What are the degrees of frostbite. How is frostbite diagnosed. What are the risk factors for developing frostbite. How can frostbite be prevented. What is the recommended treatment for frostbite. How long does it take to recover from frostbite. What are the potential long-term complications of frostbite.

The Nature and Epidemiology of Frostbite

Frostbite, also known as freezing cold injury (FCI), is a type of tissue damage that occurs when the skin and underlying tissues freeze due to exposure to extremely cold temperatures. This condition typically affects body parts that are farthest from the heart or those with less insulation from the cold, such as fingers, toes, nose, ears, cheeks, and chin.

Historically, frostbite was commonly associated with military personnel exposed to harsh winter conditions. However, in recent years, there has been a shift in the epidemiology of frostbite cases. With the increasing popularity of winter sports and outdoor activities, recreational athletes now account for a significant portion of frostbite incidents.

Certain populations are particularly vulnerable to frostbite:

• Homeless individuals
• Children
• Elderly people
• Outdoor enthusiasts and athletes
• People with certain medical conditions

What factors contribute to the risk of developing frostbite? The risk increases with prolonged exposure to cold temperatures, especially when combined with high winds or wet conditions. Additionally, several behavioral and physiological factors can elevate an individual’s susceptibility to frostbite.

Risk Factors for Frostbite

1. Inadequate clothing or shelter in cold weather
2. High wind chill factors
3. Exposure at high altitudes
4. Prolonged exposure to wet conditions
5. Altered mental status
6. Alcohol or drug abuse
7. Malnutrition
8. Immobilization
9. Age extremes (very young or very old)
10. Homelessness
11. Medical conditions (e.g., diabetes, hypothyroidism, peripheral vascular disease)
12. Smoking

The Pathophysiology of Frostbite

To understand frostbite, it’s crucial to delve into its pathophysiology. How exactly does cold exposure lead to tissue damage? The process is complex and involves several interrelated mechanisms.

When the skin is exposed to freezing temperatures, the body’s initial response is vasoconstriction – a narrowing of blood vessels to reduce heat loss. This protective mechanism can become problematic if exposure continues, as it reduces blood flow to the affected areas, potentially leading to tissue damage.

As the temperature of exposed skin drops, several events occur:

1. Endothelial cell damage causes localized edema (swelling) in the extremity.
2. Blood flow becomes hyperviscous (thicker), leading to slower circulation.
3. Microthrombi (tiny blood clots) form in small blood vessels.
4. The combination of microvascular injury, venous stasis, and microthrombi results in ischemia (inadequate blood supply to the tissues).

What happens to normal skin blood flow during frostbite? In healthy skin, blood flow is approximately 250 ml/min. However, during frostbite, this can dramatically decrease to less than 20-50 ml/min. When temperatures drop below 0 degrees Celsius, blood flow may cease entirely.

Mechanisms of Frostbite Injury

Frostbite causes tissue damage through several mechanisms:

• Direct cold damage to tissues
• Indirect damage from dehydration
• Formation of ice crystals, disrupting electrolyte balance and lipid layers
• Microvascular stasis leading to thrombus formation and ischemia
• Reperfusion injury when blood flow returns to the affected area

Degrees of Frostbite: Understanding the Severity

Frostbite is typically classified into degrees based on the depth and severity of tissue damage. How many degrees of frostbite are there? While some sources describe four degrees, a more modern classification system recognizes three main degrees of frostbite.

First-Degree Frostbite (Superficial)

What are the characteristics of first-degree frostbite?

• Affects only the outer layer of skin (epidermis)
• Skin appears white or pale and feels cold to the touch
• Numbness or tingling sensation
• Skin may appear red and swollen upon rewarming
• Generally resolves without long-term damage

Second-Degree Frostbite (Partial-Thickness)

How does second-degree frostbite differ from first-degree?

• Affects both the epidermis and part of the underlying dermis
• Skin becomes hard and waxy in appearance
• Blisters filled with clear or milky fluid develop within 24-48 hours
• More pronounced swelling and redness upon rewarming
• May result in some tissue loss but often heals without significant scarring

Third-Degree Frostbite (Full-Thickness)

What makes third-degree frostbite the most severe form?

• Affects all layers of the skin and may extend into subcutaneous tissues
• Skin appears blue or black and feels hard and cold
• Large blisters filled with blood-tinged fluid develop
• Severe pain upon rewarming, followed by numbness
• Often results in tissue death and may require amputation

Diagnosis and Evaluation of Frostbite

How is frostbite diagnosed? The diagnosis of frostbite is primarily based on clinical presentation and history of cold exposure. However, a thorough evaluation is crucial to determine the severity of the injury and guide appropriate treatment.

Clinical Presentation

What signs and symptoms should healthcare providers look for when evaluating a patient for frostbite?

• Skin discoloration (white, waxy, or bluish-gray)
• Numbness or loss of sensation in affected areas
• Hardness or stiffness of the tissue
• Blistering (in more severe cases)
• Pain or burning sensation upon rewarming

Diagnostic Tools

While the initial diagnosis is often clinical, several diagnostic tools can help assess the extent of tissue damage and predict outcomes:

1. Doppler ultrasound: To evaluate blood flow in affected areas
2. Angiography: To visualize blood vessel patency and identify areas of poor perfusion
3. Magnetic Resonance Angiography (MRA): To assess tissue viability and blood flow
4. Technetium-99 bone scans: To determine the extent of deep tissue injury
5. Thermography: To map temperature distribution in affected areas

Treatment Approaches for Frostbite

What is the recommended treatment for frostbite? The management of frostbite involves a multifaceted approach aimed at reversing tissue damage, preventing further injury, and promoting healing. The specific treatment plan depends on the severity of the frostbite and how quickly medical attention is sought.

Immediate First Aid

What steps should be taken immediately when frostbite is suspected?

1. Move the affected person to a warm, dry area
2. Remove wet or constricting clothing
3. Gently rewarm the affected area (if there’s no risk of refreezing)
4. Avoid rubbing or massaging the frostbitten area
5. Protect the area from further cold exposure

Medical Treatment

Once medical care is available, what treatments might be employed?

• Rapid rewarming in a water bath (37-39°C) for 15-30 minutes
• Pain management with NSAIDs or opioids as needed
• Tetanus prophylaxis if indicated
• Debridement of clear blisters (blood-filled blisters are typically left intact)
• Topical aloe vera or antibiotic ointments to prevent infection
• Elevation of the affected limb to reduce edema

Advanced Therapies

In severe cases or when tissue loss is imminent, more aggressive treatments may be considered:

1. Thrombolytic therapy (e.g., tissue plasminogen activator) to improve blood flow
2. Vasodilators to enhance tissue perfusion
3. Hyperbaric oxygen therapy to promote healing
4. Surgical intervention (e.g., fasciotomy or amputation) in cases of compartment syndrome or extensive tissue necrosis

Prevention Strategies for Frostbite

How can frostbite be prevented? Prevention is key when it comes to frostbite, and several strategies can significantly reduce the risk of cold-related injuries.

Proper Clothing and Protection

What clothing choices can help prevent frostbite?

• Dress in layers, with a moisture-wicking base layer
• Wear insulated, waterproof outerwear
• Protect extremities with warm gloves or mittens and insulated boots
• Cover exposed skin with scarves, face masks, and hats
• Change out of wet clothing immediately

Environmental Awareness

How can individuals stay safe in cold environments?

1. Check weather forecasts and wind chill factors before outdoor activities
2. Limit time outdoors during extremely cold weather
3. Seek shelter periodically to warm up during prolonged outdoor exposure
4. Stay hydrated and well-nourished to maintain body heat
5. Avoid alcohol consumption, which can impair judgment and increase heat loss

Special Considerations for High-Risk Groups

What additional precautions should high-risk individuals take?

• Individuals with circulatory problems should consult their healthcare provider before engaging in cold-weather activities
• Diabetics should maintain good blood sugar control to improve circulation
• Smokers should be aware of their increased risk and take extra precautions
• Elderly individuals should ensure adequate heating in their homes and limit outdoor exposure during cold snaps

Long-Term Complications and Recovery from Frostbite

What are the potential long-term complications of frostbite? While many cases of mild frostbite resolve without lasting effects, more severe cases can lead to significant long-term complications.

Potential Complications

• Chronic pain or numbness in affected areas
• Increased sensitivity to cold
• Changes in skin color or texture
• Joint stiffness or arthritis
• Growth plate disturbances in children
• Increased risk of future cold injuries
• Psychological impacts (e.g., anxiety about cold exposure)

Recovery Process

How long does it take to recover from frostbite? The recovery timeline varies depending on the severity of the injury:

1. Mild cases (first-degree): May heal within a few days to weeks with proper care
2. Moderate cases (second-degree): Recovery can take several weeks to months
3. Severe cases (third-degree): Full recovery may take months to years, and some effects may be permanent

What factors influence the recovery process?

• Promptness of treatment
• Severity and extent of tissue damage
• Individual healing capacity
• Adherence to follow-up care and rehabilitation
• Presence of underlying health conditions

Rehabilitation and Support

What types of support may be needed during frostbite recovery?

• Physical therapy to improve mobility and strength
• Occupational therapy for adapting to any functional limitations
• Pain management strategies
• Psychological support for coping with trauma or lasting effects
• Regular follow-up with healthcare providers to monitor healing progress

Emerging Research and Future Directions in Frostbite Management

What new developments are on the horizon for frostbite treatment and prevention? The field of cold injury management is continually evolving, with researchers exploring novel approaches to improve outcomes for frostbite patients.

Innovative Treatment Modalities

What cutting-edge therapies are being investigated for frostbite?

• Targeted drug delivery systems to enhance tissue perfusion
• Stem cell therapies to promote tissue regeneration
• Advanced imaging techniques for early detection of tissue viability
• Nanotechnology-based treatments to mitigate cellular damage
• Gene therapy approaches to enhance cold tolerance

Improved Prevention Strategies

How might future technologies enhance frostbite prevention?

1. Development of smart fabrics that adapt to temperature changes
2. Wearable devices that monitor skin temperature and alert users to potential cold injury
3. Advanced weather prediction models to provide more accurate cold exposure risk assessments
4. Personalized risk assessment tools based on individual physiological factors

Interdisciplinary Approach

What role does collaboration play in advancing frostbite research?

• Integration of expertise from various fields (e.g., medicine, materials science, bioengineering)
• Collaborative efforts between civilian and military research institutions
• International partnerships to study frostbite in diverse populations and climates
• Incorporation of patient experiences and outcomes into research design

As research in this field progresses, it holds the promise of significantly improving both the prevention and treatment of frostbite, potentially reducing the long-term impact of this cold-related injury on individuals and communities.

Frostbite – StatPearls – NCBI Bookshelf

Continuing Education Activity

Frostbite, also known as freezing cold injury is tissue damage that occurs due to cold exposure, occurring at temperatures below zero degrees celsius. Homeless populations, children, and the elderly are especially vulnerable to frostbite. Prolonged duration and lower temperatures increase the risk of frostbite and the extent of the injury. Certain pre-existing conditions, including peripheral vascular disease, malnutrition, Raynaud’s disease, diabetes mellitus, and tobacco use may worsen frostbite-related tissue damage. This activity reviews the evaluation and treatment of frostbite and highlights the role of the interprofessional team in improving care for patients with this condition.

Objectives:

• Identify the epidemiology of frostbite.

• Summarize how to evaluate a patient for frostbite.

• Review the treatment and management options available for frostbite.

• Explain interprofessional team strategies to improve care coordination and communication to advance treatment and prevention of frostbite, in turn leading to better patient outcomes.

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Introduction

Frostbite, also known as freezing cold injury (FCI) is tissue damage as a result to cold exposure, occurring at temperatures below 0 degrees C. It is included in a spectrum of injury, from FCI to non-FCI and frostnip.[1] Any portion of exposed skin is prone to the damaging effects of frostbite. Patients are at high risk for ischemic tissue injury and necrosis. Patients that survive cold tissue injury are prone to secondary infection and dehydration from loss of the skin barrier. 

Frostbite tend to occur when the body is exposed to intense cold, resulting in vasoconstriction. The resulting decrease in blood flow fails to deliver heat to the tissues and eventually leads to ice crystal formation. Body parts most prone to frostbite include the feet, hand, ears, lips, and nose. Most cases of frostbite occur in the winter; homeless people and those who perform outdoors activity are most susceptible to the injury. The goal of treatment is to salvage as much tissue as possible so that maximal function remains.

Etiology

Skin exposure to freezing conditions causes frostbite. Prolonged duration and lower temperatures increase the likelihood and the extent of the injury. Certain pre-existing conditions may worsen tissue injury because of frostbite, including peripheral vascular disease, malnutrition, Raynaud’s disease, diabetes mellitus, tobacco use, etc. A unifying pattern among these conditions is poor impaired internal organ insulation or dysfunctional vasculature.

Risk factors for frostbite include:

• Winter season

• No or inadequate shelter from the cold

• High wind chill factor

• Exposure at a high altitude

• Prolonged duration of exposure

• Prolonged exposure to a wet condition

• Altered mental status

• Alcohol or drug abuse

• Malnutrition

• Immobilization

• Extremes of age

• Homeless

• Presence of medical disorders like diabetes, hypothyroidism, peripheral vascular disease, stroke or arthritis

• Smoker

Epidemiology

Classically, frostbite injuries were common in military personnel. However, with the increase in technology and accessibility, recreational sports have become a significant repository for frostbite cases. Homeless populations, children, and the elderly are especially vulnerable to frostbite. Risk factors include behavioral (lack of clothing, alcohol/drug consumption, access to shelter), physiological (dehydration, high altitudes, hypoxia), and other comorbidities with a predilection for tissue hypoxia (diabetes, peripheral vascular disease, Raynaud phenomenon).[1]

Pathophysiology

Frostbite has a prejudice for distal extremities, digits, and those portions of exposed skin with decreased perfusion (nose, ears) and less insulation. As the temperature of exposed skin drops, endothelial cell damage can cause localized edema in the extremity. Hyperviscous intravascular flow and vasodilation causes slowing forces, resulting in microthrombi. The constellation of microvascular injury, venous stasis, and microthrombi all contribute to the development of ischemia attributed to frostbite.  Depending on the extent of the exposure and subsequent cellular damage, injuries may be reversible or irreversible.

Normal skin blood flow is about 250 ml/min but during frostbite, the flow drops to less than 20-50 ml/min. As the temperature drops to below 0 degrees Centigrade, blood flow ceases. The slower venous system freezes before the arterial system.

Frostbite causes injury in the following ways:

• Direct damage of the cold to the tissues

• Indirect damage caused by dehydration

• Formation of ice crystals that leads to alteration in electrolytes and lipid layers

• Stasis of the microvessels leading to thrombus formation and ischemia

• Reperfusion injury

Recovery

Frostbite injury is classified into three zones which include:

1. Zone of coagulation which is the most distal and often the most severely injured. Here the injury is irreversible

2. Zone of stasis is the middle zone where the injury can be moderate to severe. but it reversible.

3. Zone of hyperemia is the proximal zone, which is the least injured.

In most cases, recovery from frostbite can take 5-30 days, depending on the severity of injury.

Histopathology

Initially, extracellular ice crystals form in exposed tissue. Continued cold exposure can cause intracellular ice crystals to form. Cell membrane damage results in electrolyte imbalances. As the transmembrane osmolarity gradient increases, cell membranes can rupture, resulting in cell death. Should tissue thawing occur, a reperfusion-associated inflammatory response through proinflammatory cytokines may cause additional tissue damage. Even more dangerous, additional cycles of thaw-refreeze can cause progressively worsening tissue ischemia and subsequent thrombosis.[2]

History and Physical

History of the patient should include duration and external temperatures during exposures.

Physical examination may reveal blanched, white skin. Patients may complain of heaviness in an exposed extremity as numbness progresses. In later stages of frostbite, exposed areas may become dark or purplish in hue due to poor vascular tone and pooling of blood. Superficial frostbite affecting the epidermis and subcutaneous fat will have pale, white blisters upon rewarming. Deep, full-thickness frostbite will become hemorrhagic with rewarming and may become gangrenous.[3] Injured skin may be well-demarcated with surrounding viable skin.

It is important to know that the initial exam will not accurately reveal the final depth and extent of the injury.

Rewarming injury

During rewarming, edema may start to appear within 3-5 hours and may last 7 days. Blisters tend to appear within 4-24 hours.

Presence of eschar will be obvious at 10-15 days and mummification with a line of demarcation may develop in 3-8 weeks.

Evaluation

Frostbite is a clinical diagnosis. Using additional laboratory testing may be helpful in determining the extent to which comorbid conditions may be contributing to tissue ischemia.  Technetium-99 (Tc-99) triple phase scanning and magnetic resonance angiography (MRA) may help to determine extent of amputation in the first few days after injury.[4][5] Tc-99 bone imaging may also assist in determining candidacy for tPA.[6]

Treatment / Management

Patients should have protection from further injury by covering exposed areas. The care of patients with frostbite begins with rewarming in the field if there is no anticipation of refreezing, as thaw-refreezing may worsen injuries.[3] Remove patients from the wind. Remove wet clothing and replace with dry clothing. Avoid vigorous rubbing as this can cause further damage.[7]

In-hospital management includes warm water baths, approximately 40-42 degrees C. Patients with systemic hypothermia should be managed by raising core temperature above 35 degrees C using warm IV fluids, and this should precede warming of the affected extremity.[7] This rewarming protocol also includes patients with other comorbidities or significant trauma. NSAIDS (ibuprofen) are indicated for controlling pain and preventing further inflammation, but stronger analgesics including narcotics may be necessary to achieve pain control. Frequent re-examination for sensation should accompany rewarming.

Although controversial, some sources recommend drainage or excision on white, cloudy-appearing blisters, while hemorrhagic blisters should be left intact. As with burn patients, particular care to prevent infections and dehydration should be a priority. Overly aggressive surgical debridement may remove skin that is otherwise viable, so complete rewarming should be achieved before surgical debridement. Signs of compartment syndrome (edema, pulselessness, extreme pain) should prompt urgent surgery. Delayed amputation (up to 6 weeks following injury) until the determination of tissue viability may prevent surgical morbidity from unnecessary procedures.[8][9]

Patients with full-thickness injuries and evidence of ischemia and no restoration of tissue perfusion after rewarming may be candidates for thrombolytic (tPA) therapy. [10] tPA may reduce the need for digital amputation.[11] Combination therapy with tPA and IV heparin may also reduce the need for digital amputation.[6] Iloprost, a potent vasodilator, has been used as a potential treatment to prevent ischemia in frostbite.[3] IV Iloprost is unavailable in the United States.

Differential Diagnosis

Careful assessment for systemic hypothermia and full-thickness tissue injury are essential in patients with apparent frostbite. Failure to correct for underlying comorbidities associated with frostbite (i.e., intoxication, cardiovascular compromise, significant environmental exposure, trauma) may cause systemic collapse and death. 

Staging

Traditionally, frostbite has a staging system similar to burns: 

• First degree – numbness, central pallor, surrounding erythema/edema, desquamation, dysesthesia

• Second degree – skin blistering with surrounding erythema/edema

• Third degree – tissue loss involving entire thickness of skin, hemorrhagic blisters

• Fourth degree – tissue loss involving deeper structures, resulting in loss of the affected part

Another classification based on frostbite on hands/feet has been proposed, which incorporate early imaging studies and may better predict outcomes. [12]

• Grade 1 – no cyanosis on the extremity; no risk of amputation or sequelae predicted

• Grade 2 – cyanosis on distal phalanx only; amputation to soft tissue and sequelae of fingernail/toenail sequelae predicted

• Grade 3 – cyanosis on intermediate and proximal phalanges; amputation to the bone of the digit and functional sequelae predicted 

• Grade 4 – cyanosis over carpal/tarsal bones; amputation to limb and functional sequelae predicted.

With this classification system, as grade increases, so does the likelihood of limb amputation.

Prognosis

Functional sequelae of frostbitten areas depend on the extent of tissue injury.[12] Unfavorable factors in frostbite include hemorrhagic blistering, non-blanching cyanosis, and firm skin after rewarming.[3] Patients should avoid cold exposure for up to a year after the initial injury.

Frostbite injury is associated with morbidity which is worse in the presence of the following:

• Presence of hemorrhagic blisters

• No edema

• Ongoing mottling

• Frank presence of frozen tissue

Complications of frostbite include:

Complications

Frostbite survivors may have an intolerance to cold in previously frostbitten areas, which may be a consequence of vasospasm and abnormal autonomic tone following cold injury. Complex regional pain syndrome is a common complication.[10] Autoamputation of an affected digit may precede surgical amputation. 

Deterrence and Patient Education

Risk modification including proper clothing, access to shelter, and maintaining hydration and nutrition are vital for protection against frostbite.[7] Patients should be advised to keep clothing as dry as possible and to wear multiple layers if they foresee cold exposure. Alcohol consumption should be discouraged. Emollients, although traditionally believed in Nordic countries to prevent frostbite, do not have protective effects in preventing frostbite and should be discouraged.[13]

Enhancing Healthcare Team Outcomes

Frostbite is a very common problem during winter and is associated with high morbidity. Because any part of the body can be affected, the condition is best managed by an interprofessional team that includes the emergency department physician, internist, wound care nurse, and a surgeon.

A multimodal approach to the treatment of patients with frostbite may provide the best chance for functional recovery.[1]

The key is patient education; frostbite in many instances can be prevented. Patients should be advised to dress well during winter, carry extra clothing supplies if they are into winter sports and avoid tight restrictive clothing. The nurse should advise against the use of alcohol, illicit drugs, and tobacco. For those with medical problems. it is important to ensure that their health is stable before venturing on an outdoors trip during winter.

Early consultation with the surgical services specializing in frostbite is crucial. During recovery from frostbite, as with other traumatic injuries with an expected loss of, function, consultation with rehabilitation services is vital, including wound care, physical therapy, occupational therapy, physical medicine & rehabilitation specialists, among others.

Finally, one should not immediately recommend amputation. The aim is to salvage all viable tissue. Thus, a wound care nurse should follow the patient and only debride infected superficial dead skin and let the damaged skin slough off on its own. Open communication with the interprofessional team is the key so that all patients receive the optimal standard of care.

Outcomes

The outcomes after frostbite injury are guarded and depend on the extent of the injury. Most people tend to have some residual deficits; either sensory or functional.

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Figure

Frostbite to fingers/hands. Contributed by Wikimedia Commons, Winky (CC by 2.0) https://creativecommons.org/licenses/by/2.0/deed.en

References

1.

Imray CH, Oakley EH. Cold still kills: cold-related illnesses in military practice freezing and non-freezing cold injury. J R Army Med Corps. 2005 Dec;151(4):218-22. [PubMed: 16548337]

2.

Rintamäki H. Predisposing factors and prevention of frostbite. Int J Circumpolar Health. 2000 Apr;59(2):114-21. [PubMed: 10998828]

3.

Roche-Nagle G, Murphy D, Collins A, Sheehan S. Frostbite: management options. Eur J Emerg Med. 2008 Jun;15(3):173-5. [PubMed: 18460961]

4.

Cauchy E, Marsigny B, Allamel G, Verhellen R, Chetaille E. The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities: A retrospective study of 92 severe frostbite injuries. J Hand Surg Am. 2000 Sep;25(5):969-78. [PubMed: 11040315]

5.

Barker JR, Haws MJ, Brown RE, Kucan JO, Moore WD. Magnetic resonance imaging of severe frostbite injuries. Ann Plast Surg. 1997 Mar;38(3):275-9. [PubMed: 9088467]

6.

Twomey JA, Peltier GL, Zera RT. An open-label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite. J Trauma. 2005 Dec;59(6):1350-4; discussion 1354-5. [PubMed: 16394908]

7.

Handford C, Buxton P, Russell K, Imray CE, McIntosh SE, Freer L, Cochran A, Imray CH. Frostbite: a practical approach to hospital management. Extrem Physiol Med. 2014;3:7. [PMC free article: PMC3994495] [PubMed: 24764516]

8.

Hallam MJ, Cubison T, Dheansa B, Imray C. Managing frostbite. BMJ. 2010 Nov 19;341:c5864. [PubMed: 21097571]

9.

Woo EK, Lee JW, Hur GY, Koh JH, Seo DK, Choi JK, Jang YC. Proposed treatment protocol for frostbite: a retrospective analysis of 17 cases based on a 3-year single-institution experience. Arch Plast Surg. 2013 Sep;40(5):510-6. [PMC free article: PMC3785582] [PubMed: 24086802]

10.

Sheridan RL, Goldstein MA, Stoddard FJ, Walker TG. Case records of the Massachusetts General Hospital. Case 41-2009. A 16-year-old boy with hypothermia and frostbite. N Engl J Med. 2009 Dec 31;361(27):2654-62. [PubMed: 20042758]

11.

Bruen KJ, Ballard JR, Morris SE, Cochran A, Edelman LS, Saffle JR. Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy. Arch Surg. 2007 Jun;142(6):546-51; discussion 551-3. [PubMed: 17576891]

12.

Cauchy E, Chetaille E, Marchand V, Marsigny B. Retrospective study of 70 cases of severe frostbite lesions: a proposed new classification scheme. Wilderness Environ Med. 2001 Winter;12(4):248-55. [PubMed: 11769921]

13.

Lehmuskallio E. Emollients in the prevention of frostbite. Int J Circumpolar Health. 2000 Apr;59(2):122-30. [PubMed: 10998829]

Disclosure: Hajira Basit declares no relevant financial relationships with ineligible companies.

Disclosure: Tanner Wallen declares no relevant financial relationships with ineligible companies.

Disclosure: Christopher Dudley declares no relevant financial relationships with ineligible companies.

Frostbite: Answers, treatment and prevention

“Bitter, bitter cold” is the way one patient described the Upper Midwest weather conditions that left him hospitalized with frostbite. Living here, we get pretty used to the bitter temperatures that head our way each winter. Unfortunately, this familiarity can also lead us to underestimate the health risks of these freezing conditions. Such is the case for people living in winter climates everywhere, as well as visitors who are unaccustomed to the dangers of the cold.

When we don’t properly prepare for the mighty winter elements, serious injuries like frostbite can and do happen – fast. But how fast? Read on to learn more about frostbite and how to stay prepared and protected.

What is frostbite?

Frostbite is considered a type of burn that happens when the skin and tissues below it begin to freeze. It usually occurs when skin is exposed to below-freezing temperatures for a certain amount of time, which varies based on the temperature and how fast the wind is blowing (windchill).

How long does it take to get frostbite?

The colder the temperature, the faster you can get frostbite. And when you add wind and water to the mix, the process speeds up even more. Every person and every situation are different, but here are a few guidelines for understanding the risk for frostbite:

• When the temperature is zero degrees Fahrenheit or below, it takes about 30 minutes for exposed skin to get frostbite.
• At 15 degrees below zero with even a little bit of wind, frostbite is possible within 15 minutes.

Windchill temperature and frostbite chart

The chart below from the National Weather Service shows how long it might take to develop frostbite at varying temperatures and wind speeds.

What does frostbite look like?

In more mild cases of frostbite, the skin appears pale blue or grayish. In severe cases, red and swollen blisters can develop after rewarming the affected areas. Afterward, skin can turn dark purple or black if tissues are badly damaged.

Early symptoms of frostbite

Your fingers, toes, nose, ears, cheeks and chin are the most common places for frostbite. Knowing the early symptoms can help you treat frostbite fast and have the best recovery outcome. Here’s what the first signs of it look and feel like:

• Your skin starts to become cold
• You may experience a pins-and-needles sensation
• You have a loss of feeling (numbness)
• Your skin turns white or a pale, bluish gray
• Your skin feels stiff or rubbery to the touch

Stages of frostbite

There are three stages of frostbite: mild, superficial and severe. These are determined by how deeply your skin and tissues have frozen.

Mild frostbite (frostnip)

Mild frostbite is when your skin has been irritated by the cold, causing pain or numbness. You may feel a tingling, prickly sensation when the skin warms again. Mild frostbite is temporary and can be treated at home (we cover treatment remedies below).

Superficial frostbite

When skin layers have frozen farther down, it’s considered superficial frostbite. In addition to the pain and numbness of mild frostbite, at this stage your skin also becomes slightly discolored, turning light blue or grayish. When the skin is gently rewarmed, you may experience a prickly, burning sensation, swelling, and the area might feel warm (a sign it’s been affected more seriously). 12-36 hours later you may notice fluid-filled blisters. You can treat superficial frostbite with home remedies right when it happens, but you should seek medical care soon after rewarming the skin.

Deep frostbite (severe)

Deep frostbite (the most severe kind) means that all the layers of your skin and the tissues beneath it have frozen significantly. When this happens, your skin turns white or a bluish gray, and is numb to feelings of cold or pain. It may be stiff and rubbery when touched, and your joints and muscles may have difficulty working. After rewarming the skin, fluid-filled blisters may appear within 24-48 hours, and the damaged skin will turn black.

Severe frostbite has longer-term affects and requires immediate medical attention – sometimes involving hospitalization. In the most critical cases, tissues are seriously damaged and amputation may be needed if blood flow to the skin is permanently blocked. In other instances of severe frostbite, patients may avoid amputation, but experience lifelong numbness in the affected areas.

What to do if you have frostbite

If you think you’re experiencing frostbite, take these steps for first aid right away:

Protect your skin from the elements

If you can’t get to a warm place inside just yet, try to cover the affected areas to protect them from the cold and wind. You can put your hands into your pockets, sleeves or armpits to try to warm them with your body heat.

Get out of the cold

Get out of the cold and into a warmer temperature as soon as possible. Take off any wet clothing and cover up with warm, dry clothes and a blanket.

Check for signs of hypothermia

Hypothermia is a potentially life-threatening condition that happens when your body is losing heat faster than it can produce heat. If your body temperature gets too low, your critical organs (like your heart, lungs and nervous system) can’t function. To check yourself or someone else for hypothermia, look for signs like shallow breathing, weak pulse, confusion and slurred speech – and seek emergency help quickly.

Gradually warm the frostbitten areas

Warm frostbitten fingers and toes by soaking them in slightly warm (not hot) water for 15-30 minutes. It’s very important to rewarm the affected area gently and gradually, because using hot water to warm it too quickly can cause more damage. Test the temperature of the water with an area that isn’t frostbitten, like your elbow. For other areas like your face, ears or extremities, apply a warm, wet washcloth.

Note: Don’t rewarm frostbitten skin with direct heat like a fireplace or heating pad, due to the risk of burns. Remember, frostbite itself is a type of burn and needs to be cared for with gentle, moist warmth.

Heat yourself up from the inside

Drinking warm liquids like tea or soup can help your body warm up internally, too.

Over-the-counter pain medicine

Taking an over-the-counter pain medication like ibuprofen can help ease discomfort.

When to see a doctor for frostbite

As your skin rewarms and blood flow returns, you may feel a tingling or burning sensation. If you begin to notice skin discoloration, continued numbness or other symptoms that are out of the ordinary, make an appointment with a doctor right away or visit your local urgent car. Note: If your fingers or toes frequently turn white and feel tingly in regular cold conditions (even after warming up) you may want to ask your doctor if Raynaud’s could be a possible cause.

Preventing frostbite: Preparation is key

Every winter, our Regions Hospital Burn Center sees up to 60 patients come in with frostbite injuries. Many times, the frostbite happened when these patients were out doing ordinary tasks that just didn’t go as planned. Getting stranded in the cold in a stalled or disabled vehicle tends to be a common situation. There are also people who get locked out of their house, or who slip outside and can’t get up after the fall.

Limiting trips outdoors when the temperature is below zero is the best way to prevent frostbite. But if you do need to leave, remember to be prepared by expecting the unexpected. Here are our top four tips:

1. Dress (or pack) for success.Whether you’re planning to spend the whole day outdoors or just heading to the grocery store, make sure you’re wearing (or bringing along) the right clothes. The best choices are clothes made of wool, down or Thinsulate – all of which prevent the loss of body heat. And don’t forget a warm hat, mittens and a pair of boots.
2. Keep a cold weather emergency kit in your car.It’s wise to keep a box or bag in your car that contains things you might need in an emergency. In the winter months, that means extra layers of clothes, including hats, scarves, mittens and socks; a blanket; chemical hand and foot warmers; an LED flashlight; jumper cables; a snow scraper and snow shovel.
3. Keep your cell phone with you.Most of us do this anyway, but it’s still a good reminder in case of an emergency situation. Don’t assume you’ll be able to reach someone nearby – carry your phone with you and make sure its battery is fully charged. It’s also a good idea to keep a charger with you or in your car.
4. Stay calm if you find yourself exposed to extreme cold.While these situations can be very stressful, it’s important to remain calm. For one thing, you’ll have a better chance at thinking clearly if you’re calm. Secondly, fear can cause sweating, which cools the body and can make you feel chilled. Take several deep breaths and try to stay positive. Then, while you’re figuring out a plan, get your body moving to increase blood flow and make more body heat. (Just be careful not to be so active that you sweat.)

There’s so much to enjoy about the wintertime, but it’s important to stay on our guard and be prepared for temperatures to drop. When you know you’re ready to protect yourself and your family from the cold, that peace of mind allows you to embrace all the season has to offer.

Frostbite and hypothermia. Symptoms, first aid, prevention

Frostbite, or frostbite (lat. congelatio) – damage to body tissues under the influence of cold, often accompanied by general hypothermia of the body. A small memo will help to avoid the dangerous consequences of exposure to cold on the human body.

Frostbite especially often affects such parts of the body as auricles, nose, poorly protected limbs, especially fingers and toes. Most often, frostbite occurs in cold winters at ambient temperatures below minus 10-20 °C. However, it can be obtained by prolonged exposure outdoors at temperatures above zero, with high humidity and strong winds.
In addition, frostbite is promoted by tight and damp clothes and shoes, physical fatigue, hunger, prolonged immobility and uncomfortable position, cold injury, weakening of the body after illness, sweating of the legs, chronic diseases of the vessels of the lower extremities and the cardiovascular system, severe mechanical damage with blood loss, smoking, etc.

Frostbite degrees 9001 0

Frostbite I degree (mild) usually occurs with short exposure to cold. The affected area of ​​the skin is pale, reddened after warming, in some cases it has a purple-red tint; edema develops. The first signs of such frostbite are a burning sensation, tingling, followed by numbness of the affected area. Then there is skin itching and pain, which can be both minor and pronounced.
Skin necrosis does not occur. By the end of the week after frostbite, slight peeling of the skin is sometimes observed. Full recovery occurs by 5 – 7 days after frostbite.

II degree frostbite occurs with prolonged exposure to cold. In the initial period there is blanching, cooling, loss of sensitivity.
A characteristic feature is the formation of blisters filled with transparent contents in the first days after the injury. After warming, the pain is more intense and longer than with frostbite of the first degree, skin itching, burning are disturbing. Full restoration of the integrity of the skin occurs within 1 – 2 weeks, granulation and scarring are not formed.

With frostbite III degree the duration of the period of cold exposure and decrease in temperature in the tissues increases. The blisters formed in the initial period are filled with bloody contents, their bottom is blue-purple, insensitive.
The death of all skin elements occurs with the development of granulations and scars as a result of frostbite. Descended nails do not grow back or grow deformed. Rejection of dead tissues ends on the 2nd – 3rd week, after which scarring occurs, which lasts up to 1 month.

Frostbite IV degree occurs with prolonged exposure to cold, the decrease in temperature in tissues is the greatest. It is often combined with frostbite III and even II degree. All layers of soft tissues become dead, bones and joints are often affected.
The damaged area of ​​the limb is sharply cyanotic, sometimes with a marble color. Edema develops immediately after warming and increases rapidly. The temperature of the skin is much lower than that of the tissues surrounding the area of ​​frostbite. Blisters develop in less frostbitten areas where there is frostbite III – II degree. The absence of blisters with significantly developed edema, loss of sensitivity indicate frostbite of the IV degree.

Under conditions of prolonged exposure at low air temperature, not only local lesions are possible, but also general cooling of the body , which, in turn, can lead to loss of consciousness. Under the general cooling of the body should be understood as a condition that occurs when the body temperature drops below 34°C.
The onset of general cooling is facilitated by the same factors as with frostbite: high humidity, damp clothes, strong wind, physical overwork, mental trauma, past illnesses and injuries.

Symptoms of general cooling:
Mild degree : pale or moderately cyanotic skin, goosebumps, chills, difficulty speaking. The pulse is reduced to 60-66 per minute.

Moderate : characterized by severe drowsiness, depression of consciousness, a senseless look. The skin is pale, cyanotic, sometimes marbled, cold to the touch. Pulse – up to 50-60 per minute, weak filling. Breathing rare – up to 8-12 per minute, superficial.

Severe : Unconscious, convulsions, vomiting. The skin is pale, cyanotic, cold to the touch. The pulse is reduced to 36 per minute, weak filling. Breathing is rare, superficial – up to 3-4 per minute. There are severe and widespread frostbite up to glaciation.

First Aid

When giving first aid, remember not to:

• Rubbing damaged areas with snow. Not only will this worsen frostbite, but it can also lead to tissue damage and infection.
• Keep warm with dry heat, such as an open fire or a hot stove or radiator, as this warming increases the risk of irreversible damage.
• Give a large amount of alcohol or coffee, as with such a “hit” on the blood vessels, they may not withstand.
• Open blisters on frostbitten areas.

The first step is to place the victim in a warm place, take off his icy, wet clothes and call an ambulance. Before her arrival, the victim must be warmed. The best (though not always acceptable) way to warm a person is with your body. And better – two (top and bottom).

In case of frostbite of the 1st degree, the chilled areas should be warmed to redness with warm hands, light massage, rubbing with a woolen cloth, breathing, and then apply a cotton-gauze bandage.

In case of severe hypothermia, it is best to warm the victim in a warm bath (about 38 degrees, the water can be checked with your elbow, as when bathing a child), but do not immerse the victim entirely, but start from frostbitten places, warming in water for 20-30 minutes). In no case should you warm in a hot bath, as this can harm even more!

A heat-insulating bandage can be applied to the affected surface: a layer of gauze, a thick layer of cotton wool, another layer of gauze, and on top of oilcloth or rubberized cloth.

The affected limbs are fixed with the help of improvised means: a board, a piece of plywood, thick cardboard, applying and bandaging them over the bandage.

Also warm drink, hot liquid food (broth, cocoa, tea) will not hurt the victim.0009

• Do not drink alcohol – alcohol intoxication (like any other) actually causes a great loss of heat, while at the same time giving the illusion of warming. An additional factor is the inability to focus on the signs of frostbite.
• Do not smoke in the cold – smoking reduces peripheral blood circulation, and thus makes the limbs more vulnerable.
• Wear loose clothing. Wear multiple layers so that the air between them helps keep you warm. Do not go outside without mittens, hats, scarves.
• Watch your shoes. Tight shoes, lack of insoles, damp and dirty socks are often the main cause of frostbite. Warm insoles should be put in boots, and woolen ones should be worn instead of cotton socks.
• Do not wear metal jewelry (including gold, silver) in the cold – rings, earrings, etc. The metal cools much faster than the body, resulting in pain and cold injuries. In addition, the rings on the fingers impede the normal circulation of blood.
• Do not wet the skin – water conducts heat much better than air. Don’t go out into the cold with wet hair after a shower.
• Keep out of the wind – the chance of frostbite in the wind is much higher.
• Going for a walk in the cold, sometimes it is enough to have a hearty meal. It may also be useful to bring along a spare set of mittens, socks, and a thermos of hot tea.
• Remember, if you suddenly feel signs of hypothermia or frostbite in the cold, you should immediately go to the nearest warm room to warm up and inspect areas potentially vulnerable to frostbite. Try not to refrigerate re-damaged areas, as this can lead to more damage.
• After returning from the street, if you find an injured area, immediately consult a doctor. Left unattended, frostbite can lead to serious consequences, up to gangrene and loss of a limb.

Take care of yourself.

Frostbite, Reminders, Prevention

What is frostbite and its severity

Frostbite is the effect of low temperature on the human body, due to which the skin and underlying tissues are affected. This is a dangerous process that can lead to limb amputation. Such a cold injury should be treated as quickly as possible to prevent the development of irreparable complications.

Frostbite is divided into 4 degrees of severity depending on the depth of tissue damage. All types of injury differ in symptoms and treatments.

Frostbite classification:

• 1st degree is characterized by blanching of the skin area, and after warming – reddening of the affected area. In this stage of frostbite, only the upper layers of the skin are affected. The frostbitten area may tingle, hurt, or swell. Local hypothermia develops;
• The 2nd stage of frostbite includes all the symptoms of the 1st degree, but blisters are added to them, as with burns, with transparent contents. There are no scars in place of the blisters;
• 3rd degree is characterized by necrosis of the entire thickness of the skin. With frostbite of this severity, the blisters are filled with bloody contents. The victim needs urgent treatment in a hospital;
• 4th degree is the most severe. With it, the deepest damage to the skin and underlying tissues occurs. The first signs of deep frostbite – the damaged area becomes black. It has to be surgically removed, and a frostbitten leg or arm often needs to be amputated.

First aid for frostbite depends on the severity of the injury. First of all, it is necessary to determine the degree of frostbite in the patient in order to understand how to help him correctly.

How to understand that a person has frostbite and needs help

First aid for frostbite should be provided as early as possible to avoid the development of more serious conditions. In order for emergency care to arrive in a timely manner, you need to know what the first signs of frostbite look like. It is necessary to provide assistance to the victim in such cases:

• the patient complains of severe pain in the limbs, knees or other affected parts of the body;
• the skin on the affected areas has a marble tint, there is a feeling of tingling and burning in the frostbite;
• the victim has a severely low body temperature;
• limbs may swell on cooling;
• blisters appear on the skin with clear or bloody contents;
• with severe freezing, the victim is disoriented in space or is unconscious on the street.

Doctor’s advice. If you notice a person with such symptoms on the street in frosty weather, immediately call an ambulance and try to provide first aid to the victim before the arrival of specialists. And they must be taken into account, otherwise you can seriously harm the victim. The provision of first aid (PMP) for hypothermia and frostbite begins with the fact that the patient, as soon as possible, is transferred to a warm, safe place. Then you need to call an ambulance and try to alleviate the condition of the victim as much as possible. Properly rendered first aid for burns and frostbite can prevent the development of complications.

The algorithm of actions when providing first aid is as follows:

• take the patient to a warm place, remove all wet, cold clothes and shoes from him;

Cover

• with a blanket and drink a warm drink. Give the patient tea or milk, but coffee or alcohol is not allowed;
• Examine the affected areas and determine the severity of frostbite. With mild frostbite, you can do a gentle massage of the damaged areas of the skin, but only if there are no blisters;
• Apply a clean bandage to damaged areas with blisters and wait for the arrival of doctors;
• help with burns, frostbite of the 3rd-4th degree is more complicated. The patient needs to be given an anesthetic, calm, apply a sterile bandage to the affected area.

The right treatment for frostbite can save a person’s life. It is important to follow not only the procedure, but also the rules for providing assistance with hypothermia.

First aid rules for frostbite and hypothermia:

• the person providing first aid must do everything carefully and quickly so as not to harm the patient;
• should not be done with frostbite rubbing with alcohol tinctures, oils or other solutions;
• you can not open the bubbles yourself;
• should not be used for heating with a battery, hot bath, heating pad or open flame.

First aid is an important step in the treatment of frostbite of different stages. The above memo can be useful to everyone. By following the correct sequence of actions, you can alleviate the condition of the victim. But it should be remembered that careless and illiterate actions can harm the victim. Help with frostbite should be quick and correct.

In what situations is it necessary to urgently call an ambulance? But there are situations when it is necessary. It is necessary to involve specialists immediately in the following situations:

• severe condition of the victim: lack of consciousness or disorientation;
• if frostbite of limbs and other parts of the body has occurred due to winter injuries in the mountains;
• frostbite 3rd-4th degree of severity;
• severe hypothermia, body temperature does not return to normal for a long time;
• lack of sensation in the affected area;
• severe pain;
• large affected area.

In such situations, you need to call an ambulance as soon as possible so that doctors can provide high-quality specialized care to the patient.

Is it possible to rely on folk remedies for frostbite

People often turn to traditional medicine for help if there are no suitable medicines at hand. But not everyone knows in which situations such methods of treatment are beneficial, and in which they are harmful. Folk methods of treatment can only cure mild degrees of injury.

Calendula, chamomile or aloe compresses are effective as first aid for frostbite. They relieve inflammation and stimulate the healing of affected skin areas. But it is impossible to cure frostbite with traditional medicine alone, especially if the damage is serious. At 3-4 degrees, inpatient treatment is necessary, since there is a high risk of infection of the wound or an increase in the area of ​​​​the lesion.

Methods of treatment are chosen depending on the severity of frostbite. If there is an opportunity to consult a doctor, it is better to do it right away.

Prevention of frostbite

Prevention is always better and easier than cure. To protect yourself and your family from frostbite, it is enough to follow simple precautions when going outside in frosty weather.