What is the recommended management of frostbite, including rapid rewarming, analgesia, tetanus prophylaxis, wound care, fluid resuscitation, anticoagulation, thrombolytic therapy, antibiotics, and follow‑up?

Treatment of Frostbite

Immediate Field Management

Remove the patient from cold exposure immediately and transport to a medical facility without delay, as advanced treatments like thrombolytics are most effective within 24 hours and can only be administered in hospital settings. 1, 2

Critical First Steps

• Remove all jewelry, rings, watches, and tight clothing from affected extremities immediately to prevent constriction as tissue swelling develops 1, 2
• Do NOT walk on frostbitten feet or use frostbitten hands for climbing or other activities—frozen tissue cannot sense ongoing mechanical damage 1
• Protect frostbitten tissue from any further trauma or cold exposure throughout transport and treatment 1, 2

Hypothermia Takes Priority

• If the patient has moderate to severe hypothermia, rewarm the core FIRST before treating frostbite—rewarming extremities first causes dangerous core temperature drops 1, 2

Field Rewarming Decision

Do NOT attempt rewarming in the field if:

• There is ANY risk of refreezing (freeze-thaw-refreeze cycles cause exponentially worse tissue damage) 1, 2
• You are within reasonable transport time to a medical facility 2
• The patient will need to walk on frozen feet to reach safety 1

Only consider field rewarming if:

• Risk of refreezing is negligible AND transport will be significantly delayed 1

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Hospital Rewarming Protocol

Rapid Rewarming Technique

Immerse the frostbitten extremity in warm water at 37-40°C (98.6-104°F) for 20-30 minutes—this is the gold standard rewarming method. 1, 2, 3

Key technical points:

• Use a thermometer to maintain precise water temperature 1, 2
• If no thermometer available, water should feel slightly warmer than body temperature when tested against your wrist 1, 2
• Never use water above 40°C—higher temperatures cause additional tissue damage 2, 4
• Air rewarming may be used as an alternative when water immersion is not feasible 1
• Never apply chemical heat packs directly to frostbitten tissue—they can reach burn-causing temperatures 2, 4

Rewarming Expectations

• Rewarming is often extremely painful despite the frozen tissue being initially numb 2, 5
• Hyperemia, blisters, and edema develop after rewarming 5

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Pharmacologic Management

Immediate Analgesia and Anti-inflammatory Therapy

Start ibuprofen 400-600 mg every 6-8 hours immediately upon presentation—this decreases prostaglandin and thromboxane production that causes vasoconstriction, dermal ischemia, and progressive tissue damage. 1, 2, 6

• Continue ibuprofen long-term to prevent ongoing vascular complications 6
• Provide adequate analgesia for rewarming pain (which can be severe) 2, 5

Advanced Thrombolytic Therapy

For severe frostbite with documented perfusion deficits, administer intravenous tissue plasminogen activator (tPA) within 24 hours of injury—this significantly reduces amputation rates. 2, 5

• Earlier administration correlates with better tissue salvage 7
• This is the most time-sensitive intervention and requires burn center capabilities 2

Tetanus Prophylaxis

• Update tetanus immunization according to standard wound care protocols 8

Antibiotics

• Do NOT give prophylactic antibiotics—only treat documented infections 8
• Intact skin and blisters serve as natural infection barriers 1

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Post-Rewarming Wound Care

Dressing Application

Apply bulky, clean, dry gauze or sterile cotton dressings loosely in a circumferential manner:

• Place dressing material between ALL digits (fingers and toes) to prevent maceration 1, 2
• Wrap loosely enough to allow tissue swelling without constricting blood flow 1, 2
• Bulky dressings protect vulnerable tissue from trauma, absorb moisture, reduce infection risk, and distribute pressure evenly 1, 2

Blister Management

Do NOT debride intact blisters—they provide a natural sterile barrier against infection. 1, 2

• Leave intact epidermal layers undisturbed whenever possible 1

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Disposition and Follow-Up

Burn Center Transfer Criteria

Transfer patients with deep frostbite to a specialized burn center for definitive care including potential thrombolytic therapy. 1, 2

Outpatient Discharge Criteria

Discharge is safe ONLY if ALL of the following are met:

• 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

Follow-Up Timing

• Arrange podiatry or hand surgery follow-up within 24-48 hours for moderate injuries 2
• Sooner if any concern for deeper tissue involvement 2
• Frostbite severity is difficult to assess initially—tissue that appears severely damaged may recover better than expected 2, 5

Return Precautions

Instruct patients to return immediately for:

• Increasing pain, numbness, or color changes 2
• Development of new blisters 2
• Signs of infection 2
• Any tissue breakdown or wounds 2

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Long-Term Neuropathic Pain Management

First-Line Pharmacotherapy

Start duloxetine 30 mg daily for one week, then increase to 60 mg daily—this is the primary agent for chronic neuropathic pain following severe frostbite with moderate-quality evidence. 6

Second-Line Options

• Gabapentin or pregabalin if duloxetine fails or is contraindicated (trial for minimum 2 weeks at therapeutic doses before judging efficacy) 6
• Amitriptyline 10-25 mg daily as an alternative antidepressant when first-line agents are not tolerated 6
• Tramadol or strong opioids reserved for severe, refractory pain after failure of other options 6

Non-Pharmacologic Interventions

• Apply 1% menthol cream twice daily to affected areas—yields substantial pain relief with minimal toxicity 6
• Initiate early physical rehabilitation including exercise, sensorimotor training, fine-motor drills, vibration therapy, and balance exercises 6
• Acupuncture may be offered to selected individuals (limited evidence) 6

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Critical Pitfalls to Avoid

• Never rewarm if refreezing is possible—this causes exponentially worse tissue damage than remaining frozen 1, 2
• Never use water above 40°C—causes thermal injury 2, 4
• Never apply chemical warmers directly to tissue—risk of burns 2, 4
• Never debride intact blisters in the emergency department—removes protective barrier 1, 2
• Never delay tPA beyond 24 hours if indicated—efficacy drops significantly 2, 5
• Do not assume absence of pain means absence of injury in patients with diabetes or peripheral neuropathy—their impaired sensation masks early warning signs 2