UD 6-81-4 E

A Guide to Cold Weather Operations

Booklet 4

Frostbite and other injuries

HEADQUAKTERS DEFENCE COMMAND NORWAY THE ARMY STAFF 1987

UD 6-81-1 E (English edition) A Guide to Cold Weather Operations - booklet 4 Frostbite and other injuries has been issued for use by the allied wintercourses and foreign units exercising under Norwegian command.
Oslo December 1987.

D. Danielsen Major General Inspector General of the Norwegian Army

A. Pran Brigader Inspector of Infantry

UD6-81 E A GUIDE TO COLD WEATHER OPERATIONS includes:

UD6-81- l E UD6-81- 2 E UD6-81- 3 E UD6-81- 4 E UD6-81- 5 E UD6-81- 6 E UD6-81- 7 E UD6-81- 8 E UD6-81- 9 E UD6-81-10E

(Booklet (Booklet (Booklet {Booklet {Booklet {Booklet (Booklet (Booklet (Booklet {Booklet

1) Winter Conditions 2) Personal Clothing 3) Food 4) Frostbite and Other Injuries 5) Movement 6) Bivouacs 7) Cold Weather Equipment 8) Field Works and Camouflage 9) Snow, Avalanches and Rescue 10) Weapon effects

CONTENTS

Para Page Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l 6

Physiology General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physiological temperature regulation . . . . . . . . . . . . . . . . . . . . . . Temperature regulation through action . . . . . . . . . . . . . . . . . . . . Fluid balance in the body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Vital needs Water . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Food . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tolerance to cold

2 3 11 14 16 17 18 20 21 22 23 23 25 26 27 28 29 30 31 32
33

7 8 10 11 12 12 12 13 13 13 13 13 13 13 13 14 14 14 14 14
16

Acclimatization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Geographical and ethnic origin . . . . . . . . . . . . . . . . . . . . . . . . . . State of nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical stamina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Physical activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Environmental factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alcohol/Smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Medicines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Earlier cold injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ulness and injury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Wind . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prevention of cold injuries Hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The skin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The hands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The clothes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Latrine hygiene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34 35
36 37 38

16 16
16 16 17

Frostbite General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Local frostbite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Advanced cold exposure (Hygothermia) . . . . . . . . . . . . . . . . . . .

39 40 47

18 18 22

Other injuries

Sunburn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Snowblindness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Carbon monoxide poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

51 53 56

26 26 27

FIGURES

Figure l Temperature regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 2 Heat loss through convection . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 3 Heat loss through radiation . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 4 Chilling effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 5 Parts of body exposed to frostbite . . . . . . . . . . . . . . . . . . . . . . Figure 6 Palm of hand over ear, nose, cheek . . . . . . . . . . . . . . . . . . . . . Figure 7 Hands in armpit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 8 Feet against belly of a companion . . . . . . . . . . . . . . . . . . . . . . Figure 9 First aid with local deep frostbite . . . . . . . . . . . . . . . . . . . . . . . Figure 10 "Foetal" position . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 11 Makeshift snow and sun goggles . . . . . . . . . . . . . . . . . . . . . . . Figure 12 Three-cornered headscarf . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Page 7 9 9 15 19 20 20 21 21 25 27 27

INTRODUCTION

1. In cold weather alertness must be shown both by offieeres and men to secure smooth bodily functioning. The body temperature must be maintained by means of correct clothing and shelter, full utilization of food and drink and the least possible loss of energy. All cold injuries can be prevented! Treating such injuries is usually very demanding and often resuits in some degree of disablement. There is probably no place in medicine where the adage "Prevention is better thand cure" is more appropriate than nere. A considerable part of this booklet is therefore about the human body's protective mechanisms against cold exposure, the impact of the environment, and our own powers in withstanding impairment and injury. The preventive measures we recommend are resuits of bitter experience during cold weather operations in war and peace and recent research in Nato countries.

PHYSIOLOGY
General

Man's internal body temperature is regulated accurately at a constantly high level regardless of fluctuations in the exteraal temperature. Measures in the anus the body temperature is 37 C. In order to maintain normal functions this temperaturemust be keptconstant (maximum variations +/- 0.5 C). If the temperature reaches too high or too low a level, damage is inflicted on the body, which in the worst event can lead to death within a short time. The temperature of the skin, however, vanes a lot accordmg to the temperature of the environment, With clothes on, and at normal room temperature, the average temperature of the skin is 32-35 C, which is comfortable for a person. In other words, next to the skin we have a "tropical micro-climate". The temperature regulation is either physiologically based or determinert by our actions.

Figure l Temperature regulation

Physiological temperature regulation 3. The physiological temperature regulation is controlled by a centre in the brain (hypothalamus), which is independent of our own will (autonomous). a) Heat production - the basic heat production - the extre heat production.

b) Heat loss: - the circulatory regulation - perspiration.

4. The heat production in the human organism is based on chemical energyreleasing reactions. Heat production is part of the general transformation of energy and matter within the body {metabolism) and is always proportional to the activity level of this process.
5. The basic heat production is the minimum heat production which is always at work within the cells, for instance during the transformation of food into high-energy combinations or into elements for the building up of cells. Consumption of protein-rich food, for example meat and fish, will increase heat production by up to 25% a few hours after intake of this food. Fat and carbohydrates speed up metabolism to a lesser degree,

6. The extra heat production has the ability to increase metabolism by muscle contractions, in the form of physical activity or shivering. Heat production through physical activity provides most heat. With moderate physical activity metabolism increases to about 12300 kilojoules per day. Moving on skis with a heavy pack can raise the calorie requirement to about 28700 kj/day. If the body temperature drops below 37 C, a light trembling will start which can be subdued temporarily by willpower. With a body temperature of 36 C the shivering will be very pronounced and hinder movement and speech, and it cannot be checked by will. In this way heat production can be raised by 100-200 per cent, but continued shivering will deplete the body's energy reserve and exhaust the person. 7. Thus, heat production can be influenced as follows: - by eating, which will produce extra heat - by working (the harder we work the more heat we produce) - by being cold, which produces extra heat through shivering.

8. Heat loss. The body's heat loss to the surroundings chiefly occurs in four different ways:
a) By convection. The heated air layer next to the skin escapes and is replaced by cold air (convection principle). It is felt clearly when we are exposed to strong, cold wind or when we fall into water with little clothing on.

Figure 2 Heat loss by convection

b) By conduction. Contact with the body, for instance from the surface one is lying or sitting on, "steals" heat from the body (conduction principle).
c) By radiation. When a person is at rest in a moderately heated room, about 70% of the total heat loss is by radiation. Evaporation then accounts for about 25% of the heat loss.

Figure 3 Heat loss by radiation

d) By evaporation. We have a heat loss when perspiration on our skin, and in our clothing, evaporates. With physical activity evaporation is the dominant heat transfer vehicle (takes care of more than 50% of the heat loss).

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9. In order to achieve a stable body temperature, the heat loss to the surroundings is regulated accurately by means of the circulatory regulation and the regulation of the evaporation of sweat.

a) The circulatory regulation. The blood circulation in the skin and under it determines the heat conductivity of the skin. Under the impact of cold the blood vessels of the skin contract, the blood stream is reduced, the temperature of the skin drops and the skin insulation increases. tinder the influence of heat from outside the blood vessels expand, the blood stream increases, the temperature of the skin rises and insulation is reduced. The circulatory regulation is most effective in arms and legs,
b) Regulation of the evaporation of sweat. Through the evaporation of one litre of sweat no less than 2380 kilojoules are given off from the body to the surroundings. It is essential that the sweat should evaporate. If it runs off the body the result will be a fluid and salt loss, but no heat loss. The perspiration mechanism is effective but not as precise as the circulatory regulation.

10. Heat loss through the respiratorypassage is a result of constant heating of the exhaled air and loss of saturated water vapour. The heat loss is a combined loss through convection, conduction, radiation and evaporation, but is not subject to any controlled regulation. The heat loss is estimated at about 820 kj per day and the fluid loss at about 300 ml per day. In Arctic regions with dry severe cold the heat loss through the airways can be considerable; it may amount to 10 per cent of the total heat loss of the body.
Temperature regulation through action 11. Temperature regulation through action means: - changing one's clothing - changing one's accommodation - avoiding cold - willed physical reactions (indirectly influenscing metabolism),

12. Man*s ability to adapt to colder climates depends on behavioral changes, because the physiological changes in the human organism are negligible and of little importance. Only under a heavy and protracted impact of cold will there be a certain degree of physiological adaptation, which, however, will soon wear off if the influence of the cold is removed. 13. For our clothing to become effective we must keep an eye on the parts of the body that are most susceptible to heat loss. Much of the body heat will escape from an uncovered head and a bare neck: - at + 5 C 50 per cent escapes - at - 15 C no less than 75 per cent escapes.

11
The head and the neck are therefore important parts of the body when it comes to loss of heat (when bare-headed and with shirt open at the neck) and stopping heat loss {through the use of cap, scarf and headover). Hands, feet, ears, the nose and the penis are most exposed to cold injuries. Small cylindrical parts of the body, like fingers, have a heavy heat loss becase the surface is large in relation to volume. Through the use of mittens instead of gloves the total surface is reduced and it becomes easier to keep the hand warm.
The fluid balance in the body

14. The human organism contains about 60 per cent water. The kidneys excrete waste matter from metabolism and regulate the excretion of water and matter (electrolytes) from the body so that the composition and amount of the tissue fluids are kept constant. If there is a larger water deficit than two litres in the body, the kidneys will not be able to compensate for the loss, which in turn will lead to serious disturbance in body functions. When there is a water loss of about 12 per cent, death may occur. When the amount of water in the body is too low the condition is called dehydration. Dehydration is one of the most treacherous and dangerous risk factors in connection with cold injuries. Dehydrated soldiers have: - reduced temperature regulation ability - reduced resistance to cold weather - reduced physical performance,
15. The fluid loss from the body is large for soldiers on duty in cold weather. The high physical acttvity means that perspiration is in the order of several litres per day. In addition, we constantly lose fluids through the skin and from the respiratory organs while sleeping. The incisible evaportation is surprisingly high, about half a litre per day. Even a moderate degree of cooling has a disturbing effect on the kidneys and increases the secretion of water through the urine. Some substances (particularly salt) and drinks (especially coffee and tea) dehydrate. Thus we should take as little of them as possible. When losing a lot of fluids in the cold we do not feel a corresponding thirst But when the colour of the urine changes from light yellow to dark yellow, orange or brown, it is a sign for dehydration. Early symptoms are also a feeling of weakness, fretting, constipation and increasingly: disturbed consciousness. Consequently, we have to provide the organism with sufficient fluids in cold weather.

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VITAL NEEDS

Water 16. Water is a prerequisite for the normal chemical balance in the body, and for the normal functioning of vital organs. In cold weather water intake should be at least 2Vi litres per day (in addition to the water that forms part of the food) to avoid dehydration. Because of the danger of infection in stomach and intestines water should only be tken from approved supply sources. All water that is consumed in the field should be chlorinated.
Food
17. Personnel in correct clothing and in protected surroundings do not require a higher calorie intake because of the cold. The need for an increased intake occurs when we are required to move with heavy field pack in snow, either on foot, on skis or on snowshoes (an increase from 16400 kj to 28700 kj per day). It's always a good thing to warm up food and drink because it adds considerably to body heat. In cold surroundings the body temperature stays higher during the night if a meal is tken just before bedtime. If we are to operate in the cold for any length of time we ought to eat more fat in relation to protein and carbohydrates, because one gram of fat gives the organism three times as much energy as one gram of protein or of carbohydrates.

Sleep 18. Sleep is the best form of rest. To be able to maintain normal activity, physically and mentally, for a considerable period of time, we need at least six hours's uninterrupted sleep per night under safe and peaceful circumstances. Lack of sleep will particulary affect our mental performance such as reaction time, learning ability, the ability to carry out complicated tasks, alertness, etc. During operations of about one weeks's duration there will be a dramatic reduction in the performance of those who get less than 3-5 hours of sleep per night. You will not feel cold during sleep unless you are exhausted. A healthy person will wake up a long time before the danger line for hypothermia has been reached.

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TOLERANCE TO COLD
19. Tolerance to cold varies a good deal from one individual to another and is in-

fluenced by a number of factors, both physical and mental ones.

Acclimatization 20. Actual physiological acclimatization can only be achieved to a limited extent, and only after a long and heavy impact of cold.

Age 21. Within the age limits apply in the Services, age is of little consequence. The youngest soldiers are most resistant to cold injuries the oldest somewhat more susceptible.
Geographical and ethnic origin 22. Negroid people seem more prone to cold injuries than others. This is thought chiefly to be due to environmental factors and no earlier chance to getting

used to cold weather.

State of nutrition 23. Undernourishment and hunger will greatly reduce the tolerance to cold, as will also a deficit of water {dehydration}. Physical stamma 24. Good physical form is of the utmost importance in order to achieve a high de-

gree of tolerance.
Physical activity

25. Too much activity will lead to a large loss of body heat (energy) and increased
perspiration. Moisture in the clothes reduces their insulating capacity significantly. The danger of hypothermia grows with inactivity, which results in less

heat production and a subsequent drop in body temperature, particularly in

arms and legs.
En vir omen tal factors 26. Frostbite comes easily to passive soldiers with a negative attitude, who do not like to exert themselves, and who neglect preventive measures suen as using toe covers and changing socks when necessary. Overactive soldiers sweat a lot, and thus the insulating capacity of the clothing is reduced, with the consequences that this may entail.

Discipline 27. A high degree of discipline is essential in cold weather operations. Every officer has a responsibility to check that preventive measures are carried out. Sol-

diers who are to take part in winter combat operations can only master their
tasks if they possess self-discipline. So, the training for winter duty must strengthen that quality.

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Alcohol and smoking

28. Consumption of alcohol leads to an increased blood stream in the skin and subcutaneous layer, thus increasing the heat loss of the body. The resulting shivering is lessened by alcohol, the judgement of the person is weakened, and the danger of hypothermia and frostbite increases considerably, Tobacco smoke contains nicotine, which contracts the veins so that the blood circulation is slowed down. This increases the risk of frostbite.
Medicines

29. Some dmgs affect blood circulation and perspiraton. Seek advice from the unit medical officer in case you take medicines regularly.
Earlier cold injuries 30. A previously frostbitten person runs a considerably heightened risk of developing frostbite later, particularly after deep local frostbite, trenchfoot and lifebout foot (se paragraph 41).
Illness and injury 31. Cases of illness and injury pose special risks during cold weather operations because such conditions mean that the soldiers are kept inactive and thus run a greater risk of hypothermia. Several diseases involve reduced or badly disturbed temperature regulation. Blood loss or circulatory failure after injury reduces the blood supply to arms and legs and make these limbs prone to frostbite.

Wind 32. The body produces and loses heat all the time. Wind increases the heat loss by reducing the thin layer of warm air which is next to the skin. This loss is proportionate to the wind velocity at the time. When air temperature is below 0 C, and the wind is so strong that it removes the warm air faster than the body can replace it, frostbite may occur. A drop in air temperature or an increase in wind velocity has the same effect on bare skin.

15

Temperature at calm
-10" -20 -30
-40D -50 -60D

Gentle breeze 5 metres/sec

Fresh breeze 10 metres/sec

Moderate gale 15 metres/sec

Figure 4

Chilling effect
The table shows how the chilling effect on bare skin increases when the wind velocity rises. The combination of moderate temperature and wind can be more dangerous than servere cold and calm.

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PREVENTION OF FROSTBITE

Hygiene 33. Everyone is responsible for himself and his own health. In the winter we raust also check that this responsibility is exercised by all personell. Good hygiene can be practised even at low temperatures and even if the supply of clean water may be limited. The skin 34. Don't go out into the cold just after you have washed or shaved since soap and water remove the natural layer of fat from the skin. Rub vaseline or another cream not containing water into the skin in order to counteract the dehydrating effect of the cold air. Massage hands and face before you go out in severe cold. When you are out: make faces to keep the blood circulation going. At frequent intervals the officers are to order soldiers to walk together in twos to watch for white spots on the skin of their faces. Wash armpits, crotch and feet more than once a week. Snow washing or snow bathing goes a long way towards substituting for washing with water when conditions lend themselves to it.
The feet 35. Keep the feet clean, dry and warm. If your feet are cold it is difficult to keep warm even if you dress warmly. We must always carry an extra pair of dry socks with us in the rucksack for use during the night. The boots have toe be large enough for the toes to move freely. Use toe covers when mo ving, and foot bags when you are on stationary duty. If your men have cold feet during a ski march, ask them to take the skis off and continue the march on foot. Af ter a unit has pitched camp, the unit commander is to order a foot inspection. All personnel will remove their footwear and the officers will check their feet.

The hands 36. Don't touch metal objects with uncovered hands. Use woollen mitts covered in windproof mittens. Don't hang the mittens on the ski poles during halts. Instead, put them under your field jacket. The clothes 37. A good mnemonic rule for clothing under cold weather conditions is to keep reasonably cool all the time. Wool next to the skin is best. Rather several thin layers of clothing thanfew thick layers! One windproof layer on the outside. Make use of the opportunity that the field uniform offers of airing at the wrists and at the neck. Use braces instead of a belt. This provides better air eir culation. Selfdiscipline is put to a serious test when wet clothing can no longer be dried or dried only with great difficulty. Still, we may be reasonably com fortable for long periods by taking special precautions: - during march set the tempo so that perspiration does not run

17
- if you are wet with sweat, slow down the pace and try to walk yourself dry before reaching camp. (Officers responsible!) - always change to dry clothes before going to bed - take off your dry clothes in the morning, put them in the rucksack and put on the humid clothing from the day before. {Requires a high degree of selfdiscipline!). Latrine hygiene 38. This is a thing often neglected. Arrange your latrine in such a way that going there is felt to be "pleasurable", not like being in a sewer. {Officers responsible!) Stools can be held back for up to a week, but this, for most people, will lead to stomachache, headache, irritability and sleeplessness.

FROSTBITE

General 39. Frostbite may occur even at teraperatures above 0 C. Wet clothing will greatly increase the heat loss of the body, as will also wind. A combination of rain, wind and temperatures round 0 C is more dangerous than severe cold combined with calm. When a limited part of the body is injured because of freezing, we call this local frostbite. The body temperature (measured in the anus) is then normal. When the whole organism is being cooled off, and body temperature drops to 35 C or lower, we call this "advanced cold exposure" or "hypothermia".

Local frostbite 40. When skin temperature drops, the blood vessels in the exposed spot will contract and the skin turns pale. At a skin temperature of 10 C there is a passing redness, which is due to a surplus of oxygen because metabolism, and consequently the oxygen need, is considerably reduced. At this temperature pain sets inn. If there is a continuing fall of temperature, the skin will remain red because the blood vessels expand again. When skin temperature drops to about freezing point, the skin again turns white because all blood vessels in this spot have been contracted.

41. "Trenchfoot" or "Lifeboat foot". Because of the above-mentioned circulatory changes, tissue which ds not freeze, can still be damaged. 'Trenchfoot" or "Lifeboat foot" can be seen in soldiers who for a long time have been exposed to moisture and cooling. Water temperatures not lower than 17 C have been seen to result in damage if the time of impact has been long enough. The feet become pale, cold and swollen. Walking becomes difficult. Damage has then been inflicted on both skin and the deeper tissues.
42. Treatment First aid:
- sores to be covered with sterile compresses - put on dry and warm socks. Evacuation: - transport to hospital for treatment.

43. Local superflcial coldinjury. As mentioned above, the skin will turn white at a skin temperature of about 0 C. There is moderate pain and a pricking sensation on the skin, followed by a stage in which the feeling of cold and discomfort disappears. "White spots" will first appear on the nose, the cheeks, ears and fingers. This is the initial stage to ice freezing of the tissue. When the skin freezes, ice crystals form, above all in the tissue fluid between the skin cells. The skin is now insensible to pain, white and hard, but can be moved in relation to the layer under it. The skin over joints can be moved.

19

.:iv;;:-..1,. >.,. 'i-\\i.:': r....... & ?:'";. ,."', ;'.y^".v.!"'i-.

Figure 5 Parts of body exposed tofrostbite 44. Treatment First aid:

Local superficial cold injury should be treated on the spot, preferably in a sheltered place. Normally warm skin put against the affected spot is very effective. The palm of the hand may be put over nose, ear, cheek and chin. Frostbitten fingers or hand should be placed in the patienfs armpit. Ts and feet can be put against somebody's belly under the clothes. ATTENTION! - NEVER RUB! - NEVER MASSAGE WITH SNOW AND ICE! Administer a hot drink. After warming up, the affected spot must be covered with clothing. Frozen skin does not have much resistance to renewed chiiling. Evacuation: If the frostbitten part cannot be warmed up in the course of 10-15 minutes, the soldier must as quickly as possible be tken to a heated tent or house.

20

Final treatment: - warming at normal room temperature - no rabbing or massaging - skin-to-skin method - watch that the frozen part does not come too close to heaters or stove as the patient has a reduced sensation of pain and can easily be burned

- give hot drink - change to varm dry clothing, if possible - if there is an extensive superficial cold injury, hospitalization is necessary.
Frozen skin is to be warmed up by normally warm skin. Skin against skin.

Figure 6 Palm over ear, nose, cheek

Figure 7 Hands in armpit

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Figure 8 Feet against belly of a companion

45. Local deepfrostbite goes deeper than the skin: into the subcutaneous and the muscles. The frostbitten part is white, hard and numb. The skin over joints cannot be moved. The hardness is due to ice freezing of the tissue in the affected parts.

46. Treatment
First aid:

This injury is not to be treated on the spot. Tuck up the affected parts well with clothing to prevent the frostbite from spreading. Watch out for hypothermia! The patient should be wrapped in warm, dry clothes (wool next to the skin) and blankets.
A hot drink should be given, if possible.

Figure 9 First aid with local deepfrostbite

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Evacuation: If necessary, the patient may walk on a deep-frozen foot. But as soon as warming of the foot has started, he is a stretcher-case. A thawed-out deep frostbite is extremely susceptible to a renewed attack, which, if it occurs, will aggravate the injury considerably. The patient should thus be evacuated to the place where he can receive final treatment. Final treatment: It begins and ends in the place where final treatment can be given, preferably in a hospital. Measures to be tken by nonmedical personnel at hand out of hospital: - maintain normal body temperature - warm up the injured part slowly in room temperature air Never mb! In hospital: - warm up the injured part in water at a temperature of about 40 C, As a rule the patient will be in great pain during the thawing, which requires strong painkilling tablets.
Advanced cold exposure (Hypothermia)

47. Hypothermia is a great hazard, to which people often do not attach enough importance. In Norway such a cold injury may occur any time of year, for instance:
- On the mountain in summertime: Humid climate with rain, wind and air temperatures between + 10 and 0 C pose a risk of hypothermia if clothing is insufficient. - On the mountain in wintertime: Hypothermia is most frequent with personnel who are insufficiently clad, have poor equipment and are exhausted. High wind increases the danger of chilling considerably. - Injured persons who lie out in the terrain waiting to be rescued, are particularly susceptible to hypothermia. Even in warm weather the heat loss may be large when people lie in wet clothes on a moist surface. - Cold water, shipwreck: Only in the tropics, with a water temperature of about 25 C, will people stand a chance of maintaming a normal body temperature for any length of time.

48. Breakdown. For practical reasons hypothermia can be broken down into three stages. The breakdown refers to body temperature as measured in the anus. (An ordinry fever thermometer cannot be used, as it does not show lower temperatures than 34.4 C): - 35-33 C: Mild hypothermia: The patient is conscious. He feels cold and is shivering violently, unless he is exhausted. There is growing stupor and apathy.

23

- 33-30 C: Moderate hypothermia: The shivering stops. There is increasing stiffness of muscles. The patient feels comfortably warm. Growing sleepiness which gradually passes into unconsciousness. ISlow respiration and pulse. The patient is now in mortal danger. - Lower than 30 C: Deep hypotheraiia: The patient is unconscious. He is deathly pale. Respiration and pulse can only be noticed with difficulty. In this condition the patient may very eastty be mistakenfor dead. When the body temperature drops to below 28 C there is a growing chance of heart flutter, which in practice will mean heart failure. The patient will finally die of heart failure, not of respiratory failure. Artificial respiration should consequently not be attempted with deep hypothermia.

49. TYeatment.
First aid:

- remove patient from cold surroundings - get patient to a sheltered place - avoid further heat loss by tucking him up in a sleeping bag, blanket or something similar - take the patient as soon as possible to a heated tent or house - remove every wet piece of clothing, change to dry clothes, preferably of wool. ATTENTION: Look for local frostbite - if dry clothing is not to be found, the patient may, in an emergency, be put in a plastic bag tightened round the neck to prevent evaporation (heat loss) before transport to hospital - give patient a hot drink if he is awake - avoid smoking and alcohol - if the patient is unconscious, place him in a stable lateral position. Evacuation: After first aid, take the patient to the final place of treatment in an enclosed heated vehicle. Avoid draught during transport. The patient should always lie in a stable lateral position. Final Patients with mild hypothermia may have their final treattreatment: ment in a heated tent or house if conditions are otherwise satisfactory for it. The patient should be under constant supervision by qualified personnel, if possible a doctor, and should be warmed by a friend with normal body temperature who slips into the patienfs sleeping bag or under his blanket. With moderate and deep hypothermia the final treatment should be given in hospital.

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50. Falling into cold water. In water with a temperature below 20 C the body will lose heat according to the temperature of the water. The table below shows what happens at various water temperatures:
Water temperature

Helpless due to hypothermia within

2 hours Vi hour

Dead wkhin 18 hours l!/2 hour

Person in light

summer clothes

12 C 0C

The reason why the body temperature drops so quickly in water is that water conductivity is 26 times higher than that of air. The insulating air layer present in clothes is lost in water. Still, it has been proved that people who are dressed stand immersion in cold water better than people who have nothing on. The water will penetrate the various layers of clothing so that a layer of stagnant water will be formed next to the body and will be warmed by the body. It is essential to withhold this warm water. Thafs why all pieces of clothing and footwear should be kept on. It is also important to stay still because movements will squeeze the warm water out of the clothes and it will be replaced by cold water. Waterproof outer garments will thus be an advantage since they hinder water from passing in and out through them. Take up a "foetal position". If there is a strong wind, it will normally pay off to remain immobile in the water instead of clambering on to an upturned boat or some bare islet. In the latter case the water in the clothes will evaporate in the wind, and this will steal body heat. If we feel the cold more when sitting on an upturned boat than when staying in water, we should remain in the water. When, then, is it advisable to start swimming in order to reach land or another place of rescue? If the water temperature is about 10 C, it will be very risky to start a swim longer than about 500 metres. With the water temperature approaching 0 C, any swimmer, no matter how skilful, will have his maximum swimming distance reduced to 25-50 metres. A person who has been rescued after having fallen into water, is very prone to hypothermia when the temperature is below zero or a wind is blowing. Take him to a sheltered place immediately, remove his wet clothes before they freeze. Change to dry clothes. Further treatment is described in paragraph 49.

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Figure 10 "Foetal" position

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OTHER INJURIES

Sunburn 51. Sunburn is a direct harmful effect on skin cells of the ultraviolet rays in sunlight. The higher the sun is in the sky and the higher the person is above sea level (with lower atmospheric pressure) the heavier the ultraviolet radiation acting on the skin. Ultraviolet radiation also incneases with growing light reflection from the surroundings, as from water and snow. The degree of sunbura depends on the intensity and duration of the radiation. The first reaction of the skin is reddening, which comes several hours after exposure to radiation. With intense radiation blisters will also form. The skin becomes intensely sore. After 1-2 days the skin starts peeling off. The skin left after peeling is very sensitive to renewed sunburn. Pigment in the skin cells forms a defence against the sun rays. Pigment production increases when the skin is exposed to radiation from the sun. Consequently, it is possible to strengthen the tolerance to ultraviolet radiation by gradual sun bathing.

52. fteatment Preventing injury is the most important thing in this case too. We can protect the skin from radiation with clothing, for instance by covering the face with at three-cornered headscarf, by staying mostly in the shade and by applying a protective sun tan cream that reduces the effect of ultraviolet radiation. Sunburnt skin must be covered up to avoid further burning. The skin must be kept clean to avoid infection. In the case of intense itching or swelling it may be necessary to use medicines (antihistamine drugs and a steridsalve). Consult the unit medical officer.
Snowblindness

53. Snowblindness occurs because the eyes do not accept the ultraviolet rays in the sunlight. When we cross a snowcovered surface, the rays are reflected from snow crystals, and the ultraviolet rays, which only to a limited degree are stopped by clouds, fog and snowy weather, cause an infection in the outer part of the eye (the cornea). The symptoms of Snowblindness usually appear several hours after exporsure to sunlight and are felt as an intense smarting and itching of the eyes, as if there were sand on them. Light on the eyes only aggravates the situation. The condition is painful, but not dangerous.

54. Prevention. Protection against Snowblindness can be obtained by always wearing snow goggles or sun glasses in the mountains in winter. The colour of the glasses is immaterial as far as protection gs, but lightly coloured glasses are most comfortable. Makeshift sun glasses can be made by cutting out narrow slits of a cardboard piece or piece of wood in front of each eye, as shown in figure 11.

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Figure U Makeshift snow and sun goggles

Figure 12 Three-cornered headscarf

55. Tteatment. If the eyes are prtected against further ultraviolet radiation (with compresses or a scarf over the eyes) thecondition will pass off within a couple of days.
Carbon monoxide poisoning

56. Carbon monoxide (CO) is a very poisonous and dangerous gas. It is colourless and odourless, so the gas is not noticed until it starte taking effect. There is a danger of poisoning when carbon compounds (e.g. paraffin, propane) are burning without sufficient admission of oxygen. Sources of carbon raonoxide poisoning in the Services are among others: heater stoves and other paraffin burners, car engines and power supply units. Poisoning is due to the fact that carbon monoxide is absorbed more easily in the blood than oxygen, even if there

28 is enough oxygen in the air. The oxygen is "blocked" for absorption in the red blood corpuscles, and a kind of inner suffocation occurs. The first sign of carbon monoxide poisoning is a slight headache, followed by nausea. With stronger poisoning there is a more intense headache, the person starts feeling weak, then collapses and loses consciousness. A person poisoned by carbon monoxide has a strikingly red skin coiour. Poisoning can be prevented effectively by good ventilation. 57. First aid: - take the patient out into fresh air - make sure airways are unobstructed, remove bits of food and vomit - if possible, give artificial respiration by "kiss of life" - if the patient breathes, let him lie in a stable lateral position - keep the patient warm - cali a doctor as soon as possible.