UMEM Educational Pearls - By Jon Mark Hirshon

Category: International EM

Title: Unintentional Injuries- A Global Cause of Pediatric Deaths

Keywords: Children, unintentional injuries, burns, drownings, falls, road crashes, poisoning (PubMed Search)

Posted: 4/16/2015 by Jon Mark Hirshon, PhD, MPH, MD (Updated: 5/6/2015)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

In 2011, approximately 630,00 children under 15 died from unintentional injuries. Injuries are the leading cause of childhood deaths in children over 9 years old.  Ninety-five percent of these childhood injuries occur in lower- and middle-income countries.


The 2008 World Report on Child Injury Prevention listed the following as the top five causes of pediatric injury deaths globally:

1)   Road Crashes- approximately 260,000/year

2)   Drowning- approximately 175,0000/year

3)   Burns- approximately 96,000/year

4)   Falls- approximately 47,000/year

5)   Poisoning (unintentional)- approximately 45,000/year


Many of these deaths occur around the home and could be prevented through proven prevention measures, which include:

·      Child appropriate seatbelts and helmets

·      Separate children from vehicular traffic

·      Limit hot tap water temperature

·      Placing medications and potentially harmful household products in child proof containers

·      Draining unnecessary water from baths and buckets

·      Redesigning nursery furniture, toys and playground equipment

·      Strengthening emergency medical services

Show References

Category: International EM

Title: Enterovirus D68- The New Polio?

Keywords: Polio, enterovirus D68, acute flaccid paralysis (PubMed Search)

Posted: 4/1/2015 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD


  • Polio is a crippling and potentially fatal infectious disease
    • Can cause temporary or permanent acute flaccid paralysis
    • Fecal-oral or oral transmission
    • The majority of cases of polio infection are asymptomatic
    • The public/global health significance of polio has been discussed in previous UMEM Educational Pearls (See: 5/7/2014 and 12/18/2013).
  • Caused by small, single-strand, positive-sense RNA virus of the genus Enterovirus


Enterovirus D68

  • Recent widespread nationwide outbreak of this non-polio enterovirus
    • From mid-August 2014 to January 15, 2015, federal and state public health laboratories confirmed 1,153 people with infections
    • Usually seen in children
    • Usually causes mild to severe respiratory illness.
  • Concurrent with the national outbreak of Enterovirus D68, there was a concurrent increase in children with acute flaccid myelitis


Is there a relationship between Enterovirus D68 and the outbreak of acute flaccid myelitis?

  • Recent NIH funded research published in Lancet Infectious Disease analyzed the genomes of 48 patients with enterovirus infections
    • Phylogenetic analysis showed that all enterovirus D68 sequences associated with acute flaccid myelitis were part of the same clade B1 strain .
  • These findings strengthen the possible relationship between enterovirus D68 and acute flaccid myelitis


Bottom Line

  • Acute flaccid myelitis may rarely occur after Enterovirus D68 in susceptible hosts

Show References

Whether in the U.S. or overseas, there are four main phases of emergency management:


  1. Mitigation
    1. Identifying risks and hazards to reduce or eliminate the risks, such as:
      1. Building codes (for earthquakes, hurricanes, fires, etc.)
      2. Zoning rules (floodplain restrictions)
      3. Dams and levees (prevent flooding)


  1. Preparedness
    1. To enhance response capacity, such as
      1. Training, including exercises to assure adequacy of planning efforts
      2. Planning
      3. Resource procurement


  1. Response
    1. Immediate post disaster activities to save lives and property, such as
      1. Evacuating victims
      2. Response teams deployment
      3. Incident command operations


  1. Recovery
    1. Efforts to restore essential services and repair damage, such as
      1. Reconstruction of government operations and services
      2. Housing and services for displaced families/ individuals
      3. Replenish stockpiles

Show References

Category: International EM

Title: Noncommunicable (chronic) diseases- An International Perspective

Keywords: international health, noncommunicable diseases, chronic diseases, World Health Organization (PubMed Search)

Posted: 3/4/2015 by Jon Mark Hirshon, PhD, MPH, MD (Updated: 3/18/2015)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

Background: While much of international health focuses on communicable diseases, it is clear that noncommunicable diseases (NCDs), such as cardiovascular diseases, cancer and diabetes, causes substantial morbidity and mortality.



  • NCDs kill 38 million people each year
    • Approximately 28 million of these deaths occur in low- and middle-income countries.
  • Of the 38 million deaths, 16 million of these deaths occur in patients <70 years of age
    • 82% of these “premature” deaths occur in low- and middle-income countries
  • Causes of NCD deaths
    • Cardiovascular diseases (heart attacks and strokes): 17.5 million
    • Cancers: 8.2 million
    • Chronic respiratory diseases (COPD and asthma): 4 million
    • Diabetes: 1.5 million

Bottom line: As in developed countries, risk factors for NCDs deaths include physical in activity, tobacco use, unhealthy diabetes, harmful use of alcohol.

Show References

The Centers for Disease Control continues to report increased numbers of measles patients in the US. From January 1 to February 13, 2015 there have been 141 cases.  It has spread to 17 states and the District of Columbia, with 80% linked to the multistate outbreak from Disneyland.


Measles is not a benign disease!

Per the World Health Organization, there were 146,700 measles deaths globally in 2013.  Most of these deaths occur in lower- and middle-income countries,


Even in the US, measles can cause serious complications and death. Complications from measles can be seen in any age group, but particularly in children <5 years of age and in adults >20 years of age.


Measles Complications:


  • Ear infections (about 1 in 10 children)
    • Can result in permanent hearing loss
  • Diarrhea (about 1 in 10 people with measles)



  • Pneumonia (as many as 1 in 20 children)
    • Most common cause of death
  • Encephalitis (about 1 in 1,000 children)
    • Can lead to seizures, hearing loss, intellectual disability
  • Death (1 to 2 per 1,000 children)
  • Measles in pregnancy can cause premature birth and low-birth-weight babies



  • Subacute sclerosing panencephalitis (SSPE)
    • Aside from the long-term complications above, an estimate 4 to 11 out of every 100,000 will develop this fatal disease of the central nervous system 7 to 10 years after infection.


Bottom Line:

Per Dr. Anne Schuchat of the CDC: “This is not a problem with the measles vaccine not working. This is a problem of the measles vaccine not being used.”


Show References

Category: International EM

Title: Measles Update February 2015

Keywords: Measles, international, pediatrics, vaccination, public health (PubMed Search)

Posted: 2/4/2015 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

From January 1st to January 30th, 2015, 102 people from 14 states were reported to have measles. This one month total is greater than the annual number of U.S. cases from 2002 to 2012.  Most of these cases are related to a large outbreak from a Californian amusement park. Measles can spread in communities without adequate vaccination (low herd immunity). The majority of the people in the US who get measles are unvaccinated. However, measles remains common in many parts of the world.


Bottom Line:

As noted in the recent ACEP Fact Sheet, “A very high index of suspicion for Rubeola is necessary especially among patients with an exposure history, travel to foreign or domestic areas where disease is present, and those without adequate immunization. Immediate isolation of these patients should be considered in the ED or other outpatient healthcare setting.”



Show References


1502040913_Measles_Jan_2015.jpg (67 Kb)

Category: International EM

Title: Multidrug Resistant Tuberculosis (MDR TB)

Keywords: Tuberculosis, infectious disease, drug resistance, multidrug resistant tuberculosis (PubMed Search)

Posted: 1/21/2015 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

As noted previously (UMEM Pearl of 1/7/2015), tuberculosis (TB) is a major infectious disease that occurs worldwide. Strains of tuberculosis can be resistant to one or more anti-tuberculosis medications. TB strains resistant to at least one medication have been found in all surveyed countries.


What is multidrug-resistant tuberculosis (MDR TB)?

  • A TB organism resistant to at least isoniazid and rifampin
    • Two of the most common, potent and standard TB medications
  • Primary cause of MDR TB is inappropriate or incorrect usage of TB medications
  • In 2013, there were approximately 480,000 cases of MDR TB globally
    • Most cases were in India, China and the Russian Federation
  • A concerning form of resistant TB is extensively drug resistant TB (XDR TB), which is resistant to multiple anti-tuberculosis medications (see UMEM Pearl from 8/14/2013).


Treatment of MDR TB

  • MDR TB can usually be treated and cured with second-line treatments
  • Use of second-line treatments tend to be more:
    • Difficult to access the medications
    • Expensive
    • Likely to produce severe adverse reactions


Bottom line:

As noted previously, in your emergency department have a high index of suspicion for TB and MDR TB in patients with an appropriate risk profile.

  • Recent travel from appropriate countries
    • Most TB cases/deaths are in developing countries
  • Individuals infected with HIV.
  • Individuals using tobacco
    • Increases the risk of infection and death from TB.
  • Any age group, including children
    • Mostly affects young adults in their productive years

Show References

Category: International EM

Title: Tuberculosis

Keywords: Tuberculosis, infectious disease (PubMed Search)

Posted: 1/7/2015 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

Tuberculosis (TB) is a major infectious disease that occurs worldwide.

  • TB is second only to HIV/AIDS for the number of individuals killed worldwide from a single agent.
  • In 2013, 1.5 million died from TB and 9 million became ill
  • The vast majority (>95%) of TB deaths occur in low- and middle-income countries


Fortunately, public health and clinical measures have had some success.

  • The estimated number of individuals annually become ill with TB is declining
  • The TB death rate dropped 45% between 1990 and 2014
  • An estimated 37 million lives were saved between 2000 and 2013 through diagnosis and treatment


Bottom line:

  • Tuberculosis (TB) is a major killer worldwide.
  • Treatments are available to treat both latent and active disease
    • See:
  • Good clinical awareness is key to disease identification


Show References

Category: International EM

Title: New Years Eve- Be Safe!

Keywords: Injuries, alcohol, fireworks (PubMed Search)

Posted: 12/31/2014 by Jon Mark Hirshon, PhD, MPH, MD (Updated: 1/7/2015)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

As you get ready to celebrate the coming of a new year, it is important to be safe while you are having a good time.

Injuries seen during holidays, such as new years, include:

  • Firework related injuries
    • particular hand and ocular
  • Celebratory gunfire related injuries
    • including occasional deaths
  • Motor vehicle crash related injuries
    • particularly due to increased drinking and driving

If you are working, be ready to see increased alcohol and injury related visits.

If you are off and plan to celebrate, be sure to identify a designated driver or an alternate means of getting home.

Have a Happy and Safe 2015!

Background:  As discussed previously, influenza (flu) is a common respiratory disease that causes significant morbidity and mortality worldwide (see pearl from October 1. 2014).  We are now in the midst of the current flu season.


Current Update: This year’s vaccine was only a partial match (<50%) for the current influenza A (H3N2) circulating virus, so there is a significant potential for a “bad” flu season with widespread disease and severe illness.  Currently, influenza is now widespread throughout the US, with some states reporting more activity than others.  The CDC has a weekly surveillance map that highlights current disease spread.


Bottom Line:

  • Remember that influenza annually causes between 250,000 and 500,000 deaths worldwide.
  • Your emergency department will likely see many individuals with influenza this year, even if the patient received the vaccination.
  • Know your emergency department protocols and policies for cohorting influenza patients  and addressing droplet isolation precautions.

Show References


1412180413_CDC_Flu_Map_Week_49_2014.jpg (199 Kb)

Category: International EM

Title: Global Health and Emergency Care Research

Keywords: Global Health, emergency care, acute care, research (PubMed Search)

Posted: 12/3/2014 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

In December 2013, Academic Emergency Medicine published the results of the 2013 consensus conference that focused on advancing global health and emergency care research.


As noted in the issue’s executive summary, “Emergency physicians are uniquely poised to address challenges in health services, health care systems development and management, and emerging global disease burdens (both communicable and noncommunicable). “


The consensus conference covered developing research in eight focus areas, including understanding of cardiac and injury resuscitation, ethics of research, health systems development, and the education of future global health leaders.


For anyone interested in global health and emergency care, this issue of Academic Emergency Medicine is an outstanding resource and roadmap to developing research. It can be found at:

Background: As noted in a previous pearl (November 5, 2014), the Centers for Disease Control and Prevention (CDC) classifies potential bioterrorism agents into three categories. Category B & C agents are of less priority than the previously discussed Category A agents.

Category B: Second highest priority agents. These agents:

  1. are moderately easy to disseminate;
  2. result in moderate morbidity rates and low mortality rates; and
  3. require specific enhancements of CDC's diagnostic capacity and enhanced disease surveillance.

These Agents/Diseases include:

•Brucellosis (Brucella species)

•Epsilon toxin of Clostridium perfringens

•Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella)

•Glanders (Burkholderia mallei)

•Melioidosis (Burkholderia pseudomallei)

•Psittacosis (Chlamydia psittaci)

•Q fever (Coxiella burnetii)

•Ricin toxin from Ricinus communis (castor beans)

•Staphylococcal enterotoxin B

•Typhus fever (Rickettsia prowazekii)

•Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis])

•Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)


Category C agents: Third highest priority agents. These include emerging pathogens, such as hantavirus and Nipah virus, which could be potentially engineered for mass dissemination in the future.


Bottom Line: While in general of less concern, bioterrorism agents in Category B & C remain of significant risk.  Many of these diseases still occur in various parts of the globe including the United States.

Show References

Category: International EM

Title: Killer Bioterrorism Agents & Diseases: Category A

Keywords: Bioterrorism, anthrax, botulism, plague, smallpox, tularemia, viral hemmorrhagic fevers (PubMed Search)

Posted: 11/5/2014 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

Background: The Centers for Disease Control and Prevention (CDC) classifies potential bioterrorism agents into three categories, with Category A the most deadly.


Category A: These are the highest priority agents/diseases because they:

  • can be easily disseminated or transmitted from person to person;
  • result in high mortality rates and have the potential for major public health impact;
  • might cause public panic and social disruption; and
  • require special action for public health preparedness.


Specific Category A Agents/Diseases:

  • Anthrax (Bacillus anthracis)
  • Botulism (Clostridium botulinum toxin)
  • Plague (Yersinia pestis)
  • Smallpox (variola major)
  • Tularemia (Francisella tularensis)
  • Viral hemorrhagic fevers (including filoviruses such as Ebola and Marburg, as well as arenaviruses such as Lassa)


Bottom Line: With the exception of smallpox, these disease still occur in various parts of the globe including the United States. As can be seen by the current Ebola epidemic in West Africa, the U.S. public health system and healthcare providers must be prepared to recognize and treat these agents.

Show References


  • There is a great deal of fear, media attention, and misinformation concerning Ebola.  
  • As an emergency physician, you must be able to identify and appropriately manage individuals with possible Ebola presenting to your hospital. 
  • ACEP's Ebola Expert Panel worked with the Centers for Disease Control and Prevention to help create a clear and concise algorithm in case someone presents with possible Ebola.

ED Algorithm For Patients with Possible Ebola

  • Identify:
    • Do they have the right travel history (step 1)?
    • Do they have the right signs and symptoms (step 2)?

If yes to both identification questions, then:

  • Isolate (step 3):
    • Place patient in private room or separate enclosed area
      • Private bathroom or covered, bedside commode
    • Only essential personnel should evaluate patient and provide care
    • Level of personal protective equipment should be determined
      • Based upon patient’s clinical status (signs and symptoms)
  • Inform (step 4)
    • Immediately notify the hospital infection control program and other appropriate staff
    • Immediately notify the health department
  • Further evaluation and management will depend on the patient’s clinical status and other potential diagnoses (step 5).


Bottom line:

Whether the patient has Ebola or not, a well-developed response is necessary for patient management and public health preparedness. The fear of the disease is much more widespread and impactful than the disease itself.


See the full algorithm, with more details at:


1410290644_ed-algorithm-management-patients-possible-ebola.pdf (998 Kb)

Category: International EM

Title: What is Quarantine and Isolation?

Keywords: Infectious diseases, isolation, quarantine (PubMed Search)

Posted: 10/16/2014 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

With all the current concern about Ebola, it is important to understand what are quarantine and isolation and who can order these.

Per the Centers for Disease Control:

  • Quarantine: separates and restricts the movement of people who were exposed to a contagious disease to see if they become sick.
  • Isolation: separates sick people with a contagious disease from people who are not sick

Federal Law allows for quarantine and isolation:

  • From the Commerce Clause of the U.S. Constitution
  • Delegated to the Centers for Disease Control (CDC) by the U.S. Secretary of Health and Human Services
    • The CDC is "authorized to detain, medically examine, and release persons arriving into the United States and traveling between states who are suspected of carrying these communicable diseases."
  • The CDC may issue a federal isolation or quarantine order
    • Last large scale use was during the influenza pandemic of 1918-1919
  • Breaking of a federal quarantine order is punishable by fines and imprisonment

State laws allows for the enforcement of isolation and quarantine within their borders.

Bottom Line:

  • There have been no large-scale quarantine or isolation orders for 100 years. However, the CDC can issue an order that has the authority of the Constitution and federal law for enforcement.

Show References


What is it?

  • Common disease that causes significant morbidity and mortality worldwide
    • Both seasonal and pandemic influenza occurs
    • Vaccination can decrease disease incidence and spread
    • Treatment can decrease disease severity
  • Orthomyxoviruses (RNA virus)
    • 6 genera


Why do we care about influenza?

  • Pandemic Influenza
    • Can infect and kill young, healthy people
    • 1918 H1N1 Influenza pandemic infected an estimated 500 million globally
      • Approximately 20% of the world’s population
    • Killed an estimated 50 million (may be as high as 100 million)
      • 2%-3% of the world’s population died
  • Seasonal Influenza
    • Most often causes severe disease in the very young, very old, and those with chronic illnesses
    • Estimated between 3-5 million cases of severe illness around the world annually
    • Between 250,000 and 500,000 deaths


Bottom line

  • Influenza is a potentially life threatening disease.
  • Both seasonal and pandemic influenza are global concerns.
  • Morbidity and mortality can be decreased through appropriate vaccination and treatment

Category: International EM

Title: Blood Clots and Plane Travel- Are You at Risk?

Keywords: deep venous thrombosis, plane travel, blood clots (PubMed Search)

Posted: 9/16/2014 by Jon Mark Hirshon, PhD, MPH, MD (Emailed: 9/17/2014) (Updated: 9/17/2014)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

While sitting on an international flight, ever wonder what your risks are for a blood clot?


General Background:

It is estimated that the risk for a deep venous thrombosis (DVT) is 3-12% on a long-haul flight. However, the real incidence is difficult to evaluate, due in part to the lack of consensus about 1) diagnostic tests, and 2) the appropriate time frame to relate a venous thromboembolic event (VTE) to travel.


Risks Factors for VTEs on long-haul flights:

  • General:
    • stasis: prolonged sitting & crowded conditions
    • relative hypoxia
    • dehydration


  • Patient specific:
    • Age >40
    • Female gender
    • Use of estrogen-containing contraceptives/hormone replacement therapy
    • Obesity
    • Varicose veins in the legs
    • Family/personal history of prior VTEs
    • Active cancer/recent cancer treatment


Bottom Line:

  • Even healthy individuals are at risk on long-haul (>8 hour) flights.
  • The risk increases the longer the flight
  • Current data does not appear to show a risk difference between economy and business class.
  • Avoid dehydration and immobility
    • Exercise your legs/calf muscles
    • Drink plenty of fluid

Show References

Category: International EM

Title: Environmental Hyperthermia: Is it heat exhaustion or heat stroke?

Keywords: Hyperthermia, heat stroke, environmental (PubMed Search)

Posted: 9/1/2014 by Jon Mark Hirshon, PhD, MPH, MD (Emailed: 9/3/2014) (Updated: 9/3/2014)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

Hyperthermia can be defined as a core body temperature > 38.5ºC. In contrast to fever, the body’s temperature rises uncontrollably and the body is not able to dissipate the heat. There can be many causes of hyperthermia, including from environmental exposure. 


There are two main environmental heat illnesses, heat exhaustion and heat stroke.


Heat exhaustion:

  • Vague malaise, fatigue, headache
  • Core temperature may be normal or elevated (below 40ºC)  
  • May have tachycardia, orthostatic hypotension, clinical dehydration
  • Liver function tests (transaminases) may be normal or elevated
  • IMPORTANT- there is no altered mental status (i.e.: no coma or seizures)


Heat stroke

  • Usually tachycardia, orthostatic hypotension, clinical dehydration
  • May have hot, dry skin, but not always
  • Liver function tests (transaminases) are markedly elevated
  • May have rhabdomyolysis and renal failure
  • IMPORTANT- Signs of altered mental status (i.e.: coma, seizure, delirium)
  • Mortality may be up to 33%


Bottom line:

  • Heat stroke is a life threatening emergency.
    • Early recognition and rapid appropriate therapy can save a life
  • The most effective cooling is evaporative cooling along with ice packs

Show References

Category: International EM

Title: How do we gain and lose heat?

Keywords: hyperthermia, hypothermia, environmental, international (PubMed Search)

Posted: 8/12/2014 by Jon Mark Hirshon, PhD, MPH, MD (Emailed: 8/20/2014) (Updated: 8/20/2014)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

General Background:

Heat transfer is important to understand, especially when evaluating and treating someone who is hyperthermic or hypothermic. Are they really hot (or cold) from exposure, or is there an underlying metabolic or toxicological cause?


Mechanisms of Heat Transfer:

There are 4 main methods of heat transfer:

  • Radiation
    • Transfer of thermal energy through space by electromagnetic waves
    • Dependent on exposed surface area
    • Normally about 60% of heat loss
  • Conduction
    • Transfer of thermal energy through direct physical contact
    • Depends on conductivity of the surface (stone floors > water > air)
    • Can cause significant hypothermia for someone who is down for an extended period on a stone floor
  • Evaporation
    • Transfer of thermal energy through converting liquid to a gas
    • Occurs through perspiration and respiration
    • Can lead to dehydration
  • Convection
    • Transfer of thermal energy through movement of air or liquid across an object
    • Rate of heat loss depends on temperature gradient, density and velocity of moving substance
    • Can lead to extreme heat loss, especially when combined with evaporation (wet clothes on a cold, windy day)


Bottom line:

When evaluation someone for hyper- or hypothermia from a potential environmental exposure, be sure to obtain the history about where they were found and the circumstances in which they were found. This can help you develop your diagnostic differential.

Show References

Category: International EM

Title: Cold Exposure and Associated Conditions

Keywords: hypothermia, cold, environmental (PubMed Search)

Posted: 8/9/2014 by Jon Mark Hirshon, PhD, MPH, MD (Updated: 7/13/2024)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

General Information:

Hypothermia is when the body’s core temperature is less than 35º C. Often thought as a winter disease, it can occur in nearly any climate or weather condition. However, a number of cold related conditions can occur without a drop in core body temperature.


Specific Cold Related Conditions:

  • Frostnip
    • Condition: Ice crystal deposited in the dermis
    • Exposure: Freezing, damp exposure over hours to days
    • Treatment: Warm water (37º-41ºC) immersion with movement of affected area for 15-30 minutes


  • Frostbite
    • Condition: Frozen skin surface with damage to dermis and deeper structures
    • Exposure: Freezing, damp exposure over hours to days
    • Treatment: Warm water (37º-41ºC) immersion with movement of affected area for 15-30 minutes


  • Trench foot
    • Condition: Tissue necrosis without freezing
    • Exposure: Cold water exposure for hours to days
    • Treatment: Warm water (37º-41ºC) immersion with movement of affected area for 15-30 minutes


  • Chillblains
    • Condition: Epidermis repeatedly partially frozen and thawed
    • Exposure: Chronic cold, dry wind exposure over weeks
    • Treatment: Calcium-channel blockers can provide pain relief and decrease necrosis


Bottom line:

Remember that cold related injuries can occur without core hypothermia. Don’t forget the tetanus and antibiotics, as indicated.

Show References