What is the appropriate management and treatment for a patient presenting with frostbite?

Management and Treatment of Frostbite

For a patient presenting with frostbite, immediately remove constricting items, protect tissue from further injury, and rapidly rewarm the affected part by immersing it in warm water at 37-40°C (98.6-104°F) for 20-30 minutes, followed by loose bulky dressings and ibuprofen administration. 1, 2

Immediate Assessment and Priorities

First Actions at Scene

• Remove all jewelry and constricting materials from the frostbitten extremity immediately to prevent compartment syndrome as swelling develops 1, 2
• If the patient has moderate to severe hypothermia, prioritize core body rewarming before treating the frostbite 1, 2
• Protect frostbitten tissue from any additional trauma and strictly avoid walking on frozen feet or toes 1, 2
• Do not attempt field rewarming if there is any risk of refreezing, as freeze-thaw-refreeze cycles cause exponentially worse tissue damage 1, 2, 3

Critical Decision Point: To Rewarm or Not

The single most important principle is avoiding refreezing. If you cannot guarantee the tissue will stay thawed until definitive care, leave it frozen. 2, 4 Refreezing causes additional ice crystal formation and dramatically worsens tissue necrosis. 3

Rewarming Protocol

Rapid Rewarming Technique

• Immerse the affected extremity 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 thermal injury 1, 2
• Continue immersion until tissue is pliable and erythematous, indicating complete thaw 1

The 2024 American Heart Association guidelines specifically recommend this lower temperature range (37-40°C) based on animal studies showing that higher temperatures (45°C) caused harm. 1 This represents a shift from older literature that suggested 40-42°C. 3, 5

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, though it is less effective 1, 2
• Never apply chemical warmers directly to frostbitten tissue as they can reach temperatures causing burns 2

Post-Rewarming Care

Wound Management

• Apply bulky, clean, dry gauze or sterile cotton dressings to all affected areas and between every finger and toe 1, 2, 6
• Wrap circumferential dressings loosely to accommodate swelling without compromising already ischemic tissue 1, 2, 6
• Do not debride blisters in the first aid or outpatient setting—this dramatically increases infection risk and should only be performed by specialists 1, 2, 6

Pharmacologic Management

• Administer ibuprofen 400-600mg every 6-8 hours to decrease prostaglandin and thromboxane production, which causes vasoconstriction and further tissue damage 1, 2, 6
• The American Heart Association gives this a Class 2b recommendation (may be reasonable), but the American College of Cardiology recommends it for both anti-inflammatory and anti-thrombotic effects 2, 6
• Continue NSAIDs long-term to prevent ongoing dermal ischemia 6, 7

Infection Prevention

• Use alcohol-based hand rub before and after every contact with frostbitten tissue 6
• Wear clean gloves for each dressing change 6
• The intact skin barrier is the primary defense—avoid creating additional portals for bacterial entry 6

Disposition and Follow-Up

Safe for Discharge If:

• No evidence of tissue ischemia on examination 2
• Tissue has been properly rewarmed 2
• No risk of refreezing exists 2
• Patient can protect affected areas from further trauma 2

Requires Advanced Care:

• All frostbite patients should seek prompt medical attention as advanced treatments like thrombolytics are most effective within 24 hours and can only be given in hospital settings 1, 2
• Deep frostbite may require burn center care 2
• Arrange podiatry or hand surgery follow-up within 24-48 hours for moderate injuries 2

Return Precautions

Instruct patients to return immediately for: 2

• Increasing pain, numbness, or color changes
• Development of blisters
• Signs of infection
• Any tissue breakdown or wounds

Special Populations

Diabetic Patients with Neuropathy

• These patients may not feel pain during freezing or rewarming due to baseline sensory deficits 2, 6
• Absence of pain does not indicate absence of injury—rely on visual inspection 2, 6
• They are at higher risk for both initial injury and infectious complications due to impaired circulation and immune function 2, 6

Common Pitfalls to Avoid

• Never rewarm if refreezing is possible—this is worse than staying frozen 1, 2, 3
• Never use water above 40°C 1, 2
• Never debride blisters outside a hospital setting 1, 2, 6
• Never apply chemical warmers directly to tissue 2
• Never assume absence of pain means absence of injury in neuropathic patients 2, 6

Long-Term Sequelae

Patients may develop chronic neuropathic pain, altered vasomotor function, and in children, growth defects from epiphyseal plate damage. 3 For chronic neuropathic pain, duloxetine is first-line pharmacologic therapy, with gabapentin/pregabalin as second-line options. 7