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Medical problems of the rescued castaway on board the rescue vessel
The treatment of survivors will depend on the nature of the rescue facility and the number and medical condition of the survivors.
Personnel on the rescue vessel should rapidly sort all survivors, according to their physical condition, into:
a. those with minor injuries whose condition will not be worsened by delay in treatment (to be treated last or as time permits);
b. those who are sick or injured but potentially treatable with the facilities at hand.
The latter group includes those who urgently require medical attention. Some persons in this group may be given first aid and relegated to group (a). For example, a broken arm could be splinted quickly and set later, after other more critical problems have been taken care of.
Victims rescued from drowning must receive immediate treatment.
Every submersion victim, even one requiring minimal treatment, should preferably be evacuated to a hospital for follow-up care.
Cold exposure injuries (local)
Cold injuries to parts of the body (face, extremities) are caused by exposure of tissues and small surface blood vessels to abnormally low temperatures. The extent of the injury depends upon such factors as temperature, duration ofexposure, wind velocity, humidity, lack of protective clothing, or presence of wet clothing. Also, the harmful effects of exposure to cold are intensified by fatigue, individual susceptibility, existing injuries, emotional stress, smoking, and drinking alcohol.
Cold injuries to parts of the body fall into three main categories: chilblains, immersion foot, and frost-bite.
Chilblains
This relatively mild form of cold injury occurs in moderately cold climates with high humidity and temperatures above freezing (0-16 °C). Chilblains usually affect ears, fingers, and the back of the hand; but they may affect the lower extremities, especially the anterior tibial surface of the legs.
They are characterized .by the skin burning a bluish red and by a mild swelling often associated with an itching, burning sensation, which may be aggravated by warmth. If exposure is brief, these manifestations may disappear completely with no remaining signs. However, intermittent exposure results in the development of chronic manifestations, such as increased swelling, further discoloration of the skin (which becomes a deep reddish purple), blisters, and bleeding ulcers which heal slowly to leave numerous pigmented scars.
Treatment. For skin discomfort, apply a bland soothing ointment such as petrolatum. People susceptible to chilblains should avoid the cold or wear woolen socks and gloves.
Immersion foot
This form of cold injury is caused by exposure of the lower extremities to water at above-freezing temperatures, usually below 10CC, for more than 12 hours. It characteristically occurs among shipwrecked sailors existing on lifeboats or rafts in enforced inactivity, with a poor diet, with wet and constricting clothing, and in adverse weather conditions. Clinical manifestations include swelling of the feet and lower portions of the legs, numbness, tingling, itching, pain, cramps, and skin discoloration. In cases of immersion foot uncomplicated by trauma, there is usually no tissue destruction.
Treatment. After rescue every effort should be made to avoid rapid rewarming of the affected limbs. Care should be taken to avoid damaging the skin or breaking blisters. Do not massage affected limbs.
Prevention. Every effort should be made by survivors to keep their feet warm and dry. Shoelaces should be loosened; the feet should be raised and toe and ankle exercises encouraged several times a day. When possible, shoes should be removed and unwanted spare clothing may be wrapped round the feet to keep them warm. Smoking should be discouraged.
Frost-bite
This is the term applied to cold injuries where there is destruction of tissue by freezing. It is the most serious form of localized cold injury. Although the area of frozen tissue is usually small, frostbite may cover, a considerable area. The fingers, toes, cheeks, ears, and nose are the most commonly affected parts of the body. If exposure is prolonged, the freezing may extend up the arms and legs. Ice crystals in the skin and other tissues cause the area to appear white or greyish-yellow in color. Pain may occur early and subside. Often, the affected part will feel only very cold and numb, and there may be a tingling, stinging, or aching sensation. The patient may not be aware of frostbite until someone mentions it. When the damage is superficial, the surface will feel hard and the underlying tissue soft when depressed gently and firmly. In a deep, unthawed frostbite, the area will feel hard and solid and cannot be depressed. It will be cold and numb, and blisters will appear on the surface and in the underlying tissues in 12-36 hours. The area will become red and swollen when it thaws, gangrene will occur later, and there will be a loss of tissue (necrosis). Time alone will reveal the kind of frostbite that has been present. It is fortunate therefore that the treatment for various degrees of frostbite is identical except for superficial frostbite. A frostbite of the superficial, dry, freezing type should be thawed immediately to prevent a deep-freezing injury of the part involved. However, never thaw a frozen extremity before arriving at a facility with water, heat, and equipment where the extremity can be rewarmed rapidly.
Treatment. All freezing injuries follow the same sequence in treatment: first aid, rapid rewarming, and care after first aid.
{a) First aid. The principles of first aid in localized cold injury are relatively few. The two most important things are to get the patient to a place of permanent treatment as soon as possible and then to rewarm him. It is important to note that a patient can walk for great distances on frostbitten feet with little danger. Once rewarming has started, it must be maintained. All patients with local cold injuries to the lower extremities become litter cases. Refreezing or walking on a partially thawed part can be very harmful. During transportation and initial treatment, the use of alcoholic drinks should not be permitted, because they affect capillary circulation and cause a loss of body heat. Ointments or creams should not be applied.
(b) Rapid rewarming. The technique of rewarming has two phases: (1) treatment of exposure; and (2) treatment of the local cold injury. Treatment of exposure consists of actively rewarming the patient. This is done in principle by the removal of cold and the addition of warmth. Removal of cold is accomplished by removal of all cold and wet clothing and constricting items such as shoes and socks. Addition of warmth is provided from external and internal source External warmth is added by providing the patient with prewarmed clothes and blankets. Giving a patient a cold change of clothes, a cold blanket, or a cold sleeping-bag will cause a rapid dissipation of his residual heat. If necessary, it would be better to have someone give the clothing he is wearing to the patient. Someone should warm the patient's sleeping bag before he gets into it. A good source of warmth is the body heat of other people. In general, internal warmth is provided by hot liquids and an adequate diet.
(c) Care after first aid. After the rewarming of a cold injury to a lower extremity, the patient is treated as a litter case. All constricting clothing items should be removed, total body warmth should be maintained, and sleep should be encouraged.
After rewarming, the affected part should be cleansed carefully with water, or soap and water, taking care to leave the blisters intact. A soft sterile dressing should be applied. Dry, sterile gauze should be placed between toes and fingers to keep them separated. The patient should be placed in bed with the affected part elevated and protected from contact with the bedding.
If available, a bed cradle can be used, or one can be improvised from boxes to keep sheets and blankets from touching the affected area. Additional heat should not be applied.
Morphine sulfate, 10 mg,may be given intramuscularly for pain and repeated every 4 hours as needed, but only if RADIO MEDICAL ADVICE recommends it.