In our last post, we explored the classification and pathophysiology of frostnip and frostbite.  Now we will look into frostbite prevention and management.

Frostbite management is a continuously evolving science.  However, the absolute best way to manage frostbite is to not get it in the first place.   The basic tenets of prevention are reducing heat loss and maintaining perfusion.  There are some simple steps one can take to prevent frostbite in themselves or a patient:

  • Ensure adequate hydration and nutrition
  • Cease medications and drugs that decrease perfusion
  • Avoid alcohol (increases heat loss by peripheral vasodilation and impairs decision-making and protective reflexes)
  • Avoid smoking cigarettes (impairs microcirculation)
  • Protect yourself from the cold (avoid ambient temperatures less than -15°C, minimize cold exposure, cover up, wear appropriate insulation, avoid sweating or moisture to reduce heat loss)
  • Remove constrictive clothing and footwear to ensure adequate blood flow
  • Keep moving! Exercise will elevate both core and peripheral temperatures by increasing blood flow
  • Recognize the symptoms of frostnip or early frostbite and rewarm
  • If hypoxic, use supplemental oxygen when available to improve tissue oxygenation

 

If you or a patient is unfortunate enough to get frostbite, here is what you can do in the field:

  • Manage ABC’s and hypothermia! Dead patients don’t need their limbs rewarmed so be sure to address critical system problems first.
  • Remove jewelry and constrictive or wet clothing. Remove boots to assess, but anticipate that they may be impossible to get them back on if swelling occurs, which may kibosh your evacuation plan.  Put boots back on if required for evacuation.
  • Ibuprofen both improves healing and helps with pain control. Opiate pain control may also be required.
  • If there is a fracture, attempt to align the limb and splint it carefully, ensuring adequate distal perfusion
  • Decide if you are going to rewarm in the field or evacuate to definitive medical care. This can be a challenging decision and will be unique to each situation.  Generally, if transport to definitive care is less than a couple of hours, do not attempt field rewarming because of the potentially catastrophic results of improper rewarming or refreezing.
  • Avoid using the affected limb to minimize further trauma. If it must be used, limit mobility by padding and splinting.
  • The best method to rewarm is a circulating warm water bath (37-39°C). Adding an antiseptic to this bath is reasonable to reduce the risk of infection.
  • Once thawed, clear blisters can be aspirated. Hemorrhagic blisters should be left alone.
  • Use dry, loose, bulky dressings. Topical aloe vera may improve outcomes.
  • Elevate extremity to reduce edema
  • Provide oxygen if hypoxic or at high altitude
  • Evacuate to definitive medical care

 

Providers do have the potential to make frostbite worse.  Here are some things you should not do when caring for a patient with frostbite:

  • Do not rub the affected area.
  • Do not prevent the area from spontaneously rewarming (don’t keep it cold on purpose). Spontaneous rewarming will happen naturally as you keep the patient warm and hydrated and it is an acceptable option if rapid rewarming is not available.
  • Do not allow refreezing
  • Do not expose to direct heat as this will cause further tissue damage

 

I will not detail hospital management in this post but I encourage you to look into current research on the topic.  Immediate hospital management will depend on local practices but may include low molecular weight dextran, antiplatelet agents, thrombolytics (tPA), vasodilators (nitroglycerin, reserpine, iloprost – not available in United States, etc.), hyperbaric oxygen therapy, and tetanus prophylaxis.

 

Frostbite has a high morbidity and good decision-making and treatment plans are vital to optimize outcomes.  Research into hospital treatments is ongoing but what you do in the pre-hospital environment is likely the most important.

 

Alana Hawley, M.D.
Wilderness Medicine Fellowship, University of Utah
PGY-5 Emergency Medicine, McMaster University

______________
How to learn more:

Medical professionals earn Wilderness Medicine CME credit from our hands-on courses offered world wide.  Browse the course locations and schedule.

Anyone can take our Wilderness medicine courses online. Choose from topics like Zika, Ticks, Submersion Injuries and more.

 

______________

Author:  Alana Hawley, M.D.
Wilderness Medicine Fellowship, University of Utah
PGY-5 Emergency Medicine, McMaster University

 

Sources:

Auerbach, P.S. (2011).  Wilderness Medicine. Edinburgh: Mosby.

 

Zafren, K. and Giesbrecht, G.  (2014).  State of Alaska Cold Injuries Guidelines.  Juneau, AK: Department of Health and Social Services Division of Public Health Section of Emergency Programs Emergency Medical Services (EMS) Program.

 

Mcintosh, S. E., Opacic, M., Freer, L., Grissom, C. K., Auerbach, P. S., Rodway, G. W., . . . Hackett, P. H. (2014). Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Frostbite: 2014 Update. Wilderness & Environmental Medicine, 25(4). doi:10.1016/j.wem.2014.09.001

 

Photo Credit: Milo McDowell via Unsplash