Trench Foot – Diagnosis and Treatment
Environmental Injuries / Exposures
First 5 Minutes
- Consider and rule in/out necrotizing fasciitis.
- Consider and rule in/out sepsis.
- Trench foot is a condition that occurs when the feet are exposed to wet and cold conditions for a prolonged period of time. Usually occurs at temperatures above freezing, and is classified as a non-freezing cold injury (NCFI).
- Commonly observed in military and homeless demographics, mainly affecting feet but can occur in any body area.
- It can be caused by standing in water or wet soil, or by wearing wet or non-breathable footwear.
- Symptoms of trench foot include numbness, tingling, and pain in the feet, as well as redness, swelling, and blisters. In severe cases, the skin may turn black and start to peel off.
- Acute complications include skin breakdown, infection, gangrene and amputation while chronic complications include chronic pain and cold intolerance.
- May rarely coexist with frostbite, however frostbite once thawed has a sharp demarcation between affected and unaffected tissue which helps distinguish frostbite from NCFI.
- A clinical diagnosis based on history and exposure:
- Numbness, tingling, and a feeling of coldness in the affected feet.
- Swelling, redness, and pain in the affected feet.
- Tissue death (gangrene) in severe cases.
- History of exposure to cold, wet conditions for an extended period of time.
- Physical exam includes:
- Inspect the affected feet:
- Look at the feet to assess the extent of the damage, including any swelling, redness, blisters, purulent drainage, necrotic changes, tissue maceration.
- Gently press on the feet to assess for areas of numbness or tenderness.
- Neurovascular status:
- Check the posterior tibialis and dorsalis pedis pulses in the feet to assess blood flow to the affected area.
- Test the patient’s ability to feel touch, temperature, and pain in the affected feet.
- Check for muscle strength:
- Assess muscular strength of the affect feet.
- Inspect the affected feet:
- Role of imaging:
- Plain radiographs can be considered if there is history of trauma.
- CT/MRI can be considered if infection suspected to look for abscess, free air, or other stigmata of infection.
- Air drying the affected feet at room temperature and gentle passive rewarming with bed rest, do not actively re-warm.
- Elevation of feet above the level of the heart, protect from constriction or mechanical damage.
- Affected feet should be open to air or loosely dressed.
- Replace fluid losses if necessary.
- Tetanus prophylaxis is recommended.
- NSAIDs for initial pain management, can consider opioids if NSAIDs are not effective.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
This resource is based on evidence gathered mainly from a military population as this type of injury was common during warfare, and there is some but limited evidence that exists outside this population.
Zafren K. Nonfreezing cold water (trench foot) and warm water immersion injuries. In: UpToDate. Waltham, MA. Accessed December 12, 2022. Available at: https://www.uptodate.com/contents/nonfreezing-cold-water-trench-foot-and-warm-water-immersion-injuries?search=trench%20foot&source=search_result&selectedTitle=1~5&usage_type=default&display_rank=1#H2063129059
Mistry K, Ondhia C, Levell NJ. A review of trench foot: a disease of the past in the present. Clin Exp Dermatol. 2020 Jan;45(1):10-14. doi: 10.1111/ced.14031. Epub 2019 Jul 15. PMID: 31309614.
Kuht JA, Woods D, Hollis S. Case series of non-freezing cold injury: the modern clinical syndrome. BMJ Mil Health. 2020 Oct;166(5):324-329. doi: 10.1136/jramc-2018-001099. Epub 2019 Mar 2. PMID: 30826752.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 02, 2023
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