Treatment of Frostbite on the Great Toes
Immediately seek medical attention, remove any jewelry or constricting materials from the affected toes, and if the patient is not hypothermic, rapidly rewarm the great toes by immersing the foot in warm water at 37-40°C (98.6-104°F) for 20-30 minutes. 1, 2
Immediate Assessment and Priorities
Before treating the frostbite itself, you must first assess for hypothermia:
If the patient has moderate to severe hypothermia, prioritize core rewarming before treating the frostbite on the toes. 1, 2 Rewarming extremities first in hypothermic patients can cause dangerous drops in core temperature. 3
Remove jewelry, tight socks, or any constricting materials from the affected foot immediately to prevent further injury as swelling develops. 1, 2
Protect the frostbitten toes from further injury and absolutely avoid walking on frozen feet. 1, 2 The frozen tissue is completely numb, so patients may be unaware of ongoing mechanical damage from continued walking. 3
Critical Decision Point: To Rewarm or Not
Do not attempt rewarming if there is any chance the tissue might refreeze, as refreezing causes catastrophic additional tissue damage. 1, 2 The freeze-thaw-refreeze cycle destroys cell membranes through repeated ice crystal formation. 1, 3
- If you are close to a medical facility, transport immediately without field rewarming. 2
- If evacuation will take hours and refreezing can be prevented, proceed with rewarming. 4
Rewarming Protocol
The gold standard is rapid rewarming using warm water immersion at 37-40°C (98.6-104°F) for 20-30 minutes: 1, 2
- Test water temperature against your wrist—it should feel slightly warmer than body temperature. 1
- Never use water above 40°C (104°F) as temperatures of 45°C (113°F) have been shown to cause additional tissue damage. 1
- Do not use chemical warmers directly on the toes as they can reach burn-causing temperatures. 2, 5
- If warm water immersion is impossible, air rewarming is an acceptable alternative. 1
Rewarming is often extremely painful despite the tissue being numb while frozen. 2, 4 This is a normal part of the process as hyperemia develops. 4
Post-Rewarming Wound Care
After rewarming is complete:
- Apply bulky, clean, dry gauze or sterile cotton dressings between each toe and over the affected areas. 1, 2
- Wrap any circumferential dressings loosely to accommodate swelling without compressing underlying tissue. 1, 2
- Do not debride any blisters that form—this is explicitly not recommended for first aid providers. 1, 2
Pain Management and Tissue Protection
Give ibuprofen to prevent further tissue damage and treat pain. 1, 2 The mechanism involves reducing inflammatory reperfusion injury and thrombosis that occurs after rewarming. 4, 6
When Advanced Medical Care is Essential
All frostbite patients require prompt medical evaluation, as advanced treatments are time-sensitive: 1, 2
- Thrombolytic therapy administered within 24 hours of rewarming has been shown to improve tissue salvage in severe frostbite. 1, 4, 7
- Estimating the true severity and extent of tissue damage is challenging in the field setting. 1, 3
- Deep frostbite may require specialized burn center care. 2
Common Pitfalls to Avoid
- Never allow thawed tissue to refreeze—this is more damaging than leaving it frozen longer. 1, 4, 8
- Do not use dry heat sources or rub the frozen tissue. 8
- Avoid premature surgical debridement—demarcation of viable versus necrotic tissue typically takes 1-3 months. 4, 8, 7
- Be aware that diabetic patients with peripheral neuropathy may not experience typical pain responses and could have more severe injury than apparent. 2
Post-Injury Monitoring
Frozen and thawed tissues remain extremely vulnerable to pressure injury and infection. 3 The great toes are weight-bearing structures, making protection from mechanical stress particularly critical until medical evaluation occurs. 3