What is the treatment for a patient with frostbite?

Treatment of Frostbite

For severe frostbite, immediately perform rapid rewarming in warm water at 37-40°C (98.6-104°F) for 20-30 minutes, followed by ibuprofen for tissue protection, and strongly consider thrombolytic therapy or iloprost within the first 24 hours to reduce amputation risk. 1, 2, 3

Immediate Field Management

Priority Assessment:

• If the patient has moderate to severe hypothermia, prioritize core rewarming before treating the frostbite, as rewarming extremities first can cause core temperature to drop 1, 4
• Remove jewelry and constricting materials immediately from affected extremities to prevent further injury as swelling develops 1, 5
• Protect frostbitten tissue from further injury and avoid walking on frozen feet whenever possible 1

Critical Field Decision:

• Do NOT attempt rewarming if there is any chance the tissue might refreeze or if you are close to a medical facility—refreezing causes catastrophic additional damage 1, 6
• If spontaneous thawing occurs in the field, protect the thawed tissue from refreezing at all costs 6

Rapid Rewarming Protocol

Water Immersion Technique:

• Immerse the affected part in warm water at 37-40°C (98.6-104°F) for 20-30 minutes 1, 5, 7
• If no thermometer is available, test water against your wrist—it should feel slightly warmer than body temperature 1
• Never use water above 40°C as this causes additional tissue damage 1, 5
• Air rewarming can be used as an alternative when warm water immersion is not possible 1

For Superficial Frostbite (Frostnip):

• Simple skin-to-skin contact with a warm hand is sufficient 1
• Do NOT use chemical warmers directly on tissue as they can reach burn-causing temperatures 1, 5

Post-Rewarming Care

Wound Management:

• Apply bulky, clean, dry gauze or sterile cotton dressings between toes and fingers 1
• Wrap circumferential dressings loosely to allow for swelling without pressure 1
• Do NOT debride blisters in the first aid setting 1

Pharmacologic Treatment:

• Administer ibuprofen to prevent further tissue damage and treat pain (rewarming is often extremely painful) 1, 6

Advanced Medical Interventions

Thrombolytic Therapy:

• The American Burn Association conditionally recommends thrombolytics for fewer amputations and/or more distal amputation levels 3
• "Early" administration (≤12 hours from rewarming) is conditionally recommended over later administration 3
• Thrombolytic treatment within the first 24 hours after rewarming appears beneficial in severe cases 6

Iloprost (IV):

• FDA-approved for severe frostbite to reduce digit amputations 2
• In a randomized controlled trial, iloprost IV for 6 hours daily for up to 8 days resulted in 0% bone scintigraphy anomalies (predicting amputation) compared to 60% in the control group (p<0.001) 2
• Prostacyclin therapy is very promising for tissue salvage 6

Critical Assessment Points

Vascular Emergency Red Flags:

• Pale, hardened, or darkened tissue with absent sensation constitutes a vascular emergency requiring immediate transport 5
• Check pulses, capillary refill, and assess skin color progression bilaterally 5
• Complete inability to sense touch is a characteristic hallmark of acute frostbite 4

High-Risk Populations:

• Diabetic patients with peripheral neuropathy may not recognize early warning signs due to baseline reduced sensation—absence of pain does NOT mean absence of injury 1
• Poor circulation from diabetes or peripheral vascular disease increases susceptibility and alters typical pain response 1

Surgical Management

Timing of Intervention:

• Current literature recommends delayed surgery with soft tissue debridement and bone scan-guided amputations 7
• Hard eschar may form with healthy tissue deep to the eschar—estimating tissue loss is challenging early in the course 4, 6
• Fasciotomy, surgical salvage, skin grafts, and flaps are often necessary for optimizing form and function 7

Common Pitfalls to Avoid

• Never rewarm if refreezing is possible—this causes worse damage than remaining frozen 1, 6
• Never use water above 40°C during rewarming 1, 5
• Never apply chemical warmers directly to frostbitten tissue 1, 5
• Never assume absence of pain means absence of injury, especially in patients with neuropathy 1
• Never debride blisters in the first aid setting 1

All frostbite patients require prompt medical attention, with deep frostbite potentially requiring specialized care at a burn center. 1