Medication Summary
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)
Class Summary
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 (Ibuprin, Advil, Motrin, Caldolor)
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 (Aleve, Anaprox, Naprosyn, Naprelan)
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 (Clinoril)
Sulindac decreases COX activity and, in turn, inhibits prostaglandin synthesis. This results in decreased formation of inflammatory mediators.
Celecoxib (Celebrex)
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 (Mobic)
Meloxicam decreases COX activity, and this, in turn, inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.
Flurbiprofen
Flurbiprofen may inhibit COX, thereby, in turn, inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Opioid Analgesics
Class Summary
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 (Duramorph, MS Contin, Oramorph, Avinza)
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
Class Summary
Topical agents are applied to debrided clear blisters and intact hemorrhagic blisters to minimize thromboxane synthesis.
Aloe vera
Aloe vera inhibits the arachidonic cascade, especially thromboxane synthesis.
Antibiotics
Class Summary
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 (Pfizerpen)
Penicillin G interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.
Immune Globulins
Class Summary
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 (TIG) (Hyper Tet, HyperTET S/D, TIG)
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
Class Summary
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).
Diphtheria and tetanus toxoids (Decavac)
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.
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Frostbite of the foot. Photo courtesy of Kevin P. Kilgore, MD, Department of Emergency Medicine, Regions Hospital.
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Frostbite of the ear. Photo courtesy of Kevin P. Kilgore, MD, Department of Emergency Medicine, Regions Hospital.
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Frostbite of the hand.
