- Author: C Crawford Mechem, MD, MS, FACEP; Chief Editor: Dirk M Elston, MD more...
Laboratory studies of tissue samples, blister fluid, or blood ordinarily do not provide any useful, clinically relevant information in isolated frostbite. Concurrent hypothermia, prolonged exposure with systemic physiologic changes, and previous medical illnesses may exist, however, and laboratory studies in these cases may be helpful.
Routine imaging studies early in the diagnosis and treatment of frostbite are rarely helpful in determining the extent and amount of tissue damage. 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.
Frostbite is a clinical diagnosis. Although laboratory studies are not important in the initial diagnosis and management of frostbite, they may be helpful in identifying delayed systemic complications, such as wound infection with sepsis or complications of underlying hypothermia.
Baseline laboratory studies to consider include complete blood count (CBC), electrolytes, blood urea nitrogen (BUN), creatine, glucose level, and liver function tests. Urinalysis may be used to detect evidence of myoglobinuria. Obtain Gram stains and cultures from suspected frostbite wound infections.
Radiography and Angiography
Radiography often demonstrates soft-tissue edema but does not distinguish viable from nonviable tissue. Radiographs identify clinically suspected fractures or dislocations but are otherwise rarely useful in initial evaluation. They may assist in the diagnosis of long-term complications, such as osteomyelitis.
Angiography often shows slowing of blood flow to the distal vasculature, but this too does not correlate well with eventual tissue loss. When a vasodilator is added, this technique can more accurately predict the final pattern of ischemia that will be observed after 2-3 weeks of observation. Arteriography is of limited value because it only images large vessels, not microvasculature. It cannot be used to estimate bone cell perfusion or viability.
Scintigraphy and Bone Scans
Technetium-99m (99m Tc) scintigraphy is sensitive and specific for tissue injury. Some authors recommend using it early in the management of frostbite (48 hours after injury) to aid in directing earlier debridement of nonviable soft tissue. This allows nonviable tissue to be visualized earlier than by clinical examination and thus presumably shortens patient hospitalization.[36, 37] In addition, scintigraphy is useful in assessing the response of damaged tissue to therapy.
Similarly, bone scans, particularly triple-phase bone scans, may help to delineate nonviable bone but should be reserved until microscopic tissue damage has had time to present itself clinically, generally 2-3 weeks post injury.
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
Magnetic resonance imaging (MRI), when combined with physical findings, may also be helpful in the early determination of margins of tissue viability.
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].