eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Frostbite: Follow-up

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

Follow-up

Further Inpatient Care

  • Because the initial insult is not predictive of the final outcome, most patients with frostbite must be hospitalized for 24-48 hours to assess the extent of injury. The mean length of hospital stay for all levels of frostbite is from 8.5-33.2 days.
  • Daily wound care includes the following:
    • Constricting eschars are bivalved.
    • Most skin grafting and amputations occur on weeks 3-4 after the injury.
  • Use hydrotherapy (ie, whirlpool bath filled with lukewarm water [40°C] and surgical soap) for 30-45 minutes twice daily until the eschar sloughs off.
    • Reduces infection
    • Aids debridement
    • Softens eschar
  • Use cotton pledgets between frostbitten phalanges to decrease tissue maceration.
  • Encourage active motion of affected area once healing has begun.
  • Avoid smoking because nicotine causes vasoconstriction.6

Further Outpatient Care

  • Counsel patients that the frostbitten area is more vulnerable to future heat and cold injury.
  • Encourage patients to undergo active physical therapy.

Inpatient & Outpatient Medications

  • The choice of outpatient medications is dictated by the patient's hospital course and may include antibiotics, analgesics, and ibuprofen.

Transfer

  • Patients with frostbite are best treated in a pediatric burn unit or a pediatric hospital environment that uses strict aseptic techniques.

Deterrence/Prevention

  • Seek shelter from wind and cold.
  • Wear several layers of light, loose clothing, which traps air for insulation yet provides for adequate insulation. This layering provides better protection than one bulky layer or heavy clothing.
  • Wear mittens instead of gloves because they decrease surface area exposure to the cold. Also, wear lightweight gloves under mittens for protection if mittens are removed to use fingers.
  • Wear at least 2 pairs of socks.
  • Cover up the face and head.
  • Choose fabrics suited for the cold (eg, fleece, polypropylene, wool).
  • Avoid restrictive and tight clothing that reduces peripheral circulation.
  • Avoid inadequate clothing.
  • Avoid getting clothing wet.
  • Avoid remaining in the same position for prolonged periods.
  • Check skin every 10-20 minutes for frostbite.
  • Avoid smoking because it causes peripheral vasoconstriction.

Complications

The degree of long-term disability is related to the severity of frostbite injury.

  • Infection: Wound infection observed in 30% of patients is caused by Staphylococcus aureus, beta-hemolytic streptococci, and gram-negative bacilli and results in the following:
    • Increased pain, swelling, redness, and fever
    • Red streaks extending from area
    • Pus discharge
  • Tetanus predisposition
  • Tissue loss and gangrene
  • Septicemia
  • Lymphedema
  • Fascial compartment syndrome
  • Irreversible growth plate injury (ie, destruction, fragmentation, or fusion of epiphyses) leading to growth deformities and postinjury arthritis7
    • Extent of premature closure is related to severity of the frostbite.
    • Premature closure in the digits more frequently occurs from a distal-to-proximal direction.
  • Reflex sympathetic dystrophy (autonomic dysfunction)
  • Altered thermal perception at injury site, especially cold sensitivity
  • Hyperesthesia
  • Hyperhidrosis
  • Squamous cell carcinoma development at frostbitten area

Prognosis

  • Favorable prognostic indicators
    • The more superficial the injury the better
    • Early sensation to pinprick
    • Healthy-appearing skin after rewarming
    • Clear blister more favorable than hemorrhagic blister
  • Poor prognostic indicators
    • Absence of edema
    • Hemorrhagic blebs
    • Blebs not extending to tips of phalanges
    • Persistent mottling/violaceous hue (cyanosis) and anesthesia after rewarming
  • Healing can take 6-12 months.

Patient Education

See Deterrence/Prevention. Advise patients to do the following:

  • Keep hands and feet dry.
  • Use mittens instead of gloves.
  • Apply clothing in multiple layers.
  • Avoid perspiration by using adequately ventilated clothing.
  • Avoid tight clothing.
  • Increase fluid and calorie intake in cold weather.
  • Maintain current tetanus immunization.
  • Do not rub affected areas because it causes further damage due to the presence of ice crystals in the skin.
  • Do not use dry heat to thaw frostbitten areas. Moist heat is better because it allows a more complete thaw.
  • Do not allow the injury to thaw then refreeze; therefore, hospital rewarming is favored over field rewarming.

For excellent patient education resources, visit eMedicine's Environmental Exposures and Injuries Center. Also, see eMedicine's patient education article Frostbite.

Miscellaneous

Medicolegal Pitfalls

  • Be sure to correct the ABCs and life threats (eg, hypothermia) before treating the frostbite.
  • Make sure that the frostbitten area does not refreeze.
  • Rewarm the frostbitten area as quickly as possible to salvage as much tissue and function as possible. Remember to treat pain associated with rewarming.
  • Maintain the circulating water at 40-42°C. Do not allow the water to get too hot or too cold.
  • Avoid premature termination of the rewarming process.
  • Avoid early amputation until after the nonviable tissue is clearly demarcated.
  • Inform patients that the injury site is more prone to recurrent damage when exposed to even moderate changes in environmental temperature.
  • Consider obtaining a photographic record on admission, 24 hours after admission, and serially every 2-3 days until discharge.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Dawn Hackshaw, MD to the development and writing of this article.



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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