Environmental Cold Injury

and Illness Policy

Background Information2

Cold Conditions.......3

Treatment...5

Prevention Strategies.....7

Environmental Risk Factors..8

Special Concerns.....9

Documentation.11

References....12
Background Information
Athletes participating in extreme cold environmental conditions may be at higher
risk for injury or illness. While most cold wealth conditions are not typically a barrier for
athletic activity, it is important to recognize when the environment is too hazardous for
athletes to participate. If an athlete is unable to maintain body heat during cold exposure
they can not only experience discomfort but also be at risk of a life threating situation.
Understanding the physiology of the body during exercise in a cold environment will help
to create a preventative protocol can be utilized to minimize the risk of injury or illness. In
addition, should an athlete begin to be affected by the cold, it is critical to recognize the
signs and symptoms of cold injury or illness and know how to treat the condition in an
effective and efficient manner.
Physiological Response
The process of thermoregulation of the body is a very complex system.
Understanding the basic principles of thermoregulation with help to understand what
preventative measures should be taken. In a cold environment, the body combats heat
loss using two mechanisms, thermogenesis, and peripheral vasoconstriction at the skin
surface. There are two types of thermogenesis, non-shivering and shivering. Non-
shivering does not use muscle tissue to increase heat production and is not a major
source of heat. Shivering thermogenesis involves involuntary contraction of the skeletal
muscles. The larger muscles are the first to begin shivering as they produce more heat.
The intensity and onset of the shivering is dependent on the duration and temperature
of the exposure.
Vasoconstriction of the peripheral vessels decreased the amount of blood flow to
the skin surface. This response decreases the rate at which heat is lost by decreasing
the thermal gradient between the skin and the environment; it is most pronounced in the
extremities. This mechanism is regulated by cold induced vasodilation (CIVD), which
limits the magnitude and duration of the vasoconstriction to protect the local area. CIVD
can be compromised (see special concerns) and increase the risk of nonfreezing cold
injuries.
There are four modes in which heat is transferred, radiation, convection,
conduction, and evaporation. Radiation is the direct transfer of heat to the environment
and is not affected by wind or moisture. Loss of heat from radiation is increased at night,
without cloud cover, and by exposed skin. Convection is the loss of heat from the flow of
air or water across the skin. The rate of convection is affected by both activity
(running/sprinting), as well as the wind-chill. Conduction is when the athlete is in direct
contact with a cold surface such as a football tackle or a goalie diving. Heat loss is
exacerbated by moisture; both from the environment (rain or snow) and wet clothing.
Lastly, evaporation creates heat loss through sweating and respiration. While proper
clothing choice and activity level can decrease loss of heat from sweating, respirations
account for 15-25% of heat loss and cannot be reduced.

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Cold Conditions
There are three categories of cold conditions: decreased core temperature
(hypothermia), freezing injuries of the extremities, and nonfreezing injuries of the
extremities. Understanding and recognizing the symptoms of these conditions will
decrease the risk of life threatening situations occurring. Figure 1 highlights the key
symptoms of each condition.
Hypothermia
Hypothermia is defined by the decrease of the core body temperature to below
95O and is classified and mild, moderate, or severe. There are different symptom
presents for each classification. It should be taken into consideration that every athletes
symptom presentation may be different depending on previous cold weather injury,
race, geological origin, ambient temperature, use of medications, clothing attire, fatigue,
hydration, age, and activity. Athletes are most at risk to develop hypothermia in
prolonged cold and wet conditions such as endurance events (running, cycling) or team
sports (football, soccer). Key Symptoms include:
Motor function: clumsiness, loss of finger dexterity, slurred speech
Cognition: confusion, memory loss, sleepiness, change in behavior
Loss of consciousness: drop in heart rate, stress on the renal system,
hyperventilation, sensation of shivering
Freezing Injuries
Frostnip is the mildest of the freezing injuries as the tissue experiences no
permanent damage. Frostnip is a precursor to frostbite and many times occurs when
skin is in contact with cold surfaces. The most characteristic symptom is a loss of
sensation. Frostbite is the process of the tissue freezing that occurs in localized areas
and ranges from superficial (mild) to deep. Frostbite can occur within minutes and
typically affects the face, ears, fingers, or toes. If the athlete is not removed from the
environment the frostbite can become deep, in which irreversible damage occurs.
Nonfreezing Injuries
Chilblain is a non-freezing cold injury associated with extended cold and wet
exposure and results in an exaggerated or inflammatory response. Chilblain may be
observed in exposure to cold, wet conditions extending beyond one hour in endurance
and alpine events, and team sports, in which clothing remains wet. The feet and hands
are usually affected. Immersion (trench) foot initially appears as a swollen, edematous
foot with a feeling of numbness, accompanied by aches, increased pain sensitivity, and
infections. The exposure time needed to develop trenchfoot ranges from 9-12 hours to
34 days in cold-wet environments. Most commonly, trenchfoot develops when wet
socks and shoes are worn continuously over many days. The likelihood of trenchfoot in
most sporting activities is low, except in winter hiking, camping, and expeditions.

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Figure 1: Cold Injuries Signs and Symptoms
Treatment
In accordance with the 2008 NATA Position Statement on Cold Related Injuries,
the following treatment protocols should be followed when a cold injury is recognized.
Hypothermia (Mild to Severe)
Obtained rectal temperature using a thermometer (digital or mercury) that can
read below 94.6F Using tympanic, axillary, or oral temperatures instead of rectal
temperature is faulty due to environmental concerns, such as exposure to air
temperatures; however, if either axillary or oral temperature is above 95.6F, the
person is not hypothermic.
If an athlete with suspected hypothermia presents with signs of cardiac
arrhythmia, he or she should be moved very gently to avoid causing paroxysmal
ventricular fibrillation.
Begin primary survey to determine the necessity of cardiopulmonary
resuscitation (CPR) and activation of the emergency medical system.
Remove wet or damp clothing; insulate the athlete with warm, dry clothing or
blankets (including covering the head); and move the athlete to a warm
environment with shelter from the wind and rain.
When rewarming, apply heat only to the trunk and other areas of heat transfer,
including the axilla, chest wall, and groin.
o Rewarming the extremities can produce afterdrop, and may result in
cardiac arrhythmias and death.
Provide warm, nonalcoholic fluids and foods containing 6% to 8% carbohydrates
to help sustain shivering and maintain metabolic heat production. (Mild
Hypothermia Only)
Avoid applying friction massage to tissues, as this may increase damage if
frostbite is present.
If a physician is not present during the treatment phase, initiate rewarming
strategies immediately and continue rewarming during transport and at the
hospital. (Moderate/ Severe Hypothermia Only)
During the treatment and/or transport, continually monitor vital signs and be
prepared for airway management. (Moderate/ Severe Hypothermia Only)
o A physician may order more aggressive rewarming procedures, including
inhalation rewarming, heated intravenous fluids, peritoneal lavage,blood
rewarming, and use of antiarrhythmia drugs.
When immediate management is complete, monitor for postrewarming
complications, including infection and renal failure.
Frostbite (superficial)
Rule out the presence of hypothermia by evaluating observable signs and
symptoms and measuring core temperature.

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 The decision to rewarm an athlete is contingent upon resources available and
likelihood of refreezing.
Rewarm athlete at room temperature or by placing the affected tissue against
another persons warm skin. Rewarming should be performed slowly, and water
temperatures greater than 98.6F should be avoided.
If rewarming is not undertaken, protect the affected area from additional damage
and further tissue temperature decreases and consult with a physician or
transport to a medical facility.
Avoid applying friction massage to tissues and leave any vesicles (fluid-filled
blisters) intact.
Once rewarming has begun, it is imperative that affected tissue not be allowed to
refreeze, as tissue necrosis usually results.
Athletes should avoid consuming alcohol and using nicotine.
Frostbite (deep)
Rule out the presence of hypothermia by assessing observable signs and
symptoms and measuring core temperature.
To rewarm, the affected tissue should be immersed in a warm (98.6 F104.6 F)
water bath. Water temperature should be monitored and maintained.
Remove any constrictive clothing and submerge the entire affected area. The
water will need to be gently circulated, and the area should be immersed for 15
to 30 minutes.
o Thawing is complete when the tissue is pliable and color and sensation
have returned. Rewarming can result in significant pain, so a physician
may prescribe appropriate analgesic medication.
If rewarming is not undertaken, the affected area should be protected from
additional damage and further tissue temperature decreases. Consult with a
physician or transport the athlete to a medical facility.
Tissue plasminogen activators (tPA) may be administered to improve tissue
perfusion. These agents have been shown to limit the need for subsequent
amputation due to tissue death.
Do not use dry heat or steam to rewarm affected tissue
Avoid friction massage or vigorous rubbing to the affected tissues and leave any
vesicles or fluid-filled blisters intact. If vesicles rupture, they should be treated to
prevent infection.
Once rewarming has begun, it is imperative that the affected tissue not be
allowed to refreeze, as tissue necrosis usually results. Also, weight bearing
should be avoided when feet are affected. If the possibility of refreezing exists,
rewarming should be delayed until advanced medical care can be obtained.
Athletes should avoid using alcohol and nicotine.
If tissue necrosis occurs and tissue sloughs off, debridement and infection control
measures are appropriate.

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Chilblain
Upon rewarming, the skin may exhibit inflammation, redness, swelling, itching, or
burning and increased temperature.
Remove wet or constrictive clothing, wash and dry the area gently, elevate the
area, and cover with warm, loose, dry clothing or blankets.
Do not disturb blisters, apply friction massage, apply creams or lotions, use high
levels of heat, or allow weight bearing on the affected area.
During treatment, continually monitor the affected area for return
Immersion (Trench) Foot
To prevent immersion foot, encourage athletes to maintain a dry environment
within the footwear, which includes frequent changes of socks or footwear (or
both), the use of moisture-wicking sock material, controlling excessive foot
perspiration, and allowing the feet to dry if wearing footwear that does not allow
moisture evaporation
For treatment, thoroughly clean and dry the feet, and treat the affected area by
applying warm packs or soaking in warm water 102.6F110.6F

Prevention Strategies
Educating all participants in proper prevention is the key to decreasing the
possibility of cold exposure injury or illness. Individuals unaccustomed to cold conditions
that may place them at risk for cold stress may need to take extra precautionary
measures (e.g., proper clothing, warm-up routines, nutrition, hydration, sleep).
Clothing
o Individuals should be advised to dress in layers and try to stay dry.
o Moisture, whether from perspiration or precipitation, significantly
increases body heat loss.
o Layers can be added or removed depending on temperature, activity,
and wind chill.
Energy/Hydration
o Negative energy balance increases the susceptibility to hypothermia.
Stay hydrated, since dehydration affects the bodys ability to regulate
temperature and increases the risk of frostbite. Fluids are as important
in the cold as in the heat. Avoid alcohol, caffeine, nicotine, and other
drugs that cause water loss, vasodilatation, or vasoconstriction of skin
vessels.
Fatigue/Exhaustion
o Fatigue and exhaustion deplete energy reserves. Exertional fatigue
and exhaustion increase the susceptibility to hypothermia, as does
sleep loss.
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 Warm-Up
o Warm-up thoroughly and keep warm throughout the practice or
competition to prevent a drop in muscle or body temperature.
o Time the warm-up to lead almost immediately to competition.
o After competition, add clothing to avoid rapid cooling. Warm extremely
cold air with a mask or scarf to prevent bronchospasm.
Partner
o Participants should never train alone. An injury or delay in recognizing
early cold exposure symptoms could become life threatening if it
occurs during a cold-weather workout on an isolated trail.
Practice and Competition Sessions
The following guidelines, as outlined in the 2008 NATA position statement, can be used
in planning activity depending on the wind chill temperature. Conditions should be
constantly re-evaluated for change in risk, including the presence of precipitation:
30 degrees Fahrenheit and below: Be aware of the potential for cold injury and
notify appropriate personnel of the potential.
25 degrees Fahrenheit and below: Provide additional protective clothing; cover
as much exposed skin as practical; provide opportunities and facilities for re-
warming.
15 degrees Fahrenheit and below: Consider modifying activity to limit exposure
or to allow more frequent chances to re-warm.
0 degrees Fahrenheit and below: Consider terminating or rescheduling activity.

Environmental Risk Factors

To identify cold stress conditions, regular measurements of environmental
conditions are recommended during cold conditions by referring to the Wind-Chill
Equivalent Index (WCEI) (revised November 1, 2001). The WCEI is a useful tool to
monitor the air temperature index that measures the heat loss from exposed human
skin surfaces.
Wind chill is the temperature it feels like outside, based on the rate of heat loss from
exposed skin caused by the effects of the wind and cold. Wind removes heat from the
body in addition to the low ambient temperature.
Wind Chill: Increased wind speeds accelerate heat loss from exposed skin, and
the wind chill is a measure of this effect. No specific rules exist for determining
when wind chill becomes dangerous. As a general guideline, the threshold for
potentially dangerous wind chill conditions is about minus-20 degrees
Fahrenheit.

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 Wind Chill Advisory: The National Weather Service issues this product when the
wind chill could be life threatening if action is not taken.
Wind Chill Factor: Increased wind speeds accelerate heat loss from exposed
skin. No specific rules exist for determining when wind chill becomes dangerous.
As a general rule, the threshold for potentially dangerous wind chill conditions is
about minus-20 degrees Fahrenheit.
Wind Chill Warning: The National Weather Service issues this product when the
wind chill is life threatening.

Special Considerations
When dealing with athletes with special considerations it is advised to take
extreme caution during activity in the cold. Preventative measures including proper
attire, nutrition, hydration, and warm-up should all be implemented to minimize risk of
injury.
Age: Older individuals (> 60 year) are at an increased risk of hypothermia due to
blunted physiological and behavioral responses to cold. Children are at a greater risk of
hypothermia than adults due to differences in body composition and anthropometry.
Sex: The hypothermia injury rate for females is 2 times higher than for males. Sex
differences in thermoregulatory responses during cold water exposure are primarily
attributable to the womans generally greater body fat content, thicker subcutaneous fat

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layer, less muscle mass, and higher surface area-to-mass ratio than men of comparable
age and weight. However, in women and men of equivalent subcutaneous fat thickness,
the women have a greater surface area and smaller total body mass and musculature
than men, causing greater heat.
Race: Black individuals have been shown to be 2 to 4 times more likely than individuals
from other racial groups to sustain cold injuries. This may be due to cold weather
experience, but are likely due to anthropometric and body composition differences,
including less pronounced CIVD, increased sympathetic response to cold exposure, and
thinner, longer digits.
Hypoglycemia and fasting: Hypoglycemia impairs shivering and increases the risk for
hypothermia. Athletes should maintain proper nutritional habits to minimize this risk.
Nicotine, Alcohol, and Drug Use: Nicotine inhaled through smoking causes a reflex
peripheral vasoconstriction, possibly negating the CIVD. Alcohol reduces the glucose
concentration in the blood, which tends to decrease the shivering response. Drugs with
a depressive effect may impair the thermoregulatory system and so inhibit the bodys
reaction to cold by blunting the peripheral vasoconstriction and shivering responses.
Previous Cold Injuries: Having sustained a previous cold injury increases the chance
of subsequent cold injuries by 2 to 4 times, even if prior injuries were not debilitating or
resolved with no or minimal medical care.
Predisposing Medical Conditions:
Exercise-Induced Bronchospasm: Exercise-induced bronchospasm (EIB), also
called exercise-induced asthma or airway hyperresponsiveness, is a narrowing of the
respiratory tract airways. It is exacerbated by exposure to cold, dry air.
Raynaud syndrome: Raynaud syndrome is caused by cold exposure and
characterized by intermittent vasospasm of the digital vessels. This vasospasm
significantly reduces blood flow to the extremities.
Anorexia Nervosa: Anorexia nervosa results in a deficiency of body fat stores,
potential malnutrition, decreased metabolic rate, and peripheral vasoconstriction. These
changes limit the ability to maintain a normal core temperature.
Cold Urticaria: Cold urticaria may be the most common form of urticaria. The
condition has a rapid onset, presenting with wheals (hives) that may be local or
generalized, redness, itching, and edema.
Cardiovascular Disease: Individuals with cardiovascular disease are sensitive
to increased demands on the myocardium and increases in blood pressure, as well as
having potentially decreased flow to cutaneous and subcutaneous tissues. Cold
exposure coupled with exercise increases the demand on the cardiovascular system by
increased sympathetic nervous system activity, peripheral resistance, blood pressure,
and myocardial oxygen demands.

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Documentation
Should a cold injury and illness incidence occur all of the following information
should be document by the athletic trainer, or medical staff providing care.
Initial assessment (primary survey)
Treatment given
Transportation (if applicable)
Re-assessment
Preventative measures utilized
Referral to physician (if applicable)
Environmental conditions at the time of the incident

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References:
1. Cappaert T, Stone J, Castellani J, Krause B, Smith D, Stephens B. National
Athletic Trainers' Association Position Statement: Environmental Cold Injuries.
Journal Of Athletic Training (National Athletic Trainers' Association) [serial
online]. November 2008;43(6):640-658
2. Castellani JW, Young AJ, Ducharme MB, Giesbrecht GG, Glickman E, Sallis RE.
American College of Sports Medicine position stand: prevention of cold injuries
during exercise. Med Sci Sports Exerc. 2006;38(11):20122029.
3. Hamlet MP. Prevention and treatment of cold injury. Int J Circumpolar Health.
2000;59(2):108113.
4. NOAA National Weather Service, www.weather.gov/om/windchill/images/wind-
chill-brochure.pdf.

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