What is the initial treatment for a patient with frostbite (frostbite treatment)?

Initial Treatment for Frostbite

Remove the patient from cold exposure immediately, remove constricting items, and rapidly rewarm severe frostbite by immersing the affected part in warm water at 37-40°C (98.6-104°F) for 20-30 minutes, while administering ibuprofen to prevent further tissue damage. 1

Immediate Priorities and Assessment

Before treating the frostbite itself, prioritize core rewarming if the patient has moderate to severe hypothermia—treating extremities first in hypothermic patients can cause dangerous drops in core temperature. 1, 2

Critical First Steps:

• Remove jewelry and all constricting materials immediately from the affected extremity to prevent further injury as swelling develops 1, 3
• Protect frostbitten tissue from any further trauma or injury 1
• Do not allow the patient to walk on frozen feet or toes whenever avoidable 1
• Never attempt rewarming if there is any risk of refreezing or if you are close to a medical facility—refreezing causes devastating additional tissue damage 1, 4

Rewarming Protocol

For Severe or Deep Frostbite:

Rapid rewarming is the cornerstone of treatment and must be performed correctly. 1

• Immerse the affected part in warm water at 37-40°C (98.6-104°F) for 20-30 minutes 1, 3, 4
• If no thermometer is available, test the 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, 3
• Air rewarming can be used as an alternative when warm water immersion is not feasible 1

For Superficial Frostbite (Frostnip):

• Simple rewarming using skin-to-skin contact such as a warm hand is sufficient 1

Critical Rewarming Pitfalls:

• Never use chemical warmers directly on frostbitten tissue—they can reach temperatures that cause burns 1, 3
• Rewarming is often painful despite the tissue being numb during freezing 1

Pharmacologic Management

Start ibuprofen immediately (typical adult dosing 400-600mg every 6-8 hours) for both pain control and tissue protection. 1

The American Heart Association and American College of Cardiology recommend ibuprofen because it decreases prostaglandin and thromboxane production that causes vasoconstriction, dermal ischemia, and further tissue damage. 1 This provides both anti-inflammatory and anti-thrombotic effects. 1

Advanced Pharmacologic Therapy:

For severe frostbite, intravenous iloprost (AURLUMYN) is FDA-approved to reduce the risk of digit amputations. 5 In a randomized controlled trial, iloprost administered IV for 6 hours daily for up to 8 days resulted in 0% bone scintigraphy anomalies (predictive of amputation) compared to 60% in the control group (p<0.001). 5 Thrombolytic therapy with tissue plasminogen activator within the first 24 hours after rewarming may be beneficial in some severe cases, though evidence is mixed. 6, 7

Post-Rewarming Care

After rewarming is complete:

• Apply bulky, clean, dry gauze or sterile cotton dressings to affected areas and between toes and fingers 1
• Wrap circumferential dressings loosely to allow for swelling without placing pressure on underlying tissue 1
• Do not debride blisters in the first aid or emergency setting 1
• Continue ibuprofen for ongoing tissue protection 1

Disposition and Follow-Up

All frostbite patients require prompt medical attention, even if initial treatment has been provided. 1

Safe for Discharge if ALL of the Following:

• No evidence of tissue ischemia on examination 1
• Tissue has been properly rewarmed 1
• No risk of refreezing exists 1
• Patient can protect affected areas from further trauma 1

Requires Specialized Care:

• Deep frostbite may require burn center care 1
• Arrange prompt podiatry or hand surgery follow-up within 24-48 hours for moderate injuries, sooner if any concern 1
• Immediate vascular surgery referral if tissue necrosis, ulceration, or gangrene is present 3

Return Precautions:

Instruct patients to return immediately for increasing pain, numbness, color changes, development of blisters, signs of infection, or any tissue breakdown. 1

Special Considerations

Frostbite severity is difficult to assess initially—deeper tissue involvement may not be apparent for days to months. 1, 2 Débridement of necrotic tissues is generally delayed 1-3 months until clear demarcation from viable tissue develops. 4 Frozen and thawed tissues are extremely vulnerable to further injury, infection, pressure sores, and necrosis. 2