From the Guidelines
Heparin drips are not indicated for frostbite management, and treatment should focus on rapid rewarming, pain control, and wound care, with consideration of thrombolytic therapy in severe cases. The most recent guidelines from the American Heart Association and American Red Cross, published in 2024 1, emphasize the importance of estimating the size and severity of frostbitten tissue and highlight the role of advanced treatments such as thrombolytic medication in a healthcare setting. Key aspects of frostbite management include:
- Rapid rewarming in a water bath (40-42°C)
- Pain management
- Tetanus prophylaxis
- Wound care
- Consultation with specialists for consideration of advanced therapies in severe cases, such as thrombolytic therapy The use of heparin drips is not supported by current evidence as a standard recommendation for frostbite management, and the risks of systemic anticoagulation, including bleeding complications, generally outweigh potential benefits 1. Instead, modern approaches favor thrombolytic agents like tissue plasminogen activator (tPA) in severe cases where there is evidence of tissue perfusion deficits.
From the Research
Indications for Heparin Drip in Frostbite
- A heparin (unfractionated heparin) drip is indicated for frostbite in severe cases where there is a high risk of thrombosis and amputation 2, 3.
- The use of heparin in combination with tissue plasminogen activator (tPA) has been shown to improve outcomes in severe frostbite patients by reducing the risk of amputation and improving tissue salvage 2, 3, 4.
- Heparin is typically administered intravenously at a dose of 500 units/hour, in conjunction with tPA, to prevent thrombosis and promote blood flow to the affected area 2, 3.
Patient Selection
- Patients with severe frostbite, characterized by absent Doppler pulses in distal limb or digits, and no contraindications to tPA use, may benefit from heparin and tPA therapy 3.
- Patients who have undergone rapid rewarming and have no response to thrombolytic therapy, or those with more than 24 hours of cold exposure, warm ischemia times greater than 6 hours, or evidence of multiple freeze-thaw cycles, may not be ideal candidates for heparin and tPA therapy 3.
Timing of Heparin Administration
- Heparin administration should be considered as part of the initial management of severe frostbite, ideally within the first 24 hours after rewarming 5.
- The use of bedside fluorescence microangiography (FMA) may help identify patients with perfusion deficits who may benefit from heparin and tPA therapy, allowing for faster decision-making and improved times to treatment 6.