The steps for treatment of hypothermia are as follows:

1. Carefully observe respiratory effort and heart beat; CPR may be required while the warming process is underway.

2. Rewarm the victim as soon as possible. It may be necessary to treat other injuries before the victim can be moved to a warmer place. Severe bleeding must be controlled and fractures splinted over clothing before the victim is moved.

3. Replace wet or frozen clothing and remove anything that constricts the victim's arms, legs, or fingers, interfering with circulation.

4. If the victim is inside a warm place and is conscious, the most effective method of warming is immersion in a tub of warm (100 to 105F or 38 to 41C) water. The water should be warm to the elbow3/4never hot. Observe closely for signs of respiratory failure and cardiac arrest (rewarming shock). Rewarming shock can be minimized by warming the body trunk before the limbs to prevent vasodilation in the extremities with subsequent shock due to blood volume shifts.

5. If a tub is not available, apply external heat to both sides of the victim. Natural body heat (skin to skin) from two rescuers is the best method. This is called "buddy warming." If this is not practical, use hot water bottles or an electric rewarming blanket. Do not place the blanket or bottles next to bare skin, however, and be careful to monitor the temperature of the artificial heat source, since the victim is very susceptible to burn injury. Because the victim is unable to generate adequate body heat, placement under a blanket or in a sleeping bag is not sufficient treatment.

6. If the victim is conscious, give warm liquids to drink. Never give alcoholic beverages or allow the victim to smoke.

7. Dry the victim thoroughly if water is used for rewarming.

8. As soon as possible, transfer the victim to a definitive care facility. Be alert for the signs of respiratory and cardiac arrest during transfer, and keep the victim warm.

Local Cooling
Local cooling injuries, affecting individual parts of the body, fall into two categories: freezing and nonfreezing injuries. In the order of increasing seriousness, they include chilblain, immersion foot, superficial frostbite, and deep frostbite. The areas most commonly affected are the face and extremities.

CHILBLAIN.-Chilblain is a mild cold injury caused by prolonged and repeated exposure for several hours to air temperatures from above freezing 32F (0C) to as high as 60F (16C). Chilblain is characterized by redness, swelling, tingling, and pain to the affected skin area. Injuries of this nature require no specific treatment except warming of the affected part (if possible use a water bath of 90F to 105F), keeping it dry, and preventing further exposure.

IMMERSION FOOT.-Immersion foot, which also may occur in the hands, results from prolonged exposure to wet cold at temperatures ranging from just above freezing to 50F (10C). Immersion foot is usually seen in connection with limited motion of the extremities and water-soaked protective clothing.

Signs and symptoms of immersion foot are tingling and numbness of the affected areas; swelling of the legs, feet, or hands; bluish discoloration of the skin; and painful blisters. Gangrene may occur. General treatment for immersion foot is as follows:

1. Get the victim off his feet as soon as possible.
2. Remove wet shoes, socks, and gloves to improve circulation.

3. Expose the affected area to warm, dry air.
4. Keep the victim warm.
5. Do not rupture blisters or apply salves and ointments.

6. If the skin is not broken or loose, the injured part may be left exposed; however, if it is necessary to transport the victim, cover the injured area with loosely wrapped fluff bandages of sterile gauze.

7. If the skin is broken, place a sterile sheet under the extremity and gently wrap it to protect the sensitive tissue from pressure and additional injury.

8. Transport the victim as soon as possible to a medical treatment facility as a litter patient.

FROSTBITE.-Frostbite occurs when ice crystals form in the skin or deeper tissues after exposure to a temperature of 32F (0C) or lower. Depending upon the temperature, altitude, and wind speed, the exposure time necessary to produce frostbite varies from a few minutes to several hours. The areas most commonly affected are the face and extremities.

The symptoms of frostbite are progressive. Victims generally incur this injury without being acutely aware of it. Initially, the affected skin reddens and there is an uncomfortable coldness. With continued heat loss, there is a numbness of the affected area due to reduced circulation. As ice crystals form, the frozen extremity appears white, yellow-white, or mottled blue-white, and is cold, hard, and insensitive to touch or pressure. Frostbite is classified as superficial or deep, depending on the extent of tissue involvement.

Superficial Frostbite.-In superficial frostbite the surface of the skin will feel hard, but the underlying tissue will be soft, allowing it to move over bony ridges. This is evidence that only the skin and the region just below it are involved. General treatment for superficial frostbite is as follows:

1. Take the victim indoors.
2. Rewarm hands by placing them under the armpits, against the abdomen, or between the legs.

3. Rewarm feet by placing them in the armpit or against the abdomen of the buddy.

4. Gradually rewarm the affected area by warm water immersion, skin-to-skin contact, or hot water bottles.

5. Never rub a frostbite area.

Deep Frostbite.-In deep frostbite, the freezing style="mso-spacerun: yes"> reaches into the deep tissue layers. There are ice crystals in the entire thickness of the extremity. The skin will not move over bony ridges and will feel hard and solid.

The objectives of treatment are to protect the frozen areas from further injury, to rapidly thaw the affected area, and to be prepared to respond to circulatory or respiratory difficulties.

1. Carefully assess and treat any other injuries first. Constantly monitor the victim's pulse and breathing since respiratory and heart problems can develop rapidly. Be prepared to administer CPR if necessary.

2. Do not attempt to thaw the frostbitten area if there is a possibility of refreezing. It is better to leave the part frozen until the victim arrives at a medical treatment facility equipped for long-term care. Refreezing of a thawed extremity causes severe and disabling damage.

3. Treat all victims with injuries to the feet or legs as litter patients. When this is not possible, the victim may walk on the frozen limb, since it has been proven that walking will not lessen the chances of successful treatment as long as the limb has not thawed out.

4. When adequate protection from further cold exposure is available, prepare the victim for rewarming by removing all constricting clothing such as gloves, boots, and socks. Boots and clothing frozen on the body should be thawed by warm-water immersion before removal.

5. Rapidly rewarm frozen areas by immersion in water at 100F to 105F (38C to 41C). Keep the water warm by adding fresh hot water, but do not pour the water directly on the injured area. Ensure that the frozen area is completely surrounded by water; do not let it rest on the side or bottom of the tub.

6. After rewarming has been completed, pat the area dry with a soft towel. Later it will swell, sting, and burn. Blisters may develop. These should be protected from breaking. Avoid pressure, rubbing, or constriction of the injured area. Keep the skin dry with sterile dressings and place cotton between the toes and fingers to prevent their sticking together.

7. Protect the tissue from additional injury and keep it as clean as possible (use sterile dressings and linen).

8. Try to improve the general morale and comfort of the victim by giving hot, stimulating fluids such as tea or coffee. Do not allow the victim to smoke or use alcoholic beverages while being treated.

9. Transfer to a medical treatment facility as soon as possible. During transportation, slightly elevate the frostbitten area and keep the victim and the injured area warm. Do not allow the injured area to be exposed to the cold.