Frostbite

Background
Whid chill chart
  • Results from the freezing of tissue
  • It is a disease of morbidity, not mortality
  • Risk correlated with temperature and wind speed
    • Risk is <5% when ambient temperature (includes wind chill) is > –15°C (5°F)
    • Most often occurs at ambient temperature < –20°C (–4°F)
  • Can develop within 2-3sec when metal surfaces that are at or below –15°C (5°F) are touched
  • Most commonly affects distal part of extremities, face, nose, and ears
  • High-risk groups: outdoor workers, elderly, homeless, drug or alcohol abusers, psychiatric disease

Pathophysiology
  • Freezing alone is usually not sufficient to cause tissue death
    • Thawing contributes markedly to the degree of injury
    • Endothelial damage, beginning at the point of thaw, is the critical event in frostbite
      • Resulting damage results in swelling, platelet aggregation, vessel thrombosis

Zones of Injury
  1. Zone of Coagulation
    • Most severe and usually most distal
    • Damage is irreversible
  2. Zone of Hyperemia
    • Least severe and usually most proximal
    • Generally recovers without treatment in <10d
  3. Zone of Stasis
    • Middle zone characterized by severe, but possibly reversible, cell damage
    • It is this zone for which treatment may have benefit

Clinical Features

Classification

Visual determination of tissue viability is difficult in first few weeks; classify early injuries as superficial or deep

Degree First (frostnip) Second Third Fourth
PathophysPartial-skin freezingFull-thickness skin freezingTissue loss involving entire thickness of skinExtension into subcutaneous tissues, muscle, bone, and tendon; little edema
SymptomsStinging and burning, followed by throbbingNumbness followed by aching and throbbingExtremity feels like a "block of wood" followed by burning, throbbing, shooting painsDeep, aching joint pain
CourseNumbness, erythema, swelling, dysesthesia, desquamation (days later)

Substantial edema over 4-6 hours; skin blisters form within 6-24 hours; Desquamate and form hard black eschars over several days

 Hemorrhagic blisters form and are associated with skin necrosis and blue-gray discolorationSkin is mottled with nonblanching cyanosis and formation of deep, dry, black eschar
Pain with rewarmingMinimalMild to moderateSevereNone
PrognosisExcellentGoodOften poorExtremely poor
Image

Differential Diagnosis

Cold injuries

Evaluation
Second degree frostbite progression.
  • Usually clinical

Management
  • Thawing
    • Do NOT attempt until the risk of refreezing is eliminated
      • Refreezing will cause even more severe damage
    • Rapid rewarming is the core of therapy and should be initiated as soon as possible
      • Extremities
        • Place in water with temperature of 40-42C (104-107.6)
        • Approximately 20-30min, until extremity is pliable and erythematous
        • OR consider 38-40°C in whirlpool bath with antibacterial soap[1]
      • Face
        • Apply moistened compresses soaked in warm water
  • Analgesia
    • Rewarming is very painful
    • Provide parenteral opioids
  • Local wound care
    • Apply topical aloe vera cream q6hr (interrupts arachidonic acid cascade)
    • Affected digits should be separated with cotton and wrapped with sterile, dry gauze
    • Elevate involved extremities
    • Blister removal is controversial
      • Consider drainage of nonhemorrhagic bullae that interfere with movement
      • Never debride hemorrhagic bullae
  • Systemic care
    • Ibuprofen may be helpful in interrupting arachidonic cascade
    • Heparin and hyperbaric oxygen of little value
    • IV tPA reduces digit amputation rate
  • Tetanus
    • Reported complication of frostbite; provide prophylaxis
  • Antibiotics
    • Controversial
    • Penicillin G 500,000 units IV Q6 hours for 48-72 hours
    • Topical bacitracin may be as good or better than IV penicillin
    • Silver sulfadiazine cream not consistently beneficial
      • May interact with aloe vera cream
  • Surgery
    • May be required if wet gangrene or infection occurs
    • Usually not performed until full demarcation occurs (3-4wk)

Disposition
  • Patients with superficial local frostbite may be discharged home if social circumstances allow

Complications
  • Up to 65% of patients with frostbite experience sequelae from their injuries
    • Hypersensitivity to cold, pain, ongoing numbness
    • Arthritis, bone deformities, scars, and skin and nail dystrophia

See Also

Video

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References
  1. Crawford-Mechem C et al. Frostbite Treatment & Management. Aug 25, 2015. http://emedicine.medscape.com/article/926249-treatment#showall
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