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Frostbite Workup

  • Author: C Crawford Mechem, MD, MS, FACEP; Chief Editor: Dirk M Elston, MD  more...
Updated: Feb 26, 2016

Approach Considerations

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.


Laboratory Studies

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.[17]


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

Imaging Studies

Magnetic resonance imaging (MRI), when combined with physical findings, may also be helpful in the early determination of margins of tissue viability.  

Contributor Information and Disclosures

C Crawford Mechem, MD, MS, FACEP Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Emergency Medical Services Medical Director, Philadelphia Fire Department

C Crawford Mechem, MD, MS, FACEP is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.


David Cheng, MD Associate Professor of Emergency Medicine, Education Director, Associate Emergency Medicine Residency Director, Case Medical Center

David Cheng, MD is a member of the following medical societies: American College of Emergency Physicians, International Society for Mountain Medicine, Council of Emergency Medicine Residency Directors, American Heart Association, National Association of EMS Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Ramy Yakobi, MD, MBA Medical Director, Department of Emergency Medicine, Beth Israel Medical Center

Ramy Yakobi, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

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: Academic Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Womens Association, Phi Beta Kappa, Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.


H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine

H Scott Bjerke, MD, FACS is a member of the following medical societies: American Association for the History of Medicine, American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Midwest Surgical Association, National Association of EMS Physicians, Pan-Pacific Surgical Association, Royal Society of Medicine, Southwestern Surgical Congress, andWilderness Medical Society

Disclosure: Nothing to disclose.

Burt Cagir, MD, FACS Assistant Professor of Surgery, State University of New York, Upstate Medical Center; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic

Burt Cagir, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, and Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MA Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Other

Dawn Hackshaw, MD Consulting Staff, Northwest Pediatrics, Inc

Disclosure: Nothing to disclose.

David L Morris, MD, PhD Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

Disclosure: RFA Medical None Director; MRC Biotec None Director

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.

Francisco Talavera, PharmD, PhD Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Amit Tevar, MD Staff Physician, Department of Surgery, Methodist Hospital of Indianapolis and University of Indiana

Amit Tevar, MD is a member of the following medical societies: Indiana State Medical Association

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

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

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Frostbite of the foot. Photo courtesy of Kevin P. Kilgore, MD, Department of Emergency Medicine, Regions Hospital.
Frostbite of the ear. Photo courtesy of Kevin P. Kilgore, MD, Department of Emergency Medicine, Regions Hospital.
Frostbite of the hand.
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