Being outdoors in the winter—especially in the backcountry—presents a different and more complex set of safety challenges. Extreme cold and wind can render a person immobile—or worse—within minutes, complicating any additional injuries one has sustained. Here are several of the most common winter injuries, how to prevent them, and what to do if you or someone you’re with sustains them.
Ultraviolet (UV) keratitis, or photokeratitis, causes severe eye pain and decreased visual acuity, occurring 6 to 12 hours after significant or prolonged UV light exposure. If experienced as a result of time spent in a snow-covered environment, we refer to it as “snow blindness.” Think of it like a sunburn for your eyes. (Extended time on the water or at the beach can also lead to an episode, and welder’s arc burns is another well know example of this type of injury.)
In snow blindness, ultraviolet radiation damages the surface layer of the cornea—the transparent part of the eye that covers the pupil and iris—exposing multiple nerve endings, resulting in severe pain. Adventuring at altitude, where UV radiation exposure is typically higher due to snow cover and lack of tree cover, can further increase the risk of snow blindness. Classically, both eyes are affected by snow blindness. It is also not uncommon to see signs of sunburn on the snow blind person’s face.
Treatment: Patients are not aware of the UV radiation injury until 6 to 12 hours after the exposure. While this condition can be extremely painful and debilitating, it luckily is typically self-limited, and symptoms resolve in 1 to 3 days, with little, if any, risk of long-term issues or increased risk of recurrence. Oral medication can help manage early after diagnosis, with stronger pain medicine sometimes needed if symptoms persist. A doctor may also prescribe a lubricating antibiotic eye ointment to prevent infection.
Prevention: As with many things, prevention is the best approach for dealing with snow blindness. In outdoor environments where UV keratitis is a risk, wear sunglasses or goggles that block essentially all UV radiation. And while you cannot see UV light, the brightness of the light in the outdoor environment is also an issue that well-fitting eye protection can address. Sunglasses or goggles with 10 to 20 percent of visible light transmitted are typically adequate for many sunny environments, with snow-covered environments often requiring sunglasses with only 5 to 10 percent of light transmitted for comfort. A brimmed hat can also help with exposure.
While those that enjoy recreation in winter environments are generally covered up pretty well, usually there is some skin exposed to the elements and sunlight—often on the face. Ultraviolet rays can burn and damage your skin year-round, not just in the warmer months. Snow- and ice-covered environments, not to mention altitude, further increase your exposure of damaging UV radiation, raising your risk for sunburn, premature aging, and skin cancer. Apply broad spectrum sunscreen to exposed skin whenever outside, regardless of the season, to minimize your risk of sunburn.
Many people’s favorite winter outdoor activities involve some form of sliding quickly on frozen water, be it skiing, sledding, fat biking, or ice skating. These activities also share something else: the real risk of traumatic brain injury (TBI). When severe, these injuries can be deadly, with outdoor enthusiasts dying every year from brain injuries sustained while participating in the winter sports they enjoy. Mild TBIs can also have real and lasting effects. “Concussion” is a term that describes characteristic symptoms a person may experience after a TBI—symptoms like confusion, amnesia, loss of consciousness, headache, dizziness, and nausea and vomiting. Any person suspected of a TBI, mild or otherwise, should be medically evaluated by a trained health professional as quickly as possible. Appropriate helmet use should be considered mandatory for any activity where head injury is possible, be it while skiing Tuckerman Ravine or sledding down the hill in your backyard.
Anyone who enjoys playing in the outdoors in the Northeast should know how to recognize and treat hypothermia. While we sometimes think about hypothermia as a winter problem, hypothermia can set in anytime of the year.
Hypothermia is defined as a core body temperature lower than 95 degrees Fahrenheit. When the body’s heat loss is greater that its heat production, hypothermia is possible.
Risk factors for hypothermia: While the greatest risk factor for hypothermia is exposure to a cold environment, many other factors may predispose one to hypothermia. The very young and very old are at a higher risk. Insufficient fuel (from low blood sugar, extreme physical exertion, or malnutrition) can lead to a lack of internal heat. Individuals with diabetes or taking certain medications can produce less heat, leading to hypothermia. Drug and alcohol use, infections, heart and lung disease, and certain skin conditions can also lead to increased heat loss, predisposing one to hypothermia. Appropriate clothing, shelter, and equipment are critical to prevent hypothermia as we know that wet, windy, and cold environments all increase the risk.
Signs and symptoms of hypothermia: Early signs of hypothermia include shivering, slurred speech, clumsiness, and impaired judgement. Some call these the “umbles”: mumbles, grumbles, fumbles, and stumbles. When your body is shutting down and your brain is getting cold, your speech becomes slurred, you become irritable, and you have difficulty with coordination. As patients cool even further, they will actually stop shivering, their heart rate and breathing will slow, and they will become increasingly lethargic until they lose consciousness. Continued cooling will lead to cardiac arrest and, ultimately, death.
Basic hypothermia treatment: If you’re outdoors with someone exhibiting any of these signs, you should first treat and stabilize any other injuries to the best of your ability. Next, work to prevent further heat loss by insulating the patient from the environment. If you are able to provide shelter from the elements, remove wet clothing and layer the patient with thick insulating clothing, including a hat. Wrap the patient in a dry sleeping bag or blankets, followed by a wind and waterproof “vapor barrier” such as a reflective blanket or tarp. Lastly, don’t forget to insulate the patient from the cold ground by placing them on a sleeping pad or backpack.
After limiting heat loss, your next goal is to provide the patient with easily digestible calories that will fuel the body to help limit shivering and create body heat. If your patient is alert enough to swallow, warm sweet drinks like hot chocolate are good options. Foods containing simple carbohydrates—like chips or cookies—work well, too.
If you have warm water bottles or chemical heat packs, place them near the patient’s armpits and torso (not directly on the skin) for an external source of warmth. This external rewarming is critical in patients with moderate or severe hypothermia showing altered consciousness, as they can no longer generate their own heat. Handle advanced hypothermia patients gently, as their hearts are quite irritable, and jarring movements can cause fatal heart rhythms.
If the patient can walk when you encounter them, they may be able to be insulated, fed, and walked to safety. If not, keep the patient horizontal and activate local emergency response resources to aid in extrication while sheltering the patient to the best of your ability.
Frostnip and Frostbite
Unprotected exposure to cold temperatures and the effects of wind can lead to a spectrum of cold injuries. While often thought of as injuries affecting mountaineers climbing in remote parts of the world, frostnip and frostbite are very real possibilities throughout the Northeast in the colder months.
Frostnip is a superficial, nonfreezing cold injury due to vasoconstriction—the constriction of blood vessels—in exposed skin. Commonly this occurs on the cheeks, nose, and ears. Frost—or ice crystals—can appear on the skin surface. Numbness and loss of color occur and resolve after warming. Thankfully, there is no permanent tissue damage.
Frostbite is a true localized freezing of body tissue sustained by winter outdoor enthusiasts, soldiers, those who work in the cold, and others stranded in the outdoors in winter. While it may not kill you (though the often associated hypothermia can), patients can suffer permanent injury and loss of tissue as a result of frostbite. Patients may complain of skin that is numb, cold, hard, and waxy, sometimes appearing white or yellow. Blisters containing clear fluid or blood may form after rewarming. Tissue that appears blue, purple, or black after rewarming is at high risk for loss.
Risk factors for cold-induced injuries: Frostbite can develop in minutes given the right circumstances. Similar to hypothermia, any condition that increases localized heat loss or decreases heat production can increase the risk of frostbite. Heat loss due to a low temperature, wind, moisture, and contact with the cold ground, metal, or ice raise the risk. People suffering from dehydration, malnutrition, and those with poor circulation (including smokers) are also at a higher risk of frostnip and frostbite. Alcohol consumption increases the risk due to increased heat loss and impaired judgement and decision-making.
Prevention: Like hypothermia, adequate preparation and equipment can significantly reduce the risk of frostbite. Those spending time in frostbite conditions should wear layers of loose, heat-insulating, protective clothing that does not constrict body parts. Staying dry is paramount (especially hands and feet), as is protection from the wind. Wearing mittens instead of gloves can help keep fingers warm. Chemical hand and toe warmers can also be helpful, as are electric heat insoles and gloves. Boots should not be overly tight. And tending to the basics, such as staying hydrated and maintaining adequate nutrition, are important as well.
Treatment: The foundation of the treatment of frostbite is rewarming the affected area. This is best done in a controlled environment with a warm water bath of approximately 100 degrees Fahrenheit. Rewarming should never be started though if there is a chance for refreezing, as this will worsen tissue damage. Move the patient to a warm environment as soon as possible. Remove any jewelry, such as rings. Avoid walking on frostbitten feet unless absolutely necessary for evacuation. If walking is necessary, do not rewarm feet till after walking is complete. Avoid rubbing the affected area, as this can worsen tissue damage. Though tempting, fires and stoves should be avoided in rewarming as tissue can be insensate, and significant burns can occur. If refreezing is not a risk, field rewarming can be initiated by placing the affected area near the armpits, groin, or abdomen of themselves or another. A patient may need a dose of ibuprofen for its anti-inflammatory properties and control of pain associated with rewarming. Ultimately, professional medical evaluation is needed, and care may be transferred to a specialty center.