What is the management and treatment for frostbite?

Management and Treatment of Frostbite

All frostbite cases require immediate medical attention, with the cornerstone of treatment being rapid rewarming in warm water at 37-40°C (98.6-104°F) for 20-30 minutes, but only after ruling out hypothermia and ensuring no risk of refreezing. 1

Initial Assessment and Stabilization

Priority Considerations

• Assess for concurrent hypothermia first—if moderate to severe hypothermia is present, rewarm the core before treating frostbite, as rewarming extremities first can cause dangerous core temperature drops. 1, 2
• Remove all jewelry and constricting materials immediately from affected extremities to prevent further injury as swelling develops. 1
• Evaluate for complete loss of sensation to touch, which is the hallmark of acute frostbite and means patients may be unaware of ongoing mechanical damage from continued walking or movement. 2

Critical Decision Point: To Rewarm or Not

• Do not attempt rewarming if there is any chance the tissue might refreeze, as repeated freeze-thaw cycles cause worse tissue damage than delayed rewarming. 3
• Do not rewarm if you are close to a medical facility—transport the patient with the tissue still frozen. 1
• Protect frostbitten tissue from further injury and avoid walking on frozen feet and toes whenever possible. 1

Rewarming Protocol

Severe or Deep Frostbite

• Perform rapid rewarming by immersing the affected part in warm water at 37-40°C (98.6-104°F) for 20-30 minutes. 1, 3
• If no thermometer is available, test water against your wrist—it should feel slightly warmer than body temperature. 1
• Avoid water temperatures above 40°C as this causes additional tissue damage. 1
• Air rewarming can be used as an alternative when warm water immersion is not possible. 1

Superficial Frostbite (Frostnip)

• Simple rewarming using skin-to-skin contact such as a warm hand may be sufficient. 1

What NOT to Do

• Do not use chemical warmers directly on frostbitten tissue as they can reach temperatures that cause burns. 1

Post-Rewarming Care

Wound Management

• Apply bulky, clean, dry gauze or sterile cotton dressings to affected areas and between toes and fingers. 1
• Wrap circumferential dressings loosely to allow for swelling without placing pressure on underlying tissue. 1
• Do not debride blisters in the field or initial care setting. 1

Pharmacologic Management

• Administer ibuprofen to prevent further tissue damage and treat pain. 1
• Note that thawed tissues are extremely vulnerable to further injury, infection, pressure sores, and necrosis. 2

Advanced Hospital Management

Timing-Critical Interventions

• For severe frostbite presenting within 24 hours of injury, consider thrombolytic therapy (TPA) or prostacyclin (iloprost), as early thrombolytic use has a positive impact on tissue salvage. 4, 5
• Time to thrombolytics matters—earlier administration (within hours) correlates with better tissue salvage outcomes. 5

Specialist Consultation

• Deep frostbite may require specialized care at a burn center. 1
• Do not delay vascular consultation waiting for "demarcation"—in acute severe cases, hours matter for limb salvage. 3

Clinical Pitfalls to Avoid

• Never assume that rapid rewarming alone is sufficient for severe frostbite—it serves as a bridge to definitive care and potential thrombolytic therapy, not as standalone treatment. 5
• Do not attempt to predict tissue loss early in the course, as it is challenging to estimate the size and severity of frostbitten tissue, especially initially. 2
• Remember that skin color progresses from pale to hardened and dark as severity increases, and deep frostbite can cause tissue necrosis leading to digit or limb loss. 2