What is the appropriate field care for a patient with hypothermia and frostbite?

Field Management of Hypothermia with Severe Frostbite

The appropriate field care is to eliminate further cold exposure and prioritize core rewarming before addressing the frostbite, as this patient has concurrent hypothermia (95.9°F) and attempting extremity rewarming first can dangerously lower core temperature further. 1, 2

Immediate Priorities in the Field

1. Address Hypothermia First

• This patient has moderate hypothermia (core temperature 95.9°F/35.5°C) which must be treated before frostbite management. 1, 2
• Rewarming frostbitten extremities before addressing core hypothermia can cause the core temperature to drop further, potentially leading to cardiac complications. 3
• The patient should be handled gently and moved to a warm environment immediately. 1, 2

2. Eliminate Further Cold Exposure

• Remove the patient from the cold environment immediately and protect from wind and moisture. 1
• Remove any wet clothing and jewelry from the affected extremity to prevent further injury as swelling develops. 1
• Protect the frostbitten hand from any additional trauma during transport. 1, 3

What NOT to Do in the Field

Avoid Rewarming the Extremity

• Do not attempt to rewarm the frostbitten hand in the field, especially with a 40°C water bath, as this should only be done in a medical facility where definitive care is available. 1, 2
• The American Heart Association specifically warns against rewarming if there is any risk of refreezing, as repeated freeze-thaw cycles cause worse tissue damage than delayed rewarming. 2
• Given the severity (pale, hemorrhagic blisters, insensate, pulseless), this represents deep frostbite requiring specialized care at a facility with imaging and potential thrombolytic therapy. 1, 4

Do Not Massage the Extremity

• Never massage frostbitten tissue, as this causes additional mechanical trauma to already damaged cells and tissues. 1, 3
• The patient cannot sense ongoing tissue damage due to complete loss of sensation, making the tissue extremely vulnerable to further injury. 3

Do Not Debride Blisters

• First aid providers should not debride hemorrhagic blisters in the field. 1
• Blister management should be deferred to hospital-based care where sterile technique and appropriate wound care can be provided. 1

Clinical Reasoning for This Case

The presence of hemorrhagic blisters, absent radial pulse, complete insensitivity, and pale appearance indicates severe deep frostbite with vascular compromise. 2, 3 However, the concurrent hypothermia takes precedence because:

• Core rewarming must occur before extremity treatment to prevent further core temperature drop. 2, 3
• This patient requires rapid transport to a facility capable of providing both hypothermia management and specialized frostbite care (including potential tissue plasminogen activator within 24 hours of rewarming, which significantly decreases amputation rates). 4
• The severity of injury suggests this patient will need advanced imaging and likely burn center-level care. 1

Transport Strategy

• Keep the patient warm during transport but do not attempt field rewarming of the extremity. 1, 2
• Transport to a facility with vascular surgery capabilities and ideally burn center resources. 1, 2
• Protect the affected hand with loose, bulky dressings if available, but avoid any pressure or manipulation. 1