What is the management and treatment for frostbite?

Management and Treatment of Frostbite

All frostbite cases require immediate medical attention with rapid rewarming in 37-40°C water for 20-30 minutes as the cornerstone of treatment, followed by ibuprofen administration, sterile dressings, and consideration of thrombolytic therapy within 24 hours for severe cases. 1

Immediate Field Management

Priority Assessment

• If moderate to severe hypothermia is present, rewarm the core first before treating frostbite to prevent dangerous drops in core temperature 1, 2
• Remove all jewelry and constricting materials immediately as swelling develops 1
• Protect frostbitten tissue from further mechanical injury—patients cannot sense touch or ongoing damage to affected areas 2
• Do not walk on frozen feet or toes whenever avoidable 1

Critical Field Decision

• Do not attempt rewarming if any chance of refreezing exists or if close to a medical facility 1
• Frozen and thawed tissues are extremely vulnerable to further injury, pressure sores, and infection 2
• If spontaneous thawing occurs in the field, protect from refreezing at all costs 3

Definitive Rewarming Protocol

Severe/Deep Frostbite

• Immerse affected part in warm water at 37-40°C (98.6-104°F) for 20-30 minutes 1
• Test water temperature against your wrist—it should feel slightly warmer than body temperature 1
• Never exceed 40°C as this causes additional tissue damage 1
• Air rewarming is an acceptable alternative when water immersion is unavailable 1

Superficial Frostbite (Frostnip)

• Simple skin-to-skin contact with a warm hand may suffice 1

What to Avoid

• Never use chemical warmers directly on tissue—they reach burn-causing temperatures 1
• Do not debride blisters in the field 1

Post-Rewarming Care

Wound Management

• Apply bulky, clean, dry gauze or sterile cotton dressings to affected areas 1
• Place dressings between all fingers and toes 1
• Wrap circumferentially but loosely to accommodate swelling without pressure 1

Pharmacologic Treatment

• Administer ibuprofen to prevent further tissue damage and treat pain 1
• Evidence supports aspirin or ibuprofen therapy, though data is limited 3

Advanced Hospital Management

Time-Sensitive Interventions

• Thrombolytic therapy (TPA) within 24 hours of rewarming shows benefit in severe frostbite cases 3, 4
• Earlier thrombolytic administration (within 1-2 hours) correlates with improved tissue salvage 5
• Prostacyclin (iloprost) therapy is very promising for severe cases 3, 4

Specialist Referral

• Deep frostbite may require specialized care at a burn center 1
• Multidisciplinary care involving vascular surgery, plastic surgery, or interventional radiology may be needed 4

High-Risk Populations Requiring Extra Vigilance

Diabetes

• Patients with diabetes >10 years and microvascular complications face substantially higher tissue injury risk 6
• Poor glycemic control (A1C >9%) and hypoglycemia both increase vulnerability 6
• Autonomic dysfunction and microangiopathy impair vasomotor responses and tissue perfusion 6

Other Conditions

• Hypothyroidism increases risk through decreased metabolism and impaired thermoregulation 6
• Hypertension with sclerotic arterioles decreases peripheral perfusion 6

Common Pitfalls

• Estimating severity is challenging early—tissue loss is often less than initial appearance suggests 2, 3
• Hard eschar may form with healthy tissue beneath 3
• Rewarming causes hyperemia, blistering, edema, and is often painful 3
• The complete inability to sense touch is pathognomonic for acute frostbite 2