Frostbite Guidelines

Updated: Jul 29, 2019
  • Author: Bobak Zonnoor , MD; Chief Editor: Dirk M Elston, MD  more...
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Guidelines

Guidelines Summary

Guidelines on the prevention and treatment of frostbite were released in July 2019 by the Wilderness Medical Society. [56]

Prevention

Preventive measures include maintaining peripheral perfusion, exercise, and protection from cold.

The following measures can be used to ensure local tissue perfusion:

  • Maintain adequate hydration and core body temperature
  • Minimize the effects of known factors (eg, medications, diseases, other substances, including drug or alcohol usage) that may decrease perfusion
  • Insulate from the cold with the use of skin and scalp coverage
  • Minimize blood flow restriction (eg, avoidance of immobility and constrictive footwear or clothing)
  • Maintain adequate nutrition
  • Use supplemental oxygen in severely hypoxic conditions (eg, >7500 m)

Exercise can be used to maintain peripheral perfusion by elevating core and peripheral temperatures and enhancing cold-induced peripheral vasodilation. An important caveat is that it can induce exhaustion, which may lead to profound systemic heat loss.

The following measures can be used to ensure protection from the cold:

  • Avoid environmental conditions that predispose to frostbite (ie, less than -15°C [5°F])
  • Protect skin from wind, cold, and moisture
  • Avoid perspiration (sweating) or wet extremities
  • Increase skin protection and insulation with layering of clothing and using mittens rather than gloves, including the use of electric or chemical hand/foot warmers
  • Avoid behaviors or situations (eg, drug/alcohol use, hypoxemia) that deter recognition of changing environmental conditions
  • Perform regular awareness checks (self, group) for impending frostbite signs and symptoms and recognizing superficial frostbite prior to it becoming more serious
  • Minimize the duration of exposure to cold temperatures

Field and initial hospital treatment

The following is a summary of field treatment (>2 hours from definitive care):

  • Treat hypothermia or serious trauma
  • Remove extraneous material (eg, jewelry) from affected body part
  • Rapidly rewarm affected body part in water (maintain 37-39°C [98.6-102.2°F]) until the area is soft (pliable) to the touch; passive rewarm if rapid rewarming not available
  • Administer ibuprofen at 12 mg/kg/day divided twice daily, if available
  • Administer pain medication (eg, opiates) as needed, if available
  • Institute air drying (ie, do not rub at any point)
  • Protect from refreezing and direct trauma
  • Apply aloe vera gel or cream, if available
  • Use dry, bulky dressings
  • Elevate affected body part, if possible
  • Ensure systemic hydration
  • Avoid ambulation on thawed lower extremity, except if only distal toes affected

The following is a summary of initial hospital management:

  • Treat hypothermia or serious trauma
  • Rapidly rewarm affected body part in water (maintain 37-39°C [98.6-102.2°F]) until the area is soft (pliable) to the touch
  • Administer ibuprofen at 12 mg/kg/day divided twice daily
  • Administer pain medication (eg, opiates) as needed
  • Administer tetanus prophylaxis
  • Institute air drying (ie, do not rub at any point)
  • Debride with selective drainage by needle aspiration of clear blisters, leaving hemorrhagic blisters intact
  • Apply aloe vera cream or gel every 6 hours with dressing changes
  • Use dry, bulky dressings
  • Elevate affected body part, if possible
  • Ensure systemic hydration
  • Thrombolytic therapy: This should be considered for deep frostbite at distal interphalangeal joints or proximal if fewer than 24 hours have elapsed since thawing. Angiography should be used for prethrombolytic intervention and for monitoring progress. If angiography is not available, consider using intravenous thrombolysis.
  • Iloprost therapy: This should be considered for deep frostbite on or proximal to the proximal interphalangeal joint within 48 hour of the injury; this is particularly pertinent if angiography is not available or if there are contraindications to thrombolysis.
  • Clinical examination (plus angiography or technetium TC-99 bone scan if necessary): This is performed to help determine surgical margins. An experienced surgeon should perform an evaluation for possible intervention.