eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Frostbite: Differential Diagnoses & Workup

Author: David Cheng, MD, Assistant Professor of Emergency Medicine, Associate Emergency Medicine Residency Director, Associate Medical Director of Emergency Services, University of Arkansas Medical Sciences
Coauthor(s): Tonya M Thompson, MD, MA, Assistant Professor, Departments of Pediatrics and Emergency Medicine; Associate Fellowship Director, Pediatric Emergency Medicine Fellowship; Associate Medical Director, The PULSE Simulation Center, Arkansas Children's Hospital, University of Arkansas for Medical Sciences College of Medicine; Ramy Yakobi, MD, MBA, Medical Director of Emergency Department, Beth Israel/Kings Highway Division; Lecturer, Physician Assistant School, Cornell School of Medicine; Lecturer, Pre-hospital Management of Patient, Cornell/New York Presbyterian Hospital; Director of Emergency Department, New York Community Hospital
Contributor Information and Disclosures

Updated: May 13, 2009

Differential Diagnoses

Burns, Thermal

Other Problems to Be Considered

Frostnip appears as blanching of the skin with transient numbness and paraesthesia that resolves with rewarming. It is characterized by lack of ice crystal formation in the tissues and absence of tissue loss.

Trench foot results from prolonged exposure to a wet nonfreezing cold environment that produces peripheral neurovascular damage without ice crystal formation. This neurovascular damage manifests as pain, paresthesia, pallor, pulselessness, and paralysis. Trench foot is a reversible condition if diagnosed and treated early. Patients with trench foot have a better prognosis than patients with frostbite.

Perniosis (chilblain/cold sore) is less severe than trench foot and consists of painful inflammatory skin lesions caused by chronic repeated exposures to dry, nonfreezing cold temperatures. It is characterized by localized edema, erythema, plaques, nodules, vesicles, or bullae that appear as long as 12 hours after the injury.

Hypothermia, defined as core body temperature of less than 35°C, usually occurs as a concurrent disease.

Workup

Laboratory Studies

Frostbite is a clinical diagnosis. Laboratory studies are helpful to identify delayed systemic complications of frostbite, such as wound infection, sepsis, or hypothermia.

  • A baseline CBC count may be helpful to reveal hemoconcentration.
  • A baseline assessment of electrolyte, BUN, creatine, and glucose levels and baseline liver function test findings identify decreased hepatic function.
  • Urinalysis is used to detect evidence of myoglobinuria.
  • Obtain Gram stains and cultures from suspected frostbite wound infections.

Imaging Studies

  • Because transitory vascular instability lasts 2-3 weeks after the frostbite injury, no imaging technique (eg, thermography, angiography, plethysmography, radioisotope bone scanning) reliably predicts tissue demarcation during the initial frostbite presentation.
  • Technetium-99m scintigraphy 48 hours postinjury may occasionally reveal the extent of deep-tissue injury, allowing early surgical debridement and shortened patient hospitalization.
  • Radiography begins to reveal frostbite bony abnormalities 3 months after the injury. It can also help identify osteomyelitis sequelae.
  • Arteriography is rarely useful because it cannot be used to investigate the microvasculature damage. However, it is helpful for large-vessel damage.
  • Laser Doppler flowmetry is another experimental study that may help predict the extent of tissue viability.

Procedures

  • Surgical amputation of demarcated necrotic tissue (see Surgical Care)

Histologic Findings

The presence of a greater number of intracellular ice crystals compared to extracellular ice crystals suggests a rapid cooling of the skin.

The time frame of frostbite injury is as follows:

  • First hour - Endothelial leakage
  • First 6 hours - Erythrocyte extravasation
  • Within 6-24 hours - Leukocyte migration and vasculitis
  • Within 1-2 weeks - Medial degeneration, loss of intracellular attachments, and vacuolization of keratinocytes

More on Frostbite

Overview: Frostbite
Differential Diagnoses & Workup: Frostbite
Treatment & Medication: Frostbite
Follow-up: Frostbite
Multimedia: Frostbite
References
Further Reading
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References

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Keywords

frostbite, freezing, high-altitude mountaineering frostbite, freezing injury, general frostbite, cutaneous vasodilation, frostbite injury, reperfusion injury, hypothermia, frostnip, exposure to extreme cold, perniosis, hypothermia, hypoxia, neurapraxia, reperfusion inflammatory injury, edema, cold insensitivity, paresthesia, muscle atrophy, hyperhidrosis, anhidrosis, blister, diabetes mellitus, thyroid disease, vascular disease, treatment, diagnosis

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Contributor Information and Disclosures

Author

David Cheng, MD, Assistant Professor of Emergency Medicine, Associate Emergency Medicine Residency Director, Associate Medical Director of Emergency Services, University of Arkansas Medical Sciences
David Cheng, MD is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, Council of Emergency Medicine Residency Directors, International Society for Mountain Medicine, National Association of EMS Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Tonya M Thompson, MD, MA, Assistant Professor, Departments of Pediatrics and Emergency Medicine; Associate Fellowship Director, Pediatric Emergency Medicine Fellowship; Associate Medical Director, The PULSE Simulation Center, Arkansas Children's Hospital, University of Arkansas for Medical Sciences College of Medicine
Tonya M Thompson, MD, MA is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Women's Association, Phi Beta Kappa, and Southern Society for Pediatric Research
Disclosure: Nothing to disclose.

Ramy Yakobi, MD, MBA, Medical Director of Emergency Department, Beth Israel/Kings Highway Division; Lecturer, Physician Assistant School, Cornell School of Medicine; Lecturer, Pre-hospital Management of Patient, Cornell/New York Presbyterian Hospital; Director of Emergency Department, New York Community Hospital
Ramy Yakobi, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Harold K Simon, MD, MBA, Professor of Pediatrics and Emergency Medicine, Associate Division Director of Pediatric Emergency Medicine, Director of Research, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston
Harold K Simon, MD, MBA is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Pediatric Society, and Sigma Xi
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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