- Author: C Crawford Mechem, MD, MS, FACEP; Chief Editor: Dirk M Elston, MD more...
The goal of medical management is to rewarm the injury as quickly as possible, provide pain control during rewarming, reduce reperfusion injury, prevent frostbite complications, and decrease long-term sequelae.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
Pain control is essential to quality patient care. Analgesics ensure patient comfort and may have sedating properties, which are beneficial for patients who have sustained trauma or injuries.
Nonsteroidal anti-inflammatory drugs (NSAIDs) have analgesic and antipyretic activities. Their mechanism of action is not known, but these agents may inhibit cyclooxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil and platelet aggregation, and various cell-membrane functions.
Ibuprofen inhibits inflammatory reactions and pain by blocking synthesis of thromboxane and prostaglandins to reduce reperfusion injury. It prevents platelet aggregation. Ibuprofen is preferable to aspirin, which irreversibly blocks synthesis of the prostaglandins needed for normal cell function and integrity, because it is not associated with Reye syndrome.
Naproxen is a member of the propionic acid group of NSAIDs. It is available in low-dose form as an over-the-counter (OTC) medication. It is highly protein-bound, is metabolized in the liver, and is eliminated primarily in the urine. Naproxen may reversibly inhibit platelet function.
Sulindac decreases COX activity and, in turn, inhibits prostaglandin synthesis. This results in decreased formation of inflammatory mediators.
Celecoxib primarily inhibits COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID gastrointestinal (GI) toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose of celecoxib for each patient.
Meloxicam decreases COX activity, and this, in turn, inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.
Flurbiprofen may inhibit COX, thereby, in turn, inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Pain control is essential to quality patient care. Analgesics ensure patient comfort and may have sedating properties, which are beneficial for patients who have sustained trauma or injuries. These agents are used for pain control during rewarming
Morphine is the drug of choice for strong analgesia because of its reliable and predictable effects, good safety profile, and ease of reversibility with naloxone. Morphine sulfate administered intravenously (IV) may be dosed in a number of ways and is commonly titrated until the desired effect is obtained.
Topical Skin Products
Topical agents are applied to debrided clear blisters and intact hemorrhagic blisters to minimize thromboxane synthesis.
Aloe vera inhibits the arachidonic cascade, especially thromboxane synthesis.
Antibiotics are used for wound infection prophylaxis. Their use is controversial and not recommended by some experts unless signs of infection develop. If antibiotic prophylaxis is employed, it should be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Penicillin G interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Immunizing agents are used to treat any person with a wound that might be contaminated with tetanus spores. Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.
Tetanus immune globulin is used for passive immunization of any person not been previously vaccinated for tetanus who has a wound that may be contaminated with tetanus spores
Vaccines, Inactivated, Bacterial
Toxoids are used for tetanus immunization in patients at risk of frostbite-associated tetanus. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome. In a patient who was never fully immunized, these should be supplemented with tetanus immune globulin 250 U intramuscularly (IM).
Tetanus and diphtheria toxoids are used to induce active immunity against tetanus in selected patients. They are the immunizing agents of choice for most adults and children older than 7 years. Booster doses must be administered to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.
In children and adults, tetanus and diphtheria toxoids may be administered into the deltoid or the midlateral thigh muscles. In infants, the preferred site of administration is the mid thigh laterally.
Golding MR. Protection from early and late sequelae of frostbite by regional sympathectomy: mechanism of "cold sensitivity" following frostbite. Surgery. 1963;53:303-310.:
Cappaert TA, Stone JA, Castellani JW, Krause BA, Smith D, Stephens BA. National Athletic Trainers' Association position statement: environmental cold injuries. J Athl Train. 2008 Oct-Dec. 43(6):640-58. [Medline]. [Full Text].
Terra M, Vloemans AF, Breederveld RS. Frostbite injury: a paragliding accident at 5500 meters. Acta Chir Belg. 2013 Mar-Apr. 113 (2):143-5. [Medline].
Russell KW, Imray CH, McIntosh SE, Anderson R, Galbraith D, Hudson ST, et al. Kite skier's toe: an unusual case of frostbite. Wilderness Environ Med. 2013 Jun. 24 (2):136-40. [Medline].
Connor RR. Update: cold weather injuries, active and reserve components, U.S. Armed Forces, July 2009-June 2014. MSMR. 2014 Oct. 21 (10):14-9. [Medline].
McCauley RL, Hing DN, Robson MC, Heggers JP. Frostbite injuries: a rational approach based on the pathophysiology. J Trauma. 1983 Feb. 23(2):143-7. [Medline].
Heggers JP, Robson MC, Manavalen K, Weingarten MD, Carethers JM, Boertman JA, et al. Experimental and clinical observations on frostbite. Ann Emerg Med. 1987 Sep. 16(9):1056-62. [Medline].
Rivlin M, King M, Kruse R, Ilyas AM. Frostbite in an adolescent football player: a case report. J Athl Train. 2014 Jan-Feb. 49 (1):97-101. [Medline].
Ikawa G, dos Santos PA, Yamaguchi KT, Stroh-Recor C, Ibello R. Frostbite and bone scanning: the use of 99m-labeled phosphates in demarcating the line of viability in frostbite victims. Orthopedics. 1986 Sep. 9(9):1257-61. [Medline].
Koehler MM, Henninger CA. Orofacial and digital frostbite caused by inhalant abuse. Cutis. 2014 May. 93 (5):256-60. [Medline].
Uygur F, Sever C, Noyan N. Frostbite burns caused by liquid oxygen. J Burn Care Res. 2009 Mar-Apr. 30(2):358-61. [Medline].
Kanzenbach TL, Dexter WW. Cold injuries. Protecting your patients from the dangers of hypothermia and frostbite. Postgrad Med. 1999 Jan. 105(1):72-8. [Medline].
Koljonen V, Andersson K, Mikkonen K, Vuola J. Frostbite injuries treated in the Helsinki area from 1995 to 2002. J Trauma. 2004 Dec. 57(6):1315-20. [Medline].
McIntosh SE, Opacic M, Freer L, Grissom CK, Auerbach PS, Rodway GW, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Wilderness Environ Med. 2014 Dec. 25 (4 Suppl):S43-54. [Medline].
Hutchison RL. Frostbite of the hand. J Hand Surg Am. 2014 Sep. 39 (9):1863-8. [Medline].
Dana AS Jr, Rex IH Jr, Samitz MH. The hunting reaction. Arch Dermatol. 1969 Apr. 99(4):441-50. [Medline].
Hirai K, Horvath SM, Weinstein V. Differences in the vascular hunting reaction between Caucasians and Japanese. Angiology. 1970 Sep. 21(8):502-10. [Medline].
Jobe JB, Goldman RF, Beetham WP Jr. Comparison of the hunting reaction in normals and individuals with Raynaud's disease. Aviat Space Environ Med. 1985 Jun. 56(6):568-71. [Medline].
Tanaka M. Experimental studies on human reaction to cold. Differences in the vascular hunting reaction to cold according to sex, season, and environmental temperature. Bull Tokyo Med Dent Univ. 1971 Dec. 18(4):269-80. [Medline].
Zook N, Hussmann J, Brown R, Russell R, Kucan J, Roth A, et al. Microcirculatory studies of frostbite injury. Ann Plast Surg. 1998 Mar. 40(3):246-53; discussion 254-5. [Medline].
McCauley RL, Heggers JP, Robson MC. Frostbite. Methods to minimize tissue loss. Postgrad Med. 1990 Dec. 88(8):67-8, 73-7. [Medline].
Golant A, Nord RM, Paksima N, Posner MA. Cold exposure injuries to the extremities. J Am Acad Orthop Surg. 2008 Dec. 16(12):704-15. [Medline].
DeGroot DW, Castellani JW, Williams JO, Amoroso PJ. Epidemiology of U.S. Army cold weather injuries, 1980-1999. Aviat Space Environ Med. 2003 May. 74(5):564-70. [Medline].
Valnicek SM, Chasmar LR, Clapson JB. Frostbite in the prairies: a 12-year review. Plast Reconstr Surg. 1993 Sep. 92(4):633-41. [Medline].
Ervasti O, Juopperi K, Kettunen P, Remes J, Rintamäki H, Latvala J, et al. The occurrence of frostbite and its risk factors in young men. Int J Circumpolar Health. 2004 Mar. 63(1):71-80. [Medline].
Juopperi K, Hassi J, Ervasti O, Drebs A, Näyhä S. Incidence of frostbite and ambient temperature in Finland, 1986-1995. A national study based on hospital admissions. Int J Circumpolar Health. 2002 Nov. 61(4):352-62. [Medline].
Koutsavlis AT, Kosatsky T. Environmental-temperature injury in a Canadian metropolis. J Environ Health. 2003 Dec. 66(5):40-5. [Medline].
Mäkinen TM, Jokelainen J, Näyhä S, Laatikainen T, Jousilahti P, Hassi J. Occurrence of frostbite in the general population--work-related and individual factors. Scand J Work Environ Health. 2009 Oct. 35(5):384-93. [Medline].
Craig RP. Military cold injury during the war in the Falkland Islands 1982: an evaluation of possible risk factors. J R Army Med Corps. 2007. 153 Suppl 1:63-8; discussion 69. [Medline].
Burgess JE, Macfarlane F. Retrospective analysis of the ethnic origins of male British army soldiers with peripheral cold weather injury. J R Army Med Corps. 2009 Mar. 155(1):11-5. [Medline].
Maley MJ, Eglin CM, House JR, Tipton MJ. The effect of ethnicity on the vascular responses to cold exposure of the extremities. Eur J Appl Physiol. 2014 Nov. 114 (11):2369-79. [Medline].
Brown FE, Spiegel PK, Boyle WE Jr. Digital deformity: an effect of frostbite in children. Pediatrics. 1983 Jun. 71(6):955-9. [Medline].
Long WB 3rd, Edlich RF, Winters KL, Britt LD. Cold injuries. J Long Term Eff Med Implants. 2005. 15(1):67-78. [Medline].
McCauley RL. Frostbite and other cold induced injuries. In: Auerbach PS, ed. Wilderness Medicine. St Louis, MO: Mosby; 1995:129-45:
Roche-Nagle G, Murphy D, Collins A, Sheehan S. Frostbite: management options. Eur J Emerg Med. 2008 Jun. 15(3):173-5. [Medline].
Kowal-Vern A, Latenser BA. Demographics of the homeless in an urban burn unit. J Burn Care Res. 2007 Jan-Feb. 28(1):105-10. [Medline].
Ducharme MB, Giesbrecht GG, Frim J, Kenny GP, Johnston CE, Goheen MS, et al. Forced-air rewarming in -20 degrees C simulated field conditions. Ann N Y Acad Sci. 1997 Mar 15. 813:676-81. [Medline].
Britt LD, Dascombe WH, Rodriguez A. New horizons in management of hypothermia and frostbite injury. Surg Clin North Am. 1991 Apr. 71(2):345-70. [Medline].
Martínez Villén G, García Bescos G, Rodriguez Sosa V, Morandeira García JR. Effects of haemodilution and rewarming with regard to digital amputation in frostbite injury: an experimental study in the rabbit. J Hand Surg Br. 2002 Jun. 27(3):224-8. [Medline].
Ibrahim AE, Goverman J, Sarhane KA, Donofrio J, Walker TG, Fagan SP. The emerging role of tissue plasminogen activator in the management of severe frostbite. J Burn Care Res. 2015 Mar-Apr. 36 (2):e62-6. [Medline].
Twomey JA, Peltier GL, Zera RT. An open-label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite. J Trauma. 2005 Dec. 59(6):1350-4; discussion 1354-5. [Medline].
Handford C, Buxton P, Russell K, Imray CE, McIntosh SE, Freer L. Frostbite: a practical approach to hospital management. Extrem Physiol Med. 2014. 3:7. [Medline].
Bruen KJ, Ballard JR, Morris SE, Cochran A, Edelman LS, Saffle JR. Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy. Arch Surg. 2007 Jun. 142(6):546-51; discussion 551-3. [Medline].
Folio LR, Arkin K, Butler WP. Frostbite in a mountain climber treated with hyperbaric oxygen: case report. Mil Med. 2007 May. 172(5):560-3. [Medline].
Kemper TC, de Jong VM, Anema HA, van den Brink A, van Hulst RA. Frostbite of both first digits of the foot treated with delayed hyperbaric oxygen:a case report and review of literature. Undersea Hyperb Med. 2014 Jan-Feb. 41 (1):65-70. [Medline].
Poulakidas S, Cologne K, Kowal-Vern A. Treatment of frostbite with subatmospheric pressure therapy. J Burn Care Res. 2008 Nov-Dec. 29(6):1012-4. [Medline].
Purkayastha SS, Bhaumik G, Chauhan SK, Banerjee PK, Selvamurthy W. Immediate treatment of frostbite using rapid rewarming in tea decoction followed by combined therapy of pentoxifylline, aspirin & vitamin C. Indian J Med Res. 2002 Jul. 116:29-34. [Medline].
Lau KN, Park D, Dagum AB, Bui DT. Two for one: salvage of bilateral lower extremities with a single free flap. Ann Plast Surg. 2008 May. 60(5):498-501. [Medline].