What is the appropriate treatment for a patient with frostbite?

Treatment of Frostbite

Immediately rewarm frostbitten tissue by immersing it in warm water at 37-40°C (98.6-104°F) for 20-30 minutes, unless there is risk of refreezing or the patient has moderate-to-severe hypothermia requiring core rewarming first. 1

Initial Assessment and Priorities

Before treating the frostbite itself, address these critical factors:

• Hypothermia takes precedence: If the patient has moderate to severe hypothermia, rewarm the core first before addressing frostbite, as rewarming extremities first can cause dangerous core temperature drops 1, 2
• Remove constricting items immediately: Take off jewelry, rings, and tight clothing from affected areas as soon as possible to prevent further injury as swelling develops 1
• Protect from refreezing: Do not attempt rewarming if there is any possibility the tissue might refreeze, as freeze-thaw-refreeze cycles cause exponentially worse damage 1, 3
• Avoid walking on frozen feet: Protect frostbitten tissue from mechanical trauma, as frozen tissue is completely numb and patients cannot sense ongoing damage from movement 2

Rapid Rewarming Protocol (The Cornerstone of Treatment)

For severe or deep frostbite, follow this specific rewarming approach:

• Water temperature: Use warm water at precisely 37-40°C (98.6-104°F) 1, 4
• Duration: Immerse for 20-30 minutes 1
• Temperature verification: If no thermometer is available, test water against your wrist—it should feel slightly warmer than body temperature 1
• Critical upper limit: Never exceed 40°C as higher temperatures cause additional thermal injury 1
• Alternative method: Air rewarming can be used when water immersion is impossible 1

For superficial frostbite (frostnip), simple skin-to-skin contact with a warm hand is sufficient 1

Common Pitfalls to Avoid

• Never use chemical warmers directly on frostbitten tissue—they can reach temperatures high enough to cause burns 1
• Never use water above 40°C despite the temptation to rewarm faster 1
• Rewarming is often extremely painful despite the frozen tissue being numb initially, so prepare the patient and consider analgesia 1, 3

Post-Rewarming Care

After successful rewarming, implement these measures immediately:

• Dressing application: Apply bulky, clean, dry gauze or sterile cotton dressings to affected areas and between all digits 1
• Loose wrapping: Wrap circumferentially but loosely to accommodate swelling without creating pressure 1
• Ibuprofen administration: Give ibuprofen to prevent further tissue damage through anti-inflammatory and anti-thromboxane effects, and to treat pain 1, 5
• Blister management: Do not debride blisters in the first aid setting 1
• Infection prevention: Maintain intact skin barriers and protect from pressure sores as thawed tissue is extremely vulnerable 2, 5

When to Seek Advanced Medical Care

• All frostbite cases should receive prompt medical evaluation, as appropriate treatment significantly reduces tissue damage and prevents long-term complications 1
• Deep frostbite may require specialized care at a burn center 1
• Thrombolytic therapy within the first 24 hours after rewarming has shown benefit in severe cases and requires hospital-level care 3, 4

Special Considerations for High-Risk Patients

Diabetic patients with peripheral neuropathy require particular attention:

• They may not recognize early warning signs due to baseline reduced sensation 1
• Absence of pain does not mean absence of injury in these patients 1
• Poor circulation increases susceptibility and may alter typical pain responses 1
• Visual inspection is essential as they cannot rely on sensory feedback 1

Long-Term Management

For patients who develop chronic sequelae:

• Duloxetine is first-line pharmacologic therapy for chronic neuropathic pain following severe frostbite 5
• NSAIDs (ibuprofen) should be continued long-term to prevent ongoing prostaglandin and thromboxane-mediated vasoconstriction and dermal ischemia 5
• Gabapentin/pregabalin may be considered as second-line options, though they should not be used as first-line therapy 5
• Bulky, loose dressings help protect extremities from pressure sores and necrosis 5