Treatment of Frostbite
For suspected frostbite, immediately seek medical attention, remove constricting items, protect from refreezing, and if definitive care is available, rapidly rewarm the affected tissue in warm water at 37-40°C (98.6-104°F) for 20-30 minutes. 1, 2
Immediate Field Management
Critical First Steps
- Remove jewelry and constricting materials immediately from the frostbitten extremity to prevent further injury as swelling develops 1, 2
- Assess for concurrent hypothermia first - if moderate to severe hypothermia is present, prioritize core rewarming before treating the frostbite 1, 2, 3
- Protect frostbitten tissue from further injury and avoid walking on frozen feet and toes whenever possible 1, 2
The Refreezing Rule
Do not attempt rewarming if there is any risk of refreezing - repeated freeze-thaw cycles cause worse tissue damage than delayed rewarming 1, 4, 5. This is a critical pitfall to avoid. Only rewarm in the field if you can guarantee the tissue will not refreeze and you cannot reach definitive care quickly 1.
Rewarming Protocol
Rapid Warm Water Immersion (Preferred Method)
For severe or deep frostbite, immerse the affected part in warm water at 37-40°C (98.6-104°F) for 20-30 minutes 1, 2, 6. This temperature range is critical - water above 40°C can cause additional tissue damage 1. If no thermometer is available, test the water against your wrist where it should feel slightly warmer than body temperature 1.
Alternative Rewarming Methods
- For superficial frostbite (frostnip), simple skin-to-skin contact with a warm hand may be sufficient 1, 2
- Air rewarming can be used as an alternative when warm water immersion is not possible 1
- Never use chemical warmers directly on frostbitten tissue as they can reach temperatures that cause burns 1, 2
Post-Rewarming Care
Wound Management
- Apply bulky, clean, dry gauze or sterile cotton dressings to frozen and thawed tissue and between toes and fingers 1, 2
- Wrap circumferential dressings loosely to allow for swelling without placing pressure on underlying tissue 1, 2
- Do not debride blisters - this is explicitly not recommended for first aid providers 1, 2
Pain and Inflammation Management
It may be reasonable to give ibuprofen to prevent further tissue damage and treat pain 1, 2, 5. While the evidence for NSAIDs in frostbite is not definitively established in human studies, the 2024 American Heart Association guidelines support this approach 1.
Advanced Medical Treatment
Thrombolytic Therapy
For severe frostbite presenting within 24 hours, intravenous iloprost has FDA approval and demonstrated significant benefit in reducing digit amputations 7. In a randomized controlled trial, iloprost IV for 6 hours daily for up to 8 days resulted in 0% bone scintigraphy anomalies compared to 60% in the control group (p<0.001) 7. This advanced treatment can only be administered in a healthcare setting and is most effective when given early 1.
Surgical Considerations
Delay surgical debridement and amputation until there is clear demarcation of viable versus necrotic tissue, typically 1-3 months after initial exposure 8, 6. The exception is immediate escharotomy or fasciotomy when circulation is compromised 8.
Common Pitfalls to Avoid
- Do not delay vascular consultation waiting for "demarcation" in cases of acute arterial ischemia - hours matter for limb salvage 4
- Do not rewarm extremities first in hypothermic patients as this can cause core temperature to decrease 3
- Estimating severity is challenging in the first aid setting - when in doubt, treat as severe and seek advanced care 1, 3
- Frozen tissue is completely numb - patients may be unaware of ongoing mechanical damage from continued walking or movement 3