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ORIGINAL ARTICLE
Year : 2020 | Volume
: 22
| Issue : 2 | Page : 136-140
Epidemiology and treatment outcome of frostbite at high altitudes in North India – A cross-sectional study
Vivek Agrawal1, MS Prakash2, Pallab Chatterjee3, R Vishnuprasad4, Abhimannyu Choudhury5, Abhijeet Lal6, Atul Kotwal7
1 Department of Vascular Surgery, Army Hospital R&R, Delhi Cantt, India
2 Prof Nephrology, Rajarajeswari Medical College and Hospital, Bangalore, India
3 Depatment of Plastic Surgery, Army Hospital R&R, Delhi Cantt, India
4 Public Health Specialist, Firozepur Cantt, India
5 Deparmtent of General Surgery, Military Hospital, Namkum, India
6 Deparmtent of General Surgery, Air Force Hospital, Jodhpur, India
7 Public Health Specialist, Jalandhar Cantt, India
Correspondence Address:
Dr. R Vishnuprasad
NP23 Site 10 Jhoke Road, Firozepur Cantt, Punjab
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jmms.jmms_60_19
Context: Frost bite is an important cause of morbidity among armed forces personnel who are employed in high altitude areas. Aims: The aim of the present study was to evaluate the epidemiological aspects and treatment outcome of frostbite injuries among healthy adults working in sub-zero temperatures of the Himalayas. Settings and Design: The study was carried out as a retrospective observational study among all frost bite patients (n = 72) reporting to two zonal hospitals in Northern sector of India from during January 2014 to November 2016. Methods and Material: Patients who had no signs of life on arrival, and patients with injuries due to sunburn / UV rays were excluded from the study. Statistical Analysis Used: Means and proportions were calculated for continuous and nominal variables respectively. Results: All patients were males with mean age of 27.8±2.5 years. Majority of cases 57 (79.2%) had first and second degree frost bite while, third and fourth degree frost bites were noted in 10 and five patients respectively. Maximum cases were reported during the months of December and January. Wound debridement (6.9%), and hyperbaric oxygen therapy (5.6%) were the most common adjunct procedures. Auto amputation was observed in 8.3%. Full recovery was noted in most of the patients except four, who had to undergo amputation of the affected part. Conclusion: Frostbite can result in a wide spectrum of injury, ranging from complete resolution without significant sequelae to major limb amputation and its functional morbidity. First and second degree frost bite were the most common, predominantly noticed in young individuals during peak winter months of December and January.
Keywords: Epidemiology, Frost bite, High altitude
Initial reports on frostbite injuries date back up to 5000 years old are described in pre-Columbian mummies.[1] Frostbite is not uncommon in military medicine because of soldiers' deployment in the extremes of weather. During WWII, frostbite accounted for 2%–4% of the combat surgical trauma and 1%–2% of the total mortality and morbidity among the Red Army.[2] Indian troops are posted at the altitudes of 12,000–22,000 feet above the sea level in the northern regions to man the international borders. Medical care to these personnel at peripheral farthest posts is provided by the echelons of field hospitals comprising doctors, paramedics, equipment for first aid, and essential medicines. Frostbite remains one of the major health hazards in the troops posted in that area and mountaineers. Young people who are active are the most commonly affected. The frequently involved include armed forces personnel, agricultural workers, mountaineers, cross-country skiers, expedition members, and climbers. In most occurrences, the patients are not aware about the onset and progress of frostbite until it is severe. Vasoconstriction following blood clotting results from exposure to extreme cold weather. Ice crystals form in the tissues and the capillaries, when the atmospheric temperature drops below −4°C, ultimately leading to cell membrane damage. As the dead cells are replaced by fibroblasts, scar tissue forms.[3] Insensitivity and clumsiness are the common symptoms noted by the affected individual, at first. When remedial measures such as rewarming are instituted, these symptoms tend to disappear rapidly. The spectrum of illness presented by frostbite patients varies widely from minimal tissue loss with mild long-term sequelae to major necrosis of the distal limbs, even leading to amputations of the affected part, thus, resulting in significant morbidity, loss of extremities, or even mortality in extreme cases. Some of the common predisposing factors include alcohol consumption (46%), psychiatric illness (17%), vehicular failure (19%), and drug misuse (4%).[4] Temperature, wind chill factor, duration of exposure, wet/dry cold, immersion, clothing, and patient comorbidities such as smoking, peripheral vascular disease, neuropathies, and Raynaud's disease tend to determine the severity of illness.[5],[6] Many soldiers have even lost their limbs/lives due to adverse climatic conditions while occupying the strategic heights in the extreme adverse climatic conditions of North Indian borders. These incidents highlight the extreme risks that soldiers face in manning the inhospitable terrain at heights of 21,000 feet under extreme weather conditions on the world's highest battlefield (redundant). There is a lack of comprehensive Indian statistics about the epidemiology of frostbite injuries occurring in these regions. The purpose of this study is to evaluate the epidemiological aspects and treatment outcome of frostbite injuries among healthy adults working in subzero temperatures of the Himalayas.
Materials and MethodsThe present study was carried out as a retrospective observational study of frostbite patients reporting to two zonal hospitals in the northern sector of India during the study period starting from January 2014 to November 2016. The hospital catered to the population of the defence services in the northern sector. All serving personnel who are deployed in such areas are screened for any comorbidities and those who are found fit were only engaged. All patients reporting to the hospital with frostbite were included in the study. Patients who had no signs of life on arrival and patients with injuries due to sunburn/ultraviolet rays were excluded from the study. On arrival, patients were evaluated and managed as per the hospital management protocols, which are predesigned based on the existing updated medical knowledge.[7],[8] Predisposing or precipitating factors were assessed, including the duration of exposure, time interval of onset of disease, and initiation ofFirst Aid were documented by the authors. The lesions were divided into four degrees and treated accordingly. The affected parts were cleaned and kept in lukewarm water (37°C–39°C) for 15 min to 1 h. Thereafter, dressing was done with frostbite cream which was made by mixing soframycin cream, lignocaine ointment, and silver sulfadiazine ointment and subsequently covered with framycetin sulfate (Sofra Tulle ®) dressing and highly absorbent padding.[7],[8] Bullas were punctured to remove the fluid collection; however, the overlying skin was left intact. Patients were kept in ambient environment at 26°C–30°C temperature. A predesigned pro forma was used for data collection by the investigators, which included detailed description demographic factors, various possible risk factors, symptoms/signs of various degrees of frostbite, severity of the disease, and management. The patients were asked to define the body parts affected (by choosing from a list of locations, namely the hands, feet, nose, and ears), height of post, duration of exposure, the season in which the injury occurred, the appropriateness of the equipment being used (checked against a list of indispensables consisting of proper boots, socks, gloves with cover, and windbreaker), whether they were properly trained or educated by a designated trainer and patients' perception on the cause of frostbite. An inquiry was also made regarding alcohol and tobacco consumption and/or the use of other drugs. The dead tissues were excised only after a clear line of demarcation. In the absence of infection, amputations were usually delayed up to 3 months to give all possible chances to the deeper tissues to recover spontaneously.[7],[8] The Institutional Ethical Committee Clearance was sought and obtained before the study was begun. Informed written consent was obtained from all the patients before including them in the study. Statistical analysis: data entry was carried out using MS Excel 2013, and data analysis was carried out using IBM SPSS (Statistical Package for the Social Sciences) software version 21.0, New York, United States. Means and proportions were calculated for the continuous and nominal variables, respectively.
ResultsThe present study included 72 patients who reported with frostbite during the study period. All patients were males, with a mean age of 27.8 ± 2.5 years. Only four patients were under the age of 20 years, 48 (66.7%) were between 20 and 30 years, 18 (25%) were between 30–40 years, and 2 (2.8%) were over 40 years. None of the patients were suffering from any chronic disease such as coronary heart disease, diabetes mellitus, and hypertension. Majority of the patients (57; 79.2%) reported with frostbite who were exposed to freezing cold of up to 3–6 h. Of these, 22 of them were caught in blizzards with freezing cold and developed frostbite in <3 h of exposure. After 6–12 h of cold exposure, 10 patients (13.9%) developed frostbite, whereas five cases (6.9%) had exposure of more than 12 h. Only 27 (37.5%) patients could be evacuated to the nearest hospital within 6 h from the site of occurrence, and 39 patients (54.7%) were evacuated in 6–12 h time. The rest six patients (8.3%) could reach the hospital only after 12 h of incident. A history of smoking of 6–10 cigarettes/day was given by the six patients. These patients also had delayed recovery and poor prognosis than nonsmokers. On evaluation, two patients were found to have evidence of peripheral vascular disease. They developed frostbite only in 3–4 h of cold exposure. The majority of the cases (42, 58.3%) developed frostbite at an altitude between 12,000 and 17,000 feet above the sea level, followed by 27 (37.5%) patients who developed frostbite between 17,000 and 21,000 feet. Only 3 cases (4.2%) had frostbite above 21,000 feet. The maximum cases affected were during the month of January (n = 13) followed by December (n = 11), November (n = 9), and October (n = 8). From October to January, there are more blizzards and “wind-chill effect” due sudden fall in atmospheric temperature (up to − 35°C). Only 13 cases (18%) had frostbite during the summer months (April to September) [Table 1]. Feet were the most frequently affected part (44, [61.1%]). In 23 cases (31.9%), hands were affected. Head-and-neck exposure usually involved nose and ears and was observed in five cases (6.9%). At least, two body parts were involved in 45 cases (62.5%), and 21 (29.2%) had one body part affected. Six patients were noted having the involvement of three body parts. Majority of cases (57, [79.2%]) had the first- and second-degree frostbite, whereas third- and fourth-degree frostbites were noted in 10 and five patients, respectively [Figure 1] and [Figure 2]. Majority of the patients required only a conservative dressing (65%), whereas nearly one third of the patients required adjunctive procedures in the course of management. Wound debridement (6.9%) and hyperbaric oxygen therapy (5.6%) were the most common adjunct procedures. Amputation was done in 6.9% cases, whereas autoamputation was observed in 8.3% of the study participants [Table 2]. Complete healing and full recovery were noted in the rest of the patients. Causalgia (8.3%) and infection (6.9%) were the most common sequelae following frostbite [Table 3].
Table 1: Distribution of the study participants based on the baseline characteristics (n=72)
Figure 1: Distribution of the study participants based severity of frostbite
Figure 2: (a) Third degree frostbite in the healing phase. (b) Fourth degree frostbite with dry gangrene of the fingers. (c) Fourth degree frostbite with dry gangrene of toes. (d) Fourth degree frostbite with dry gangrene of great toe. (e) Second degree frostbite having bullae filled with clear fluid. 
Table 2: Distribution of the study patients based on the type of management (n=72)
Table 3: Distribution of the study participants based on sequelae after frostbite (n=25) Discussion In the past years, frostbite was chiefly encountered in the military populations; however, the demographic trends have now loosened to include homeless individuals, outdoor workers, mountaineers, and winter sports enthusiasts.[9],[10] In patients with frostbite, early recognition and timely evacuation to the nearest hospital are directly proportional to the degree of frostbite and the better outcome. Prevention is through wearing proper clothing, maintaining hydration and nutrition, avoiding low temperatures, and staying active without becoming exhausted. The present study results revealed a higher incidence of cases among the younger age group (<30 years) and this is similar to the observations of the other studies carried out among military personnel. In a study among military personnel, it was noted that the majority of the affected were females <20 years old.[11] This could be because of the fact that individuals in the armed forces who are deployed for tasks in such high altitude areas are usually moung and healthy. However, it is also noted that the higher prevalence among the general public and mountaineers was found to be in the age group of 30–49 years.[12] A study among 637 mountaineers reported that the mean age of their study population was 28.8 ± 1.1 years, and the youngest among them was 16 years and the oldest was 65 years.[13] Strohle et al. reported in their research work that the mean patient's age was 41.6 ± 17.5 years, ranging from 20 to 90 years.[14] These demographic observations of frostbite cases were concordant with that of the present study findings. After detailed epidemiological investigation, it was noted that the most common risk factors were tight boots, nonadherence to the instructions regarding self-examination, not doing regular foot parade, use of wet socks, and exhaustion. The foot parade consists of self-examination of feet, washing them with lukewarm water, and jumping on feet which helps in rewarming. In our study, among 23 cases (31.9%), hands were affected which was also due to the use of single or wet glove. All the study patients recovered without amputation except four. Two cases required proximal phalanx amputation of one finger, one required proximal phalanx amputation of left great toe, and one required amputation of all fingers at the junction of metacarpophalangeal joints. In a large review among the British military personnel, it was reported that extremities (hands and feet) accounted for the majority of cases (60.8%), only hands in 28.9%, only feet in 23.7%, and 7% had both hands and feet involvement. Face and neck involvement was recorded in 1% of the study sample.[15] However, another study stated that feet and the hands accounted for 90% of injuries while it also affects the buttocks (sitting) and penis (joggers).[12] In a study among Norwegian armed forces personnel, 96% suffered frostbite on fingers/hands or toes/feet.[16] These results were comparable to that of the present study findings, in terms of body part involved. The correlation of the independent effect of height on the degree of frostbite showed that height adversely affected the lesions beyond 17,000 feet. The decline beyond 21,000 feet was because of the fact that persons who went and stayed at those heights were confined to their shelters with very little movement. However, the study reported the majority of the affected patients at altitude levels starting from 12,000 to 17,000 feet as compared to the higher altitude. This could be explained by the fact that a relatively higher number of personnel are deployed at this altitude range as compared to the higher altitude, thereby increasing the number of incident case, however not the incidence rate. Incidence rates could not be estimated in our study because of constantly mobile military population in the study area. Furthermore, complacency in the prevention measures among these personnel could be a potential explanation, which may not be expected among individuals at greater altitude levels. An Australian Alps study also reported that most of the frostbite injuries occurred over 5000 feet (67.8%).[14] A prospective study was conducted in four different geographical regions of the Himalayas and reported that the first-, second-, and third-degree frostbite comprised 62.2%, 34.3%, and 3.49% of patients, respectively.[17] These findings were similar to that of the present study reports. In the study on frostbite cases in the Australian Alps, rescue of affected was mostly terrestrial (32.3%), followed by helicopter (38.7%), and the rest (22.6%) cases involved both.[14] The present study setting involved a similar hilly terrain with restricted access by land; however, most patients were evacuated by road when possible while air evacuation to the hospital was also used based on the prevailing weather conditions. The seasonal distribution of frostbite shows the highest occurrence in January and February (with at least three times as many injuries as in other months), with another less striking rise in the incidence during summer months when large-scale expeditions to high peaks are scheduled. Inappropriate clothing was believed by the mountaineers to be the main cause of the injury followed by the lack or incorrect use of equipment and lack of knowledge about dealing with cold and severe cold weather.[13]
The principles of treatment in frostbite include prevention of refreezing, aspirin and ibuprofen can be given to prevent clotting and inflammation, managing coexisting hypothermia, antibiotics are added if there is trauma, skin infection (cellulitis), or severe injury, and debridement or amputation of necrotic tissue should be delayed. Early hyperbaric oxygen therapy is also documented to curb amputations.[18] Tissue loss and autoamputation are the potential consequences of frostbite. In a retrospective study of 265 frostbite injuries in Canada, it was noted that 35% of patients with deep frostbite had operative interventions and autoamputations occurred in 28% of them.[19] Although the present study did not evaluate the proportion of adjunctive procedures among the subclasses of frostbite, because of relatively smaller sample size, these proportions observed in the above study are comparable to that of the present study. Treatment is usually conservative. If the part becomes gangrenous, it should be left to autoamputate. Surgical amputation should be done if the patient has intolerable pain or wound gets infected. The use of hyperbaric oxygen, medical sympathectomy using intraarterial reserpine, and recombinant tissue plasminogen activator have also been attempted with limited success.[7],[8],[20],[21],[22] More randomized control studies are required to establish their role in the management. The limitations of the study include that the study involved only personnel of the armed forces who are in most occasions young and healthy, which makes the study population not easily comparable with that of the general population.
Timely prehospital and definitive hospital management are important to minimize the final tissue loss and maximize the functionality of the affected limb. Frostbite can result in a wide spectrum of injury, ranging from complete resolution without significant sequelae to major limb amputation and its functional consequences. The first- and second-degree frostbite was the most common, predominantly noticed in young individuals during peaks winter months of December and January. The higher proportion of adjunct operative procedures is required as the severity of frostbite increases. Once in the hospital setting, the best outcomes will be achieved for the patient when a multidisciplinary approach is utilized.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
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