What are the treatment options for an adult patient with no significant pre-existing medical conditions based on the grade of frostbite?

Treatment of Frostbite by Grade

For severe frostbite in adults, initiate rapid rewarming in warm water (37-40°C) for 20-30 minutes, administer ibuprofen for anti-inflammatory and anti-thrombotic effects, and consider IV iloprost (AURLUMYN) within 24 hours to reduce the risk of digit amputation. 1, 2

Initial Assessment and Stabilization

Hypothermia Takes Priority

• If the patient has moderate to severe hypothermia, rewarm the core first before treating frostbite, as rewarming extremities first can cause core temperature to drop dangerously 1, 3
• Remove all jewelry and constricting materials immediately to prevent further injury as swelling develops 1
• Protect frostbitten tissue from further trauma and avoid walking on frozen feet whenever possible 1

Critical Decision Point: To Rewarm or Not

• Do not attempt rewarming if there is any chance of refreezing or if you are close to a medical facility 4, 1
• Refreezing after thawing causes catastrophic additional tissue damage 3
• If evacuation to definitive care will take more than a few hours and refreezing can be prevented, proceed with field rewarming 1

Treatment by Frostbite Severity

Superficial Frostbite (Frostnip)

• Use simple skin-to-skin contact rewarming with a warm hand 4, 1
• This grade typically heals well with conservative management alone 5
• Complete healing occurs in approximately 8-16 days with conservative treatment 5

Deep/Severe Frostbite (Grade 3-4)

Rapid Rewarming Protocol

• Immerse the affected part in warm water at 37-40°C (98.6-104°F) for 20-30 minutes 4, 1, 6
• If no thermometer is available, test 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, 6
• Do not place chemical warmers directly on tissue as they can cause burns 4, 1
• Rewarming is often extremely painful; prepare the patient for this 7

Pharmacologic Management

Ibuprofen (First-Line)

• Start ibuprofen 400-600mg every 6-8 hours immediately after rewarming 1
• This decreases prostaglandin and thromboxane production that causes vasoconstriction, dermal ischemia, and further tissue damage 1
• Continue throughout the acute phase for both anti-inflammatory and anti-thrombotic effects 1

IV Iloprost (AURLUMYN) for Severe Cases

• FDA-approved specifically to reduce the risk of digit amputations in severe frostbite 2
• Indicated for severe frostbite with cyanosis persisting proximal to the distal phalanx (Grade 3-4) and demonstrated loss of perfusion at or proximal to the middle phalanx immediately after rewarming 8
• Must be initiated within 24 hours of rewarming for maximum benefit 7, 8
• Administered as continuous IV infusion over 6 hours daily for up to 8 consecutive days 2
• Start at 0.5 ng/kg/minute and titrate up to 2 ng/kg/minute based on tolerability 2
• Common dose-limiting adverse reactions include headache, flushing, jaw pain, myalgia, nausea, and vomiting 2

Post-Rewarming Wound Care

• Apply bulky, clean, dry gauze or sterile cotton dressings between all digits 1
• Wrap circumferential dressings loosely to accommodate swelling 1
• Do not debride blisters in the field or emergency department 1
• Blisters and edema develop after rewarming as part of the normal inflammatory response 7

Surgical Management Timing

Conservative Approach First

• Wait at least 3 weeks before any amputation or debridement to allow clear demarcation of viable versus non-viable tissue 5, 9
• Hard eschar may form with healthy tissue deep to it—early appearance is deceptive 7
• The amount of tissue loss is often less than initial appearances suggest 7, 5

Surgical Indications

• Grade 2 frostbite: May require skin grafting after debridement in some cases, but many heal with conservative treatment alone in approximately 29-39 days 5
• Grade 4 frostbite: Typically requires amputation, but delay until demarcation is clear 5
• Free or non-free skin grafting for closure of stumps improves functional outcomes 9

Disposition and Follow-Up

Safe for Discharge If:

• 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

Mandatory Follow-Up

• Arrange podiatry or hand surgery follow-up within 24-48 hours for moderate injuries, sooner if any concern 1
• Deeper tissue involvement may require burn center care 1

Return Precautions

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

Common Pitfalls to Avoid

• Never rewarm if refreezing is possible—this causes worse damage than remaining frozen 4, 1
• Never use hot water above 40°C—this adds thermal injury to frozen tissue 1, 6
• Never rush to amputation—wait for clear demarcation, which takes weeks 5, 9
• Never apply chemical warmers directly to skin—they reach burn-causing temperatures 4, 1
• In patients with diabetes or peripheral neuropathy, absence of pain does not mean absence of injury due to impaired sensation 1