How to Handle Frostbite
All patients with frostbite should seek immediate medical attention, and the affected extremity should be rapidly rewarmed by immersion in warm water at 37-40°C (98.6-104°F) for 20-30 minutes, but only if there is no risk of refreezing. 1, 2
Immediate Field Management
Priority Assessment
- If the patient has moderate to severe hypothermia, core rewarming must be completed before treating frostbite, as rewarming extremities first can cause dangerous drops in core temperature 1, 2, 3
- Remove all jewelry and constricting materials from the affected extremity immediately to prevent further injury as swelling develops 1, 2
Protection from Further Injury
- Protect frostbitten tissue from any additional trauma or mechanical damage 1, 2
- Avoid walking on frozen feet and toes at all costs, as patients cannot sense ongoing tissue damage due to complete loss of touch sensation 1, 3
- Do not attempt rewarming if there is any possibility of refreezing, as this causes catastrophic additional tissue damage from repeated ice crystal formation 1, 2
- If close to a medical facility, transport the patient without field rewarming 2
Rewarming Protocol
Water Immersion Technique (Preferred Method)
- Immerse the affected part in warm water at 37-40°C (98.6-104°F) for 20-30 minutes 1, 2
- If no thermometer is available, test water against your wrist—it should feel slightly warmer than body temperature 1, 2
- Never use water above 40°C as this causes additional tissue damage 1, 2
- Continue immersion until the tissue is pliable and color/sensation returns 1
Alternative Rewarming Methods
- For superficial frostbite (frostnip), skin-to-skin contact with a warm hand is sufficient 2
- Air rewarming can be used when water immersion is impossible 1, 2
- Never apply chemical warmers directly to frostbitten tissue, as they can reach burn-causing temperatures 2
Important Rewarming Caveat
- Rewarming is often extremely painful despite the frozen tissue being numb initially 2, 4
- Patients with diabetic neuropathy or peripheral vascular disease may not experience typical pain responses and may not recognize injury severity 2
Post-Rewarming Care
Wound Management
- Apply bulky, clean, dry gauze or sterile cotton dressings to all affected areas and between fingers and toes 1, 2
- Wrap circumferential dressings loosely to accommodate swelling without compressing underlying tissue 1, 2
- Thawed tissues are extremely vulnerable to pressure sores, infection, and further necrosis 3
Pharmacologic Management
- Administer ibuprofen to prevent further tissue damage and treat pain, as it blocks prostaglandin and thromboxane-mediated vasoconstriction 1, 2, 4, 5
- Pain control with analgesics is essential during and after rewarming 6, 4
What NOT to Do
- First aid providers should not debride blisters, as this increases infection risk and tissue damage 1, 2
- Avoid any manipulation of the affected tissue beyond protective dressing application 1
When to Seek Advanced Medical Care
- All frostbite cases require prompt medical evaluation, as estimating severity is challenging in the field and advanced treatments like thrombolytics are most effective within 24 hours 1, 2, 4
- Deep frostbite may require specialized burn center care 2
- Advanced hospital treatments may include thrombolytic therapy, prostacyclin therapy, physical therapy, sympathectomy, or fasciotomy 6, 4
Critical Pitfalls to Avoid
- Refreezing after thawing causes devastating additional damage—this is the single most important complication to prevent 1, 2
- Patients cannot sense ongoing mechanical damage to frozen tissue, so immobilization and protection are essential 3
- Underestimating injury severity based on initial appearance, as tissue loss is often less than expected and evolves over time 1, 4
- Using excessively hot water (>40°C), which compounds thermal injury 1, 2