eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Frostbite: Treatment & Medication

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

Treatment

Medical Care

• Address ABCs and life threats before the frostbite.
• Correct any systemic hypothermia to a core temperature of 34°C before treating the frostbite.
• The goal of frostbite treatment is to salvage as much tissue as possible, to achieve maximal return of function, and to prevent complications.
• Remove the patient from cold.
• Replace wet and constrictive clothing with dry loose clothing.
• Rewarm the frostbitten area if no danger of refreezing is observed. Walking on frozen frostbitten areas and risking tissue chipping and fracture is considered better than thawing and refreezing.
• Avoid rubbing the area.
• Rapid rewarming is the single most effective therapy for frostbite.³ Avoid inadvertent slow rewarming or overheating.
• Rewarm in circulating water (ie, whirlpool bath) at 40-42°C.
• Thawing takes about 20-40 minutes for superficial injuries and as long as 1 hour for deep injuries.
• Treatment is complete when the distal area of the extremity is flushed, soft, and pliable.
• Encourage active gentle motion of the frostbitten area during the rewarming.
• Constantly monitor water temperature to ensure it does not exceed 43.3°C.
• The most common error is premature termination of the rewarming process from noncompliance because of reperfusion pain.
• Avoid dry heat because of unequal heating, inability to control the temperature, and the tendency to desiccate the tissue.
• Avoid massaging the area during rewarming because it further traumatizes the injury.
• Analgesics (eg, ibuprofen, morphine) for pain relief are indicated during and after rewarming.
• Once the skin is thawed, protect the area from further injury and reexposure to cold. Elevate the area and splint. Change the sterile nonadherent dressing 2-4 times a day. Prevent infection. Aid circulation. Provide rehabilitation.
• Provide local wound care with dressing changed 2-4 times a day.
• Apply topical aloe vera cream to all frostbitten areas every 6 hours to inhibit arachidonic cascade, especially thromboxane synthesis. Other arachidonic cascade inhibitor agents currently being investigated include topical methimazole (thromboxane synthetase inhibitor) and topical methylprednisolone acetate (phospholipase A2 inhibitor).
• Aspirate clear blisters to prevent thromboxane and prostaglandin-mediated tissue damage.
• In order to avoid desiccation and infection of underlying deep layers, do not debride hemorrhagic blisters.
• Manage fractures and dislocations conservatively until thawing is complete.
• Providing medical sympathectomy with intravenous reserpine (alpha-blocking agent) at 0.5 mg into the affected terminal artery for adult patients achieves better pain relief and edema reduction than surgical sympathectomy. The reserpine effect begins in 3-24 hours and persists for 2-4 weeks. However, the intravenous form is no longer available in the United States and has not been used on pediatric patients.
• Administer tetanus prophylaxis.
• Antibacterial prophylaxis can be considered because the postthaw edema is predisposed to infection.
  • Frostbite infections tend to involve staphylococci, streptococci, enterococci, and Pseudomonas pathogens.
  • Avoid topical antibiotics because they interfere with the aloe vera cream.
  • Administer penicillin G intravenously every 6 hours for 48-72 hours.
• Investigational therapy is available. Numerous ancillary modalities have been suggested, but efficacy is questionable because of lack of well-controlled human trials.
  • Thrombolysis using intra-arterial tissue plasminogen activator (t-PA) in deep frostbite to decrease tissue loss via 10% when administered within 24 hours of exposure
  • Limaprost (prostaglandin E1 analogue) as therapeutic vasodilator to increase peripheral blood flow
  • Alpha-blocker buflomedil to increase peripheral blood flow
  • Low molecular weight dextran as antisludging agent to decrease RBC clumping (may be effective if administered very early in the treatment process)
  • Arachidonic acid cascade inhibitors
  • Heparinization
  • Hyperbaric oxygen (anecdotal)
  • Subatmospheric pressure therapy (anecdotal)⁴
  • Pentoxifylline
  • Vitamin C

Surgical Care

• The only indication for early surgical intervention is postthaw compartment syndrome warranting fasciotomy.
• Because of extreme difficulty in differentiating viable tissue from nonviable tissue in the first few weeks after frostbite injury, amputation surgery is best avoided until a complete demarcation and separation of gangrenous tissue occurs. This process normally takes 6-8 weeks. Consider early amputation if liquefaction, moist gangrene, or infection develops in the frostbitten area.
• Skin grafting may be required.
• Escharotomy may be appropriate if the eschar is preventing circulation or limb motion.
• Fasciotomy may be appropriate if elevated compartment pressure occurs.
• Surgical sympathectomy may be appropriate.
  • Paradoxically, it increases tissue edema formation if performed too early after the frostbite injury.
  • If reserved for 24-48 hours after rewarming, sympathectomy increases peripheral blood flow to salvage tissues.
• Long-term surgical management includes the following options:
  • Debridement of demarcated nonviable tissue: The demarcation process usually takes 1-3 months from the time of initial exposure.⁵
  • Skin grafting
  • Reconstruction of nose, ears, fingers, and toes
  • Referral to physical rehabilitation

Consultations

Frostbite treatment is a multidisciplinary process using the following specialists:

• Pediatric emergency medicine physician to stabilize the patient
• Pediatrician to provide inpatient medical treatment
• Surgeon to provide the surgical care
• Physical therapist to provide the rehabilitation
• Psychiatrist to help the child and family cope with any permanent disability

Diet

• No restriction on diet is required, but a high-protein, high-calorie diet is suggested to promote healing.

Activity

• Rest the injured area initially.
• Elevate injured area to reduce swelling.
• Perform physical therapy to increase flexibility and dexterity once the injury begins to heal.

Medication

The goal of medical management is to rewarm the injury as quickly as possible, provide pain control during the rewarming, reduce reperfusion injury, prevent frostbite complications, and decrease long-term sequelae.

Analgesics

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.

Ibuprofen (Advil, Motrin)

Blocks synthesis of thromboxane/prostaglandins to reduce reperfusion injury. Prevents platelet aggregation. Preferable to aspirin because not associated with Reye syndrome.

Morphine (Duramorph, MS Contin)

DOC for strong analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone.

Herbal products

These agents are applied to debrided blisters and intact hemorrhagic blisters to minimize thromboxane synthesis.

Aloe vera

Inhibits arachidonic cascade, especially thromboxane synthesis.

Antibiotics

Antibiotic prophylaxis must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Penicillin G (Pfizerpen, Wycillin, Permapen)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Immunizing agents

These agents are used to treat any person with a wound that might be contaminated with tetanus spores.

Tetanus immunoglobulin (Hyper-Tet)

Used for passive immunization in patients who have not been previously vaccinated for tetanus.

Diphtheria-tetanus toxoid (DT, Td adsorbed)

Used to induce active immunity against tetanus in selected patients. Immunizing agent of choice for most adults and children >7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Patients who are pregnant should receive only tetanus toxoid, not a product containing diphtheria antigen.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is the mid thigh laterally.

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