methods in detail.

At the XXIY All-Union Congress of Surgeons (1934), the position of the school of S.S. Girgolava and T.Ya. Ariev about the need for rapid warming of tissues during frostbite to quickly restore blood circulation in the affected limb, while slow warming of the tissue is doomed to further hypoxia. Active warming was achieved by massaging the affected limb and using baths with an increase in water temperature from 180 to 380 C for 30-40 minutes and continuing the bath itself for another 40-50 minutes.

However, already at that time there were opponents of rapid warming - M.V. Alferov (1939), D.G. Goldman (1939). They believed that when the tissues are warmed from the outside, when their vital activity is restored, the need for oxygen increases with the blood circulation still insufficiently restored. In developing these ideas, A.Ya. Golomidov (1955), on the basis of experimental data and clinical observations, proposed his own principle of treatment: using a heat-insulating material, isolate the limb from the effects of external heat and carry out general warming of the patient, achieving warming of the frostbitten limb from the inside. The method found its followers (A.N. Dubyaga, N.K. Gladun..1976), who, having tested it on themselves, brilliantly demonstrated it to patients. It would be desirable for everyone to read their article in the Bulletin of Surgery, No. 9 - 1976.

However, until the mid-1980s, the direction of Aryev continued to dominate. So, at the plenum of the All-Russian Society of Surgeons, the head of the All-Union Burn Center (A.V. Vishnevsky Institute), MD. V.I. Likhoded stood for forced rewarming. The WPH guidelines and textbooks recommended the method of active rewarming. At present, in the light of modern knowledge, the method of forced external heating of tissues, in the form in which it was proposed by S.S. Girgolav and T.Ya. Ariev, is not only ineffective, but also harmful (V.P. Kotelnikov, 1988).

Indeed, if we turn to the structure of the structure of tissues, for example, a finger, recall the vascular theories of the pathogenesis of frostbite and imagine that both the main feeding vessel and the capillaries extending from it and going to the surface layers are clogged with immobile erythrocyte sludge, i.e. there is no blood circulation as such, and at this time massage and active warming of the surface layers with hot baths are carried out. What happens? These layers warm up from the outside, the metabolism in them increases, the need for oxygen increases, and its supply is not provided, since the vessels are impassable. There comes asphyxia of tissues, here you have necrosis! Therefore, before warming, it is necessary to restore the fluidity of the blood.

Principles of treatment according to A.Ya. Golomidov (not so much treatment as assistance):

1. Applying a heat-insulating bandage to the injured limb from any available material with poor thermal conductivity (blanket, padded jacket, thick cotton-gauze bandage). The dressing should be applied outdoors, before bringing the victim into a warm room, in order to prevent exposure of the skin to external heat.

2. Given that fabrics exposed to cold are fragile, it is necessary to use a transport tire, i.e. fabrics should be treated with respect! A.N. Dubyaga in his article cites the following observation: a woman who was naked on the street at T = -400C for 10 hours was bandaged and splinted by students of the medical institute who were on duty at the hospital, holding her foot by 1 toe. Subsequently, necrosis of the IY stage occurred. just this finger.

3. Inside - hot sweet tea with small doses of alcohol.

Subcutaneously - vasodilating drugs (papaverine).

Intra-arterially - 200 mg of acetylcholine, 5000 units. heparin in 20 ml of 0.25% novocaine solution.

Intravenous - heated to 39-400 C solutions: glucosone-vocaine mixture (300 ml of 0.25% novocaine and 700 ml of 5% glucose solution), gemodez, reopoliglyukin, saline solutions, i.e. solutions of rheological action.

The heat-insulating dressing and splint are removed after full recovery of sensitivity. Movement in the joints of the limb should not be started until the bandage is removed, otherwise they may be damaged!

Co-author of the article N.K. Gladun conducted experiments on himself. Was on the street for 4 hours at T = -400 C with open ears. Then, on the street, they put a heat-insulating bandage on his ears, inside the room - warming from the inside, the bandage was removed after the restoration of sensitivity. There was no frostbite.

With regard to providing assistance in MP, the Golomidov method can be (and should!) Be implemented almost completely, with the exception of intra-arterial administration of drugs, and intravenously administered heated solutions are already a lot, of course, a thermal insulating bandage and immobilization must be applied.

As for surgical treatment, it is indicated when necrosis of any degree occurs, and treatment should be carried out in wartime at the stage of specialized care, and in peacetime - in the hospital.

It should only be emphasized that the primary surgical treatment consists of necrotomy and necrectomy, i.e. stretched out in time.

9. Freezing

Freezing is a common pathological hypothermia of humans and animals.

Human heat sensation is formed under the influence of 3 meteorological factors: temperature, humidity, wind speed. The combination of their actions is called "effective temperature", which determines the occurrence of freezing, which is based on a violation of the thermoregulation of the body.

Hypothermia are divided (I.R. Petrov, E.V. Gubler, 1961) into:

1 - physiological (winter hibernation of animals);

2 - artificial (therapeutic and prophylactic);

3 - symptomatic (with pathological processes - severe poisoning, diseases, etc.);

4 - pathological (external cooling).

Clinic and classification of freezing.

Initial symptoms (A.V. Orlov, 1946): a feeling of weakness, turning into adynamia; drowsiness and then loss of consciousness; dizziness, headache, increased saliva and sweat.

There are 3 stages (A.V. Orlov):

adynamic stage. Consciousness is preserved or clouded. Weakness, fatigue, dizziness, headache. Speech is articulate, intelligible, but quiet and slow. T rectal = + 34-320 degrees.

Stuporous stage. Drowsiness, depression of consciousness, impaired speech, a meaningless look, lack of facial expressions are on the 1st plane. T \u003d + 32-300. Pulse - 30-50 beats. BP is about 90 mm Hg. There are no deep respiratory failures.

Convulsive. The latest and heaviest. Consciousness is absent. The skin is pale, on the exposed parts of the body slightly cyanotic, cold to the touch. The muscles are tense, trismus is pronounced, the tongue is bitten. Upper limbs in the position of convulsive flexion contracture. In especially severe cases, the abdominal muscles are tense. Breathing shallow, wheezing, irregular rhythm. Pulse of weak filling, threadlike, rare, in some cases arrhythmic. Involuntary urination or complete urinary incontinence. The pupils are constricted, the reaction to light is sluggish or absent. Eyeballs sunken (enophthalmos). The eyelids are usually not completely closed. T \u003d + 30-280. Revival is possible.

Complications:

disorders of the nervous system;

disorders of the cardiovascular system, which are especially dangerous when warming, acute heart failure may develop;

pneumonia;

dysfunction of the stomach (in those who are frozen at autopsy on the gastric mucosa of the Vishnevsky spot);

exacerbation of tuberculosis.

Treatment largely depends on the stage of freezing.

At the adynamic stage, all means can be used: self-heating at room temperature; inside - hot tea, alcohol; intravenously 40-60 ml of 40% glucose, calcium chloride 10% - 10 ml.

However, in more severe forms of freezing, the use of stimulating treatment, the introduction of drugs that enhance metabolism (glucose, caffeine, strophanthin, adrenaline), aggravated the condition and led to death.

It must also be remembered that general hypothermia, as a rule, is accompanied by local tissue changes, primarily on the limbs. Therefore, active general warming should be carried out according to the principle of warming from the inside.

Conclusion

In peacetime, general freezing is much more common than diagnosed:

there are no electrothermometers in medical posts, and it is impossible to fix the temperature below 34 degrees with medical thermometers;

sometimes death from freezing was regarded as dystrophy;

mild degree responds well to treatment.

Peculiarities of cooling people in case of ship accidents at sea.

In the world, about 200,000 people die every year as a result of maritime disasters, of which 100,000 die along with ships and ships, 50,000 die directly in the water after a shipwreck, and 50,000 die on life-saving equipment before the rescue ships arrive, and in conditions that are not really deadly. Cause of death: hypothermia, inability to swim, neuropsychic stress.

A feature of cooling in water is the predominant effect of cold on the spine (spinal cord). Due to the sharp cooling of the spinal vascular centers, the latter can stop functioning simultaneously with the bulbar centers or even before them. Rhythmic contractions of the heart are weakened, extrasystoles and fibrillation occur, then cardiac arrest. The activity of the respiratory center may initially be enhanced by hypoxic excitation. Then the breathing stops.

Hypothermia as a degree of danger to life is often underestimated. The water temperature, at which a person immersed in it does not lose heat, should be about 100 C higher than air, and reach 33-340 C. At a water temperature of +40, a person loses consciousness after 12 minutes, death occurs within 1 hour. At T \u003d +180 C, death occurs after 3 hours. So, at the sinking of the ship "Laconia" after 3 hours, 113 people in life jackets were found dead.

Swimming helps to increase the formation of heat in the body, but it is advisable only when the T of water is above 25 C. At a lower T, swimming leads to an increase in conventional heat. Therefore, in cold water, immobility should be advised to victims in life jackets.

Hypothermia also occurs in people in boats and longboats. At T = +50 and below, no more than 42% of victims survive.

The psychological state is of great importance. The West German auto-training specialist H. Lindemann crossed the Atlantic Ocean alone in an inflatable boat. He sat continuously for 72 days. Ulcers should have formed on the buttocks, and from sea water, sun and wind - cracks and abscesses on the arms and legs. But his self-hypnosis and psychological preparation prevented this. More than 100 young people after the successful voyage of H. Lindemann tried to repeat the experiment, but only one survived.

The main principles of assistance after extraction from the water and treatment are:

dressing in warm dry, preferably woolen, underwear;

inside hot tea with alcohol;

bed rest.

Active warming in the bath, massage, the use of intravenous glucose, vitamins and other stimulants are an additional burden on the heart, which can lead to its stop.

As a result of the accident of the Komsomolets nuclear submarine, 59 sailors were overboard: 28 sailed to the raft and climbed on it, 31 people remained in the water, some of them held onto the raft with their hands. After 75-80 minutes, the mother ship "A. Khlobystov, 30 victims were rescued: 23 (out of 28) were removed from the raft, 7 (out of 31) were pulled out of the water. Of those rescued from the water, 3 more people died on the same day ... Most of them had: lethargy, adynamia, drowsiness, a tendency to bradycardia and a decrease in blood pressure. Some (of those who were on the raft) were observed: some excitement, chills, muscle tremors, cyanosis of the lips, pallor of the skin, mucous membranes, a tendency to tachycardia and increased blood pressure. Everyone was placed in warm cabins, dressed in warm dry linen, wrapped in blankets, and given hot tea with 30-40 ml of cognac. Those in the most serious condition were placed in baths with warm water 38-400 C, they were also injected subcutaneously with cordiamine or caffeine. Three, feeling better, suddenly died after the first puff of cigarettes (inadequate reaction of the coronary vessels to nicotine). The fat people survived. (V.T. Ivashkin et al., 1989, VMZH, N 11).

And at the end of the lecture, you should draw your attention to the fact that it is not someone else in the unit, namely you, who will be engaged in the prevention of both frostbite and freezing, for which you must prepare an appropriate draft order during the transition from summer to winter.

Literature

1. Petrov S.V. General surgery: teacher of universities. - M.: GEOTAR-Media, 2005-2010. with CD.

2. Gostishchev V.K. General surgery: textbook. - M.: GEOTAR-MED, 2006. -608 p.

3. Chernov V. N. General surgery. Practical lessons: Proc. allowance for medical universities / V.N. Chernov, A.I. Maslov. - M.; Rostov on Don: Publishing house. Center "March", 2004. -256 p.

4. Care of surgical patients. Textbook for medical students. institutions. Ed. prof. V. A. Privalova. Chelyabinsk, 1992.

5. Anesthesiology and resuscitation / OA Dolina. - M.: GEOTAR, 2007.

6. Abaev Yu. K. Wound infection in surgery: Textbook for postgraduate medical students. education. - Minsk.: Belarus, 2003.

7. Topical issues of drug therapy of malignant tumors. Chelyabinsk, 1996.

8. Andreitsev A. N. Cases of group damage by atmospheric electricity. // Clinical Medicine, 1990, T68, No. 5.

9. Anzhigitov G. N. Osteomyelitis. M., Medicine, 1998 - 228 p.

10. Andrievskikh I. A. Hereditary roots of surgery: textbook. - Chelyabinsk: ChklGMA, 2010.