As Seen In: USA Today, Discovery Channel, US News & World Report

Medical Considerations

Improper acclimatization poses many problems for medical personnel. Facilities and supplies may be inadequate to treat all victims. After acclimatization, personnel can still become injured (sprains, strains, fractures, frostbite, hypothermia, and trench foot). Mountain sickness and other illnesses may also occur. Evacuation of the sick and wounded is compounded by the terrain and weather.

Illness and Injury

Units operating in mountainous regions are exposed to varied types of injuries and illnesses not associated with other areas. Medical considerations are like those for other environments; however, there are some unique aspects of mountain operations to be considered if effective support is to be provided. Most injuries in the mountain environment are soft tissue injuries. These include sprains, strains, abrasions, contusions and fractures. As with any other injuries, the most life threatening are treated first with the emphasis on airway control, breathing management, and circulatory support. Skills in basic first aid are essential to the mountain leader and should be reinforced with regular sustainment training.

Treatment and Evacuation

In harsh mountain weather, the most important course of action is to provide injured soldiers with medical aid as soon as possible. Immediate first aid is given on site. Due to rough terrain, medical units can seldom reach unit aid stations by vehicle to evacuate casualties. Litter bearers are required to move casualties to the rear where they can be evacuated by ground or air to clearing stations. The victim is protected from the weather and shock during transportation. Rendezvous points are coordinated with medical units as far forward as possible. Training must be accomplished with all litter bearers on evacuation techniques and first aid. Lightly wounded personnel may need assistance to move over rough terrain.

Solar Injuries

Solar injuries can happen in warm weather or in cold weather. These types of injuries can be just as incapacitating as most other injuries but usually are not fatal. The peak hours of ultraviolet (UV) radiation are between the hours of 1100 and 1500. Due to the long wavelengths of ultraviolet light, cloudy days can be more dangerous than sunny days. On sunny days the soldier takes more care due to the bright conditions. On cloudy days the soldier tends not to wear sunglasses or sunscreen.

a. Sunburn. Sunburn is the burning of exposed skin surfaces by ultraviolet radiation.

(1) Contributing factors include fair skin, improper use of para-amino benzoic acid (PABA)-based sunscreens, and exposure to intense ultraviolet rays for extended periods.

(2) Symptoms of sunburn are painful, burning, red or blistered skin with a slight swelling. The skin may be warm to the touch. In severe cases chills, fever, and headaches may occur.

(3) To treat sunburn, apply cool saline dressings to alleviate pain and swelling. Do not pop blisters. If blisters do break, wash thoroughly, bandage, and seek medical attention. A solution of vinegar (acetic) and water can be lightly applied with sterile gauze to alleviate burning. The tannic acid in used tea bags can also be applied to alleviate burning. Administer pain medication if needed.

(4) To prevent sunburn, skin should be covered with clothing or PABA-based sunscreens (at least sun protection factor [SPF] 15) should be applied liberally to exposed skin during the peak hours of UV exposure. The SPF means that you can stay exposed to the suns UV rays that many times longer than without it. (For example, an SPF of 15 means that skin can be exposed to UV rays 15 times longer than without sunscreen.) During sustained activity, the sunscreen should be regularly reapplied to maintain the SPF.

b. Snowblindness. Snowblindness is sunburn of the cornea of the eye caused by exposure to ultraviolet radiation.

(1) A contributing factor is the reflection of sunlight from all directions off the snow, ice, and water. Ultraviolet rays can cause vision problems even on cloudy days. They are less filtered at high altitudes than at low altitudes.

(2) Symptoms of snowblindness are painful, red, watery eyes; a gritty feeling; blurred vision; and a headache.

(3) To treat snowblindness, patch both eyes with cold compresses for 24 hours. Topical anesthetics such as Tetracaine Ophthalmic can be used to relieve pain. Avoid rubbing the eyes. If still painful, keep the victim’s eyes patched and administer oral pain medication. Snowblindness will usually resolve in about 24 hours for mild to moderate cases. Victims are rarely in need of evacuation unless the case is unusually severe.

(4) To prevent snow blindness, use quality sunglasses even on cloudy days in snow-covered terrain. Proper sunglasses should provide 100 percent UVA and UVB protection and have hoods on the sides to prevent reflected light from entering the eye. (Currently, the U.S. Army does not have these types of "glacier" sunglasses in their inventory and they must be acquired from nonmilitary sources.) In an emergency, improvise slit glasses from materials such as cardboard or birch bark.

Cold-Weather Injuries

Cold-weather injuries can occur during any season of the year. Death has resulted in temperatures as high as 10 degrees Celsius (50 degrees Fahrenheit). A loss of body heat combined with shock produces devastating results. However, most of these accidents can be prevented by proper planning to include: timely requisition and receipt of supplies and proper clothing; thorough training of personnel with respect to the hazards of cold weather; effective methods for the receipt, dissemination, and use of cold-weather data; periodic inspections of clothing, personnel, and equipment; and personnel receiving a balance of water, rest, and nutrition.

a. Soldiers must be prepared to survive, move, and fight in winter conditions. Intense cold affects the mind as well as the body. Simple tasks take longer to perform, and they take more effort than in a temperate climate. When weather conditions become extreme the problems of survival become more significant. Warmth and comfort become the top priorities. The effects of extreme cold and the probability of injury are magnified due to the lack of proper diet and sleep. The most important measure in the prevention of cold-weather injuries is the education of personnel and their leaders.

b. Cold injuries may be divided into two types: freezing and nonfreezing. The freezing type is known as frostbite. The nonfreezing type includes hypothermia, dehydration, and immersion foot. Cold injuries result from impaired circulation and the action of ice formation and cold upon the tissues of the body. Temperature alone is not a reliable guide as to whether a cold injury can occur. Low temperatures are needed for cold injuries to occur, but freezing temperatures are not. Wind speed can accelerate body heat loss under both wet and cold conditions. All commanders and subordinate leaders/instructors must be familiar with and carry GTA 5-8-12, which includes a wind chill equivalent temperature chart (Figure 2-1).

Figure 2-1. Wind Chill Chart.

Figure 2-1. Wind chill chart.

c. Many other factors in various combinations determine if cold injuries will occur.

(1) Previous Cold Injuries. If a soldier has had a cold injury before, he is at higher risk for subsequent cold injuries.

(2) Race. Blacks are more susceptible to cold-weather injuries than Caucasians.

(3) Geographic Origin. Personnel from warmer climates are more susceptible to cold injury than those from colder climates.

(4) Ambient Temperature. The temperature of the air (or water) surrounding the body is critical to heat regulation. For example, the body uses more heat to maintain the temperature of the skin when the temperature of the surrounding air is 37 degrees Fahrenheit than when it is 50 degrees Fahrenheit.

(5) Wind Chill Factor. The commander should know the wind chill factor. When the forecast gives a figure that falls within the increased danger zone or beyond, caution must be taken to minimize cold injury. The equivalent wind chill temperature is especially important when the ambient temperature is 0 degrees Celsius (32 degrees Fahrenheit) or less. Tissue can freeze if exposed for a prolonged period and if frequent warming is not practiced. The lower the wind chill, the faster tissue freezing can occur. Wind chill is the rate of cooling. Wind does not lower the ambient temperature. The ambient temperature alone determines freezing or nonfreezing injuries. Frostbite Wind chill may cause faster cooling due to increased convection, but not below the ambient temperature.

(6) Type of Mission. Combat action requiring prolonged immobility and long hours of exposure to low temperatures, or not having an opportunity to warm up increases the possibility of cold injuries.

(7) Terrain. Minimal cover and wet conditions increase the potential for cold injury.

(8) Clothing. Clothing for cold weather should be worn with the acronym C.O.L.D. in mind.

  • C—Clothing should be clean since prolonged wear reduces its air-trapping abilities and clogs air spaces with dirt and body oils.
  • O—Overheating. Avoid overheating. Appropriate measures should be taken when a change in weather or activity alters the amount of clothing needed to prevent overheating and, therefore, accumulation of perspiration.
  • L—Loose and in layers (to trap air and to conserve body heat). The uniform should be worn completely and correctly to avoid injury to exposed body surfaces. The cold-weather uniform is complete when worn with gloves and inserts.
  • D—Dry. Keep dry. Wet clothing loses insulation value.

(9) Moisture. Water conducts heat more rapidly than air (25 percent). When the skin or clothing becomes damp or wet, the risk of cold injury is greatly increased.

(10) Dehydration. The most overlooked factor causing cold injuries is dehydration. Individuals must retain their body fluids. In cold weather the human body needs special care, and the consumption of water is important to retain proper hydration.

(11) Age. Within the usual age range of combat personnel, age is not a significant factor.

(12) Fatigue. Mental weariness may cause apathy leading to neglect of duties vital to survival.

(13) Concomitant Injury. Injuries resulting in shock or blood loss reduce blood flow to extremities and may cause the injured individual to be susceptible to cold injury, which in turn can accelerate shock.

(14) Discipline, Training, and Experience. Well-trained and disciplined soldiers suffer less than others from the cold.

(15) Nutrition. Good nutrition is essential for providing the body with fuel to produce heat in cold weather. The number of calories consumed normally increases as the temperature becomes colder.

(16) Excess Activity. Excess activity (overheating) results in loss of large amounts of body heat by perspiration. This loss of body heat combined with the loss of insulation value provided by the clothing (due to perspiration dampening the clothing) can subject a soldier to cold injuries.

(17) Radical Changes in the Weather. Weather conditions in mountainous terrain are known to change considerably throughout the day. Weather can quickly change to extremely cold and wet conditions, especially in higher elevations.

d. Commanders should ensure that the following measures are taken.

(1) Soldiers’ uniforms are kept as dry as possible and are protected from the elements.

(2) Soldiers are educated on proper use of clothing systems to avoid the effects of overheating and perspiration (layer dressing and ventilate).

(3) The buddy system is used to watch for early signs of cold-weather injuries.

(4) All soldiers waterproof their equipment.

(5) The rate of movement should be slow, deliberate, and careful. Soldiers should not move out at a force march pace and then be stationary after they have perspired heavily. Soldiers should not wear excessive cold-weather clothing while moving.

e. Medical procedures are needed when sickness and injuries occur. Leaders should—

  • Assess the situation (tactical and environmental).
  • Approach the victim safely (avoid rock or snow slide).
  • Perform emergency first aid.
  • Treat for shock (always assume that shock is present).
  • Check for other injuries/cold injuries.
  • Develop a course of action (decide on a means of evacuation).
  • Execute the plan and monitor the victim’s condition.

f. Body heat may be lost through radiation, conduction, convection, or evaporation.

(1) Radiation. The direct heat loss from the body to its surrounding atmosphere is called radiation heat loss. The head can radiate up to 80 percent of the total body heat output. On cold days, personnel must keep all extremities covered to retain heat. This accounts for the largest amount of heat lost from the body.

(2) Conduction. Conduction is the direct transfer of heat from one object in contact with another (being rained on or sitting in snow).

(3) Convection. Convection is the loss of heat due to moving air or water in contact with the skin. Wind chill is convection cooling. Clothing that ventilates, insulates, and protects must control the layer of warm air next to the skin.

(4) Evaporation. The evaporation of perspiration causes heat loss. Wet clothing can cause heat loss by conduction and evaporation. Dressing in layers allows soldiers to remove or add clothing as needed.

g. Some of the most common cold-weather injuries are described in the following paragraphs.

(1) Shock. Shock is the depressed state of vital organs due to the cardiovascular (heart) system not providing enough blood. Although shock is not a cold-weather injury, it is a symptom or a result of other injuries. Any illness or injury can produce shock, which increases the instance and severity of a cold-weather injury. Shock should be assumed in all injuries and treated accordingly. Even minor injuries can produce shock due to cold, pain, fear, and loss of blood.

(a) Symptoms. Initial symptoms of shock include apprehension, shortness of breath, sweating, cold skin, rapid and faint pulse, and excessive thirst. If the victim is not given adequate first aid immediately, his condition may digress into incoherence, slower heart beat, unconsciousness, and possibly death.

(b) Treatment. To treat shock, restore breathing and heart rate through artificial respiration or cardiopulmonary resuscitation. Treat the injury and control hemorrhaging. Make the victim as comfortable as possible and try to relieve the pain. Keep the victim warm but do not overheat him. Elevate the back and head, or feet. If the victim is conscious and has no abdominal injuries, administer water. The victim should receive proper medical attention as soon as possible.

(2) Dehydration. Dehydration is the loss of body fluids to the point that normal body functions are prevented or slowed. This is usually caused by overexertion and improper water intake. Dehydration precedes all cold-weather injuries and is a major symptom in acute mountain sickness. It contributes to poor performance in all physical activities—even more so than lack of food. Cold weather requirements for water are no different than in the desert. They may, in fact, exceed desert requirements because of the increased difficulty in moving with extra clothing and through the snow. At high altitudes, the air is dry. Combined with a rapid rate of breathing, as much as two liters of liquid may be lost each day through respiration. A soldier needs about three to six quarts of water each day to prevent dehydration when living and performing physical labor in a cold or mountainous environment. Coffee and tea are diuretics and cause excessive urination and should be avoided. The adequacy of liquid intake can best be judged by the urine color and volume. Dark amber colored urine instead of light yellow or the absence of a need to urinate upon awakening from a night’s sleep are indicators of dehydration. Thirst is not a good indicator of hydration.

(a) Contributing Factors. Factors that contribute to dehydration in cold weather are:

  • The thirst mechanism does not function properly in cold weather.
  • Water is often inconvenient to obtain and purify.
  • The air in cold climates and at high altitudes lacks moisture.
  • Cold causes frequent urination.

(b) Symptoms. Symptoms of dehydration include darkening urine, decreased amounts of urine being produced, dry mouth, tiredness, mental sluggishness, lack of appetite, headache, fainting, rapid heartbeat, dizziness, higher temperature, upset stomach, and unconsciousness. The symptoms of dehydration are similar to those of hypothermia. To distinguish between them, open the victim’s clothes and feel the stomach. If the stomach is cold, the victim is probably hypothermic; if it is warm, he is probably dehydrated. However, this test is not conclusive since cold-weather dehydrating can also lead to total body cooling. The cold environment may act as a diuretic and impair the body’s ability to conserve fluid (cold-induced diuresis and increased rate of urination).

(c) Treatment. Prevent dehydration by consuming three to six quarts of fluids each day (forced drinking in the absence of thirst is mandatory) and avoid caffeine and alcohol, which may chemically contribute to dehydration. Keep the victim warm and treat for shock. In advanced cases, administer fluids by mouth if the victim is conscious. Do not let him eat snow; eating snow uses body heat. Allow the victim to rest. If he fails to improve within one hour or is unconscious, evacuate him to a medical facility immediately.

(3) Hypothermia. Hypothermia is the lowering of the body core temperature at a rate faster than the body can produce heat. Hypothermia may be caused by exposure or by sudden wetting of the body such as falling into a lake or being sprayed with fuel or other liquid. Hypothermia can occur even on moderate days with temperatures of 40 to 50 degrees Fahrenheit with little precipitation if heat loss exceeds heat gain and the condition of the soldier is allowed to deteriorate. Hypothermia is classified as mild (core temperature above 90 degrees Fahrenheit or 32 degrees Celsius) or severe (core temperature below 90 degrees Fahrenheit or 32 degrees Celsius). An individual is considered to be "clinically hypothermic" when the core temperature is less than or equal to 95 degrees Fahrenheit.

(a) Contributing Factors. Factors that contribute to hypothermia are:

  • Dehydration.
  • Poor nutrition.
  • Diarrhea.
  • Decreased physical activity.
  • Accidental immersion in water.
  • Change in weather.
  • High winds.
  • Inadequate types or amounts of clothing.

(b) Symptoms. The first symptom of hypothermia is when the body core (rectal) temperature falls to about 96 degrees Fahrenheit. Other symptoms include:

  • Shivering, which may progress to an uncontrollable point making it hard for an individual to care for himself. Shivering begins after a drop in body temperature of one to two degrees. This is followed by clumsiness (stumbling or falling), slow reactions, mental confusion, and difficulty in speaking.
  • Body temperature drop from 95 degrees Fahrenheit to 90 degrees Fahrenheit, which can cause sluggish thinking, irrational thought, apathy, and a false sense of warmth. The victim becomes cold and pale; cannot perform simple tasks; experiences amnesia and hallucinations; develops blueness of skin and decreased heart and respiratory rate with a weak pulse; pupils of the eyes dilate; speech becomes slurred; and visual disturbance occurs.
  • Body temperature drop from 90 degrees Fahrenheit to 85 degrees Fahrenheit, which causes irrationality, incoherence, loss of contact with the environment, muscular rigidity, disorientation, and exhaustion. The soldier might stop shivering after his core temperature drops below 90 degrees Fahrenheit.
  • Body temperature drop from 85 degrees Fahrenheit and below, which causes muscle rigidity, unconsciousness, comatose state, and faint vital signs. The pulse may be faint or impalpable, and breathing is too shallow to observe.

(c) Prevention. Prevent hypothermia by using the buddy system to watch each other for symptoms; consume adequate amounts of liquids daily; rest; and eat properly.

(d) Avoidance. Hypothermia can be avoided by dressing in layers, which permits easy additions or deletions to prevent overheating, becoming too cold, or getting wet or windblown. If the soldier is in a situation that precludes staying warm and dry, he should seek shelter. Sweets and physical activity help to produce body heat.

(e) Treatment. Treatment methods vary based on the severity of the hypothermia.

  • Mild cases: If a soldier shows symptoms of hypothermia, prevent additional heat loss by getting the victim into a shelter; removing wet clothing and replacing it with dry, insulated clothing; insulating the victim from the ground; and sharing a sleeping bag (cover head) to transfer body heat. Make a diagnosis (rectal temperature). Rehydrate the victim with warm liquids, sweets, and food. If the tactical situation allows, build a fire. Above all else, keep the victim conscious until his vital signs are normal, and seek medical assistance. If possible, keep the victim physically active to produce body heat.
  • Severe cases: If the victim is unconscious or appears dead without any obvious injury, prevent further heat loss. Rapid rewarming of an unconscious victim may create problems and should not be attempted. It is best to evacuate as soon as possible. At all times, the victim should be handled gently so as not to cause the cold blood from the extremities to rush to the heart. Do not allow the victim to perform ANY physical activity. Immediately transport the victim to the nearest medical facility. Field reheating is not effective and may be hazardous. Provide artificial respiration if breathing stops. If no pulse is detectable, be aware that in hypothermia there is often effective circulation for the victim’s hypothermic state. In such a case, cardiac compression (such as CPR) may be fatal. The exception is acute hypothermia with near drowning.
  • Breathing warm, moist air is the fastest way to warm the inside of the body. If breathing steam is not possible, place tubing under the rescuer’s shirt so the victim will still breathe warm, moist air. This process can be done while on the move. In addition to breathing moist, warm air the victim must be gradually rewarmed using external heat sources. Padded hot water bottles or heated stones should be placed in the armpits.
  • If conscious, the victim can be given warm, sweet drinks.
  • The Hibler Pack is an improvised method of rewarming hypothermic victims in the field. This is used to heat the body core first so the vital organs are warmed and not the extremities. As the body warms up the warm blood will eventually warm all parts of the body. First lay out a blanket or sleeping bag and place a poncho or space blanket inside of it. The poncho or space blanket should go from the base of the skull to the base of the butt. This keeps the sleeping bag/blanket dry and acts like a vapor barrier. Lay the hypothermic patient inside the sleeping bag/blanket. Using a stove, warm water until it is hot to the touch (but not hot enough to burn the patient) and completely dampen any absorbable materials (such as T-shirt, towel, BDU top, and so on). Place the warm, wet items inside a plastic bag or directly in the armpits and chest of the patient. After the warm, wet item has been placed on the patient, wrap the patient tightly inside the poncho/space blanket and the blanket/sleeping bag. Continually check the temperature of the wet material and keep it warm.
  • All bodily systems in hypothermia are brittle so treat the victim gently. As these attempts are being made, try to evacuate the victim. Severe complications may arise as the body temperature rises, which may result in cardiac arrest even though the victim seems to be doing well.

(4) Immersion or Trench Foot. This is damage to the circulatory and nervous systems of the feet that occurs from prolonged exposure to cold and wet at above freezing temperatures. This can happen wearing boots or not. A soldier may not feel uncomfortable until the injury has already begun.

(a) Contributing Factors. Factors that contribute to immersion or trench foot are:

  • Stepping into water over the boot tops.
  • Not changing socks often enough.
  • Improper hygiene.
  • Prolonged exposure (three to five days).

(b) Symptoms. Symptoms of immersion or trench foot include the sensation of tingling, numbness, and then pain. The toes are pale, and feel cold and stiff. The skin is wet and soggy with the color turning from red to bright red, progressing to pale and mottled, and then grayish blue. As symptoms progress and damage appears, the skin becomes red and then bluish or black. Swelling may occur. Because the early stages of trench foot are not painful, soldiers must be constantly aware to prevent it.

(c) Treatment. To prevent this condition, keep the feet dry and clean. Change socks often, drying the insides of boots, massaging the feet, and using foot powder. Drying the feet for 24 hours usually heals mild cases. Moderate cases usually heal within three to five days. The feet should be handled gently—NOT rubbed or massaged. They should be cleaned with soap and water, dried, elevated, and exposed to room temperature. The victim must stay off his feet and seek medical attention. Severe cases, when feet are not allowed to dry, are evacuated as a litter casualty.

(5) Blisters. When first noticed and before the formation of a blister, cover a hotspot with moleskin (over the area and beyond it). Use tincture benzoin to help the moleskin adhere to and toughen the skin. Once a blister has formed, cover it with a dressing large enough to fit over the blister, and then tape it. Never drain blisters unless they are surrounded by redness, or draining pus indicates infection. If this occurs, drain the blister from the side with a clean sterile needle. After cleaning with soap and water, gently press out the fluid leaving the skin intact. Make a doughnut of moleskin to go around the blister and apply to the skin. For toe blisters, wrap the entire toe with adhesive tape over the moleskin. (Toenails should be trimmed straight across the top, leaving a 90-degree angle on the sides. This provides an arch so that the corners do not irritate the skin.)

(6) Frostbite. Frostbite is the freezing or crystallization of living tissues due to heat being lost faster than it can be replaced by blood circulation, or from direct exposure to extreme cold or high winds. Exposure time can be minutes or instantaneous. The extremities are usually the first to be affected. Damp hands and feet may freeze quickly since moisture conducts heat away from the body and destroys the insulating value of clothing. Heat loss is compounded with intense cold and inactivity. With proper clothing and equipment, properly maintained and used, frostbite can be prevented. The extent of frostbite depends on temperature and duration of exposure. Frostbite is one of the major nonfatal cold-weather injuries encountered in military operations, but does not occur above an ambient temperature of 32 degrees Fahrenheit.

(a) Categories of Frostbite. Superficial (mild) frostbite involves only the skin (Figure 2-2). The layer immediately below usually appears white to grayish with the surface feeling hard, but the underlying tissue is soft. Deep (severe) frostbite extends beyond the first layer of skin and may include the bone (Figure 2-3). Discoloration continues from gray to black, and the texture becomes hard as the tissue freezes deeper. This condition requires immediate evacuation to a medical facility.

Figure 2-2. Superficial Frostbite.

Figure 2-2. Superficial frostbite.

Figure 2-3. Deep frostbite.

Figure 2-3. Deep frostbite.

(b) Contributing Factors. Factors that contribute to frostbite are:

  • Dehydration.
  • Below-freezing temperatures.
  • Skin contact with super cooled metals or liquids.
  • Use of caffeine, tobacco, or alcohol.
  • Neglect.

(c) Symptoms. Symptoms of frostbite vary and may include a cold feeling, pain, burning, numbness, and, in the final stages, a false sense of warmth. The skin first turns red, then pale. It may be bluish in color and then may appear frosty or waxy white. The skin may feel hard, may not be movable over the joints and bony prominences, or may be frozen. Identification of deep versus superficial frostbite is difficult to determine and often requires three to seven days after rewarming for medical personnel to diagnose. Blisters, swelling, and pain may occur after thawing.

(d) Treatment. Using the buddy system is one of the primary ways to prevent frostbite. Buddies must watch each other for symptoms of frostbite and provide mutual aid if frostbite occurs. Frostbite should be identified early with prompt first-aid care applied to prevent further damage.

  • Treat early signs of frostbite by rewarming with skin-to-skin contact or by sheltering the body part under the clothing next to the body. Do this immediately. If tissues have frozen, evacuate the victim before they thaw. If the feet are involved, evacuate the victim as a litter patient.
  • Thawing of a frostbitten victim is a hospital procedure. If the victim has frostbite with frozen extremities, protect the frozen parts and evacuate as a litter patient.
  • If frostbite is not recognized before it thaws, do not let the area refreeze since this causes more damage. The most often-affected body parts are the hands, fingers, toes, feet, ears, chin, and nose. If evacuation of the victim as a litter case is not possible and the body part has not yet thawed, have the victim walk out on his own. Walking out on frozen feet is better than having them thaw and refreeze. Self-evacuation may be tactically necessary. Walking on frozen feet does less harm than walking on thawed feet.
  • If reheating is inevitable, do not overheat the affected body parts near flame; the warming temperature should not be greater than normal body temperature. Do not rub the parts—the crystallized tissues may break internally and cause more damage. Do not pop blisters; cover them with a dry, sterile dressing. Keep the victim warm (apply loose, bulky bandages to separate toes and fingers.)
  • Once a part is rewarmed it will become painful. Pain may be managed with narcotic analgesics.
  • Once the foot is rewarmed it will swell and putting the boot back on will not be possible.

(7) Constipation. Constipation is the infrequent or difficult passage of stools.

(a) Contributing Factors. Factors that contribute to constipation are a lack of fluids, improper nutrition, and not defecating when needed.

(b) Symptoms. Symptoms include headache, cramping, lack of bowel movement, painful bowel movement, and loss of appetite.

(c) Treatment. Constipation is prevented by consuming adequate amounts and varieties of food, drinking from four to six liters of liquid each day, and defecating regularly. If allowed to progress beyond self-care stages, victims will need medical aid.

(8) Carbon Monoxide Poisoning. This is the replacement of oxygen in the blood with carbon monoxide.

(a) Contributing Factor. A contributing factor is inhaling fumes from burning fuel, such as fires, stoves, heaters, and running engines, without proper ventilation.

(b) Symptoms. Symptoms are similar to other common illnesses and include headaches, fatigue, excessive yawning, nausea, dizziness, drowsiness, confusion, and unconsciousness. Death may occur. The one visible symptom is bright red lips, mouth, and inside of the eyelids.

(c) Treatment. Remove the victim from the source of contamination; administer oxygen, if available; and evacuate to a medical facility. Severe complications may develop even in casualties who appear to have recovered. If the victim is unconscious, administer rescue breathing and CPR as needed.

Heat Injuries

Heat injuries, although associated with hot weather, can occur in cold-weather environments. Most heat injuries can be avoided by planning, periodic inspections of personnel clothing (ventilation) and equipment, a balance of water and food intake, and rest.

a. Heat Cramps. Heat cramps are caused by an accumulation of lactic acid in the muscles and a loss of salt through perspiration.

(1) Contributing Factor. Strenuous exertion causes the body to heat up and to produce heavy perspiration.

(2) Symptoms. Symptoms of heat cramps include pain and cramping in the arms, legs, back, and stomach. The victim sweats profusely and cannot quench his thirst.

(3) Treatment. Have the victim rest in a cool, shady area, breath deeply, and stretch the cramped muscle as soon as possible to obtain relief. Loosen the victim’s clothing and have him drink cool water. Monitor his condition and seek medical attention if pain and cramps continue.

b. Heat Exhaustion. Heat exhaustion may occur when a soldier exerts himself in any environment and he overheats. The blood vessels in the skin become so dilated that the blood flow to the brain and other organs is reduced.

(1) Contributing Factors. Factors that contribute to heat exhaustion are strenuous activity in hot areas, unacclimatized troops, inappropriate diet, and not enough water or rest.

(2) Symptoms. Symptoms of heat exhaustion may be similar to fainting but may also include weakness; dizziness; confusion; headache; cold, clammy skin; and nausea. The victim may also have a rapid but weak pulse.

(3) Treatment. Move the victim to a cool, shady area and loosen his clothes and boots. Have the victim drink water and, if possible, immerse him in water to aid in cooling. Elevate the victim’s legs to help restore proper circulation. Monitor his condition and seek medical attention if the symptoms persist.

c. Heat Stroke. Heat stroke is a life-threatening situation caused by overexposure to the sun. The body is so depleted of liquids that its internal cooling mechanisms fail to function.

(1) Contributing Factors. Factors that contribute to heat stroke are prolonged exposure to direct sunlight, overexertion, dehydration, and depletion of electrolytes.

(2) Symptoms. Symptoms of heat stroke include hot, dry skin; dizziness; confusion and incoherency; headache; nausea; seizures; breathing difficulty; a slow pulse; and loss of consciousness.

(3) Treatment. Cool the victim at once, and restore breathing and circulation. If the victim is conscious, administer water. If possible, submerge the victim in water to reduce his temperature, treat for shock, and prepare for immediate evacuation.

Acute Mountain Sickness

Acute mountain sickness is a temporary illness that may affect both the beginner and experienced climber. Soldiers are subject to this sickness in altitudes as low as 5,000 feet. Incidence and severity increases with altitude, and when quickly transported to high altitudes. Disability and ineffectiveness can occur in 50 to 80 percent of the troops who are rapidly brought to altitudes above 10,000 feet. At lower altitudes, or where ascent to altitudes is gradual, most personnel can complete assignments with moderate effectiveness and little discomfort.

a. Personnel arriving at moderate elevations (5,000 to 8,000 feet) usually feel well for the first few hours; a feeling of exhilaration or well-being is not unusual. There may be an initial awareness of breathlessness upon exertion and a need for frequent pauses to rest. Irregular breathing can occur, mainly during sleep; these changes may cause apprehension. Severe symptoms may begin 4 to 12 hours after arrival at higher altitudes with symptoms of nausea, sluggishness, fatigue, headache, dizziness, insomnia, depression, uncaring attitude, rapid and labored breathing, weakness, and loss of appetite.

b. A headache is the most noticeable symptom and may be severe. Even when a headache is not present, some loss of appetite and a decrease in tolerance for food occurs. Nausea, even without food intake, occurs and leads to less food intake. Vomiting may occur and contribute to dehydration. Despite fatigue, personnel are unable to sleep. The symptoms usually develop and increase to a peak by the second day. They gradually subside over the next several days so that the total course of AMS may extend from five to seven days. In some instances, the headache may become incapacitating and the soldier should be evacuated to a lower elevation.

c. Treatment for AMS includes the following:

  • Oral pain medications such as ibuprofen or aspirin.
  • Rest.
  • Frequent consumption of liquids and light foods in small amounts.
  • Movement to lower altitudes (at least 1,000 feet) to alleviate symptoms, which provides for a more gradual acclimatization.
  • Realization of physical limitations and slow progression.
  • Practice of deep-breathing exercises.
  • Use of acetazolamide in the first 24 hours for mild to moderate cases.

d. AMS is nonfatal, although if left untreated or further ascent is attempted, development of high-altitude pulmonary edema (HAPE) and or high-altitude cerebral edema (HACE) can be seen. A severe persistence of symptoms may identify soldiers who acclimatize poorly and, thus, are more prone to other types of mountain sickness.

Chronic Mountain Sickness

Although not commonly seen in mountaineers, chronic mountain sickness (CMS) (or Monge’s disease) can been seen in people who live at sufficiently high altitudes (usually at or above 10,000 feet) over a period of several years. CMS is a right-sided heart failure characterized by chronic pulmonary edema that is caused by years of strain on the right ventricle.

Understanding High-Altitude Illnesses

As altitude increases, the overall atmospheric pressure decreases. Decreased pressure is the underlying source of altitude illnesses. Whether at sea level or 20,000 feet the surrounding atmosphere has the same percentage of oxygen. As pressure decreases the body has a much more difficult time passing oxygen from the lungs to the red blood cells and thus to the tissues of the body. This lower pressure means lower oxygen levels in the blood and increased carbon dioxide levels. Increased carbon dioxide levels in the blood cause a systemic vasodilatation, or expansion of blood vessels. This increased vascular size stretches the vessel walls causing leakage of the fluid portions of the blood into the interstitial spaces, which leads to cerebral edema or HACE. Unless treated, HACE will continue to progress due to the decreased atmospheric pressure of oxygen. Further ascent will hasten the progression of HACE and could possibly cause death.

While the body has an overall systemic vasodilatation, the lungs initially experience pulmonary vasoconstriction. This constricting of the vessels in the lungs causes increased workload on the right ventricle, the chamber of the heart that receives de-oxygenated blood from the right atrium and pushes it to the lungs to be re-oxygenated. As the right ventricle works harder to force blood to the lungs, its overall output is decreased thus decreasing the overall pulmonary perfusion. Decreased pulmonary perfusion causes decreased cellular respiration—the transfer of oxygen from the alveoli to the red blood cells. The body is now experiencing increased carbon dioxide levels due to the decreased oxygen levels, which now causes pulmonary vasodilatation. Just as in HACE, this expanding of the vascular structure causes leakage into interstitial space resulting in pulmonary edema or HAPE. As the edema or fluid in the lungs increases, the capability to pass oxygen to the red blood cells decreases thus creating a vicious cycle, which can quickly become fatal if left untreated.

High-Altitude Pulmonary Edema

HAPE is a swelling and filling of the lungs with fluid, caused by rapid ascent. It occurs at high altitudes and limits the oxygen supply to the body.

a. HAPE occurs under conditions of low oxygen pressure, is encountered at high elevations (over 8,000 feet), and can occur in healthy soldiers. HAPE may be considered a form of, or manifestation of, AMS since it occurs during the period of susceptibility to this disorder.

b. HAPE can cause death. Incidence and severity increase with altitude. Except for acclimatization to altitude, no known factors indicate resistance or immunity. Few cases have been reported after 10 days at high altitudes. When remaining at the same altitude, the incidence of HAPE is less frequent than that of AMS. No common indicator dictates how a soldier will react from one exposure to another. Contributing factors are:

  • A history of HAPE.
  • A rapid or abrupt transition to high altitudes.
  • Strenuous physical exertion.
  • Exposure to cold.
  • Anxiety.

c. Symptoms of AMS can mask early pulmonary difficulties. Symptoms of HAPE include:

  • Progressive dry coughing with frothy white or pink sputum (this is usually a later sign) and then coughing up of blood.
  • Cyanosis—a blue color to the face, hands, and feet.
  • An increased ill feeling, labored breathing, dizziness, fainting, repeated clearing of the throat, and development of a cough.
  • Respiratory difficulty, which may be sudden, accompanied by choking and rapid deterioration.
  • Progressive shortness of breath, rapid heartbeat (pulse 120 to 160), and coughing (out of contrast to others who arrived at the same time to that altitude).
  • Crackling, cellophane-like noises (rales) in the lungs caused by fluid buildup (a stethoscope is usually needed to hear them).
  • Unconsciousness, if left untreated. Bubbles form in the nose and mouth, and death results.

d. HAPE is prevented by good nutrition, hydration, and gradual ascent to altitude (no more than 1,000 to 2,000 feet per day to an area of sleep). A rest day, with no gain in altitude or heavy physical exertion, is planned for every 3,000 feet of altitude gained. If a soldier develops symptoms despite precautions, immediate descent is mandatory where he receives prompt treatment, rest, warmth, and oxygen. He is quickly evacuated to lower altitudes as a litter patient. A descent of 300 meters may help; manual descent is not delayed to await air evacuation. If untreated, HAPE may become irreversible and cause death. Cases that are recognized early and treated promptly may expect to recover with no aftereffects. Soldiers who have had previous attacks of HAPE are prone to second attacks.

e. Treatment of HAPE includes:

  • Immediate descent (2,000 to 3,000 feet minimum) if possible; if not, then treatment in a monoplace hyperbaric chamber.
  • Rest (litter evacuation)
  • Supplemental oxygen if available.
  • Morphine for the systemic vasodilatation and reduction of preload. This should be carefully considered due to the respiratory depressive properties of the drug.
  • Furosemide (Lasix), which is a diuretic, given orally can also be effective.
  • The use of mannitol should not be considered due to the fact that it crystallizes at low temperatures. Since almost all high-altitude environments are cold, using mannitol could be fatal.
  • Nifidipine (Procardia), which inhibits calcium ion flux across cardiac and smooth muscle cells, decreasing contractility and oxygen demand. It may also dilate coronary arteries and arterioles.
  • Diphenhydramine (Benadryl), which can help alleviate the histamine response that increases mucosal secretions.

High-Altitude Cerebral Edema

HACE is the accumulation of fluid in the brain, which results in swelling and a depression of brain function that may result in death. It is caused by a rapid ascent to altitude without progressive acclimatization. Prevention of HACE is the same as for HAPE. HAPE and HACE may occur in experienced, well-acclimated mountaineers without warning or obvious predisposing conditions. They can be fatal; when the first symptoms occur, immediate descent is mandatory.

a. Contributing factors include rapid ascent to heights over 8,000 feet and aggravation by overexertion.

b. Symptoms of HACE include mild personality changes, paralysis, stupor, convulsions, coma, inability to concentrate, headaches, vomiting, decrease in urination, and lack of coordination. The main symptom of HACE is a severe headache. A headache combined with any other physical or psychological disturbances should be assumed to be manifestations of HACE. Headaches may be accompanied by a loss of coordination, confusion, hallucinations, and unconsciousness. These may be combined with symptoms of HAPE. The victim is often mistakenly left alone since others may think he is only irritable or temperamental; no one should ever be ignored. The symptoms may rapidly progress to death. Prompt descent to a lower altitude is vital.

c. Preventive measures include good eating habits, maintaining hydration, and using a gradual ascent to altitude. Rest, warmth, and oxygen at lower elevations enhance recovery. Left untreated, HACE can cause death.

d. Treatment for HACE includes:

  • Dexamethasone injection immediately followed by oral dexamethasone.
  • Supplemental oxygen.
  • Rapid descent and medical attention.
  • Use of a hyberbaric chamber if descent is delayed.

Hydration in HAPE and HACE

HAPE and HACE cause increased proteins in the plasma, or the fluid portion of the blood, which in turn increases blood viscosity. Increased viscosity increases vascular pressure. Vascular leakage caused by stretching of the vessel walls is made worse because of this increased vascular pressure. From this, edema, both cerebral and pulmonary, occurs. Hydration simply decreases viscosity.

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