Later Management of Cold Injuries LEARNING OBJECTIVE: Determine the steps needed for the later management of cold-exposure injuries. When the patient reaches a hospital or a facility for definitive care, the following treatment should be employed: 1. Maintain continued vigilance to avoid further damage to the injured tissue. In general, this is accomplished by keeping the patient at bed rest with the injured part elevated (on surgically clean sheets) and with sterile pieces of cotton separating the toes or fingers. Expose all lesions to the air at normal room temperature. Weight bearing on injured tissue must be avoided. 2. Whirlpool baths, twice daily at 98.6F (37C) with surgical soap added, assist in superficial debridement, reduce superficial bacterial contamination, and make range of motion exercises more tolerable. 3. Analgesics may be required in the early post- thaw days but will soon become unnecessary in uncomplicated cases. 4. Encourage the patient to take a nutritious diet with adequate fluid intake to maintain hydration. 5. Perform superficial debridement of ruptured blebs, and remove suppurative scabs and partially detached nails. MORPHINE USE FOR PAIN RELIEF LEARNING OBJECTIVE: Recall morphine dosage, administration routes, indications, contraindications, and casualty marking procedures. As a Corpsman, you may be issued morphine for the control of shock through the relief of severe pain. You will be issued this controlled drug under very strict accountability procedures. Possession of this drug is a medical responsibility that must not be taken lightly. Policies pertaining to morphine administration are outlined in BUMEDINST 6570.2, Morphia Dosage and Casualty Marking. MORPHINE ADMINISTRATION Morphine is the most effective of all pain-relieving drugs. It is most commonly available in premeasured doses in syrettes or tubexes. Proper administration in selected patients relieves distressing pain and assists in preventing shock. The adult dose of morphine is 10 to 20 mg, which may be repeated, if necessary, in no less than 4 hours. Morphine has several undesirable effects, however, and a Corpsman must thoroughly understand these effects. Morphine  is a severe respiratory depressant and must not be given to patients in moderate or severe shock or in respiratory distress.  increases intracranial pressure and may induce vomiting. These effects may be disastrous in head injury cases.  causes constriction of the pupils (pinpoint pupils). This effect prevents the use of the pupillary reactions for diagnosis in head injuries.  is cardiotoxic and a peripheral vasodilator. Small doses of morphine may cause profound hypotension in a patient in shock.  poisoning is always a danger. There is a narrow safety margin between the amounts of morphine that may be given therapeutically and the amounts that produce death.  causes considerable mental confusion and interferes with the proper exercise of judgment. Therefore, morphine should not be given to ambulatory patients.  is a highly addictive drug. Morphine should not be given trivially and must be rigidly accounted for. Only under emergency circumstances should the Corpsman administer morphine. Rigidly control morphine administration to patients in shock or with extensive burns. Because of the reduced peripheral circulation, morphine administration by subcutaneous or intramuscular routes may not be absorbed into the bloodstream, and pain may persist. When pain persists, the uninformed often give additional doses, hoping to bring about relief. When resuscitation occurs and the peripheral circulation improves, the stored quantities of morphine are released into the system, and an extremely serious condition (morphine poisoning) results. 4-65