What is the management approach for a patient with frostbite?

Frostbite Management

Immediately seek medical attention for all frostbite cases, remove constricting items, and if hypothermia is present, prioritize core rewarming before treating the frostbite; then rapidly rewarm frozen tissue by immersing in warm water at 37-40°C (98.6-104°F) for 20-30 minutes. 1, 2

Immediate Field Assessment and Priorities

Critical first steps:

• Remove jewelry and constricting materials from the affected extremity immediately to prevent further injury as swelling develops 1, 2
• If moderate to severe hypothermia is present, core rewarming MUST occur before treating frostbite 1, 2—rewarming extremities first in hypothermic patients can dangerously decrease core temperature 3
• Protect frostbitten tissue from further injury and strictly avoid walking on frozen feet and toes 1, 2

Key decision point on field rewarming:

• Do NOT attempt rewarming if there is ANY chance of refreezing—tissue refreezing causes devastating additional damage due to repeated ice crystal formation destroying cell membranes 1, 2
• Only rewarm in the field if you can guarantee continuous warmth until reaching medical care 2, 4
• If close to a medical facility, transport without rewarming 2

Rewarming Protocol

For severe or deep frostbite requiring rewarming:

• Rapid rewarming via warm water immersion at 37-40°C (98.6-104°F) for 20-30 minutes is the gold standard 1, 2
• If no thermometer available, test water against your wrist—it should feel slightly warmer than body temperature 1, 2
• Never use water above 40°C (104°F) as temperatures of 45°C (113°F) have been shown to cause additional tissue damage 1, 5
• Air rewarming can substitute when water immersion is impossible 1, 2

For minor/superficial frostbite (frostnip):

• Simple skin-to-skin contact with a warm hand is sufficient 2, 3

Critical pitfall to avoid:

• Never apply chemical warmers directly to frostbitten tissue—they can reach burn-causing temperatures 2, 5

Post-Rewarming Care

Wound management:

• Apply bulky, clean, dry gauze or sterile cotton dressings to affected areas and between all digits 1, 2
• Wrap circumferential dressings loosely to accommodate swelling without compressing underlying tissue 1, 2
• Do NOT debride blisters—this is contraindicated in the first aid setting 1, 2

Pharmacologic intervention:

• Administer ibuprofen to prevent further tissue damage and treat pain 1, 2—this has both analgesic and tissue-protective effects 4

Advanced Hospital Management

For severe frostbite presenting within 24 hours:

• Patients may be candidates for thrombolytic therapy with tissue plasminogen activator (tPA) administered intra-arterially, which has shown significant tissue salvage benefits 6, 7
• Prostacyclin (iloprost) therapy administered intravenously is very promising for severe cases 4, 6, 7
• These interventions require immediate transfer to facilities with interventional radiology and 24/7 laboratory services 6, 7

Tissue assessment challenges:

• Estimating severity and extent of tissue loss is extremely difficult initially 1, 3—hard eschar may form with healthy tissue beneath, and final tissue loss is often less than initial appearance suggests 4
• Deep frostbite may require specialized care at a burn center 2

Special Population Considerations

Diabetic patients with peripheral neuropathy:

• These patients have baseline reduced pain sensation that masks both initial injury and rewarming pain 2
• Never assume absence of pain means absence of injury—impaired sensation prevents recognition of frostnip until visual inspection reveals damage 2
• Poor circulation from diabetes or peripheral vascular disease increases susceptibility and alters typical pain response 2

Emergency Red Flags Requiring Immediate Transport

Vascular emergency indicators:

• Complete inability to sense touch in affected area 5, 3
• Skin appearing pale, hardened, or darkened 1, 5, 3
• Absent sensation with color changes 5
• Any signs of tissue necrosis, ulceration, or gangrene 5
• Unilateral coldness suggesting arterial occlusion 5