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Treatment
of Frostbite
Introduction Frostbite
is the freezing of tissue and may involve only superficial tissues or may extend
to the bone. ·
*Poor or inadequate insulation
from the cold or wind; ·
*Immersion; ·
*Altitude; ·
*Impaired circulation from tight
clothing or shoes; ·
*Fatigue; ·
*Injuries; ·
*Circulatory disease; ·
*Poor nutrition; ·
*Dehydration; ·
*Hypothermia; ·
*Alcohol or drug use; and ·
*Use of tobacco products.
between
the cells, and by resulting changes in electrolyte concentration within the
cells. Damage occurs
during the freezing process. Further damage occurs during reperfusion of
frostbitten tissue. Frostbite
is frequently seen in and
treated by the patient at home. Occasionally, it is severe enough to warrant
transport to a medical
facility for evaluation and treatment. Seldom will it be necessary for emergency
medical personnel
to perform in-field rewarming for deep frostbite. It may, however, be necessary
to treat patients
with superficial frostbite who have sustained other injuries, (e.g. a motor
vehicle crash patient
who has been exposed to sub-zero temperatures while awaiting the arrival of
rescue and medical
personnel).
General
Points A).
Hypothermia and other life threatening conditions may be present in the patient
with frostbite
and must be evaluated and treated immediately. B).
When caring for a patient in extremely cold temperatures, take great care to
prevent hypothermia.
Protect tissues from becoming frostbitten, and already frostbitten tissues from worsening. C).
If the decision has been made not to rewarm frostbitten tissue in the field, it
should be protected,
during transport, from additional injury and temperature changes. D). Superficial
frostbite affects the dermis and shallow subcutaneous layers of the part exposed,
and is recognized by white or gray colored patches. The affected skin feels
firm, but
not hard. The skin initially turns red and, once frostbitten, is not painful. No
deep tissue loss
will occur when treated with rapid rewarming. E.) Deep
frostbite affects the dermal and subdermal layers and may involve an entire
digit or body
part. The skin feels hard and cold and the affected tissue is white or gray. A
pulse cannot
be felt in the deeply frostbitten tissue and skin will not rebound when pressed. F).
Large blisters on the frostbitten area indicate that deep frostbite has
partially or totally thawed. G.)
Treatment of deep frostbite may be painful and is best accomplished in a medical
facility. Before
electing to rewarm frostbitten tissue in the field, advice should be sought by
radio or telephone,
if possible, from a physician who is knowledgeable about field treatment of frostbite. If
transport time will be short (1-2 hours at most), the risks posed by
improper rewarming
or refreezing outweigh the risks of delaying treatment for deep frostbite. If
transport will be prolonged (more than 1-2 hours), frostbite will often thaw spontaneously.
It is more important to prevent hypothermia than to rewarm frostbite rapidly in
warm water. This does not mean that a frostbitten extremity should be kept in
the cold to prevent
spontaneous rewarming. Anticipate that frostbitten areas will rewarm as a consequence
of keeping the patient warm and protect them from refreezing at all costs. H).
Tissue which is thawed and then refrozen almost always dies. Consequently, the
decision to thaw
the frostbitten tissue in the field commits the provider to a course of action
which may involve
pain control, maintaining warm water baths at a constant temperature, and protecting
the tissue from further injury during rewarming and eventual transport. Once an extremity
is rewarmed in the field, it should not be used for ambulation. I).
In most cases, the patient should be transported as promptly as circumstances
allow. When frostbite
is mild and is not complicated by other injuries, and there are resources
available to care
for the patient without transport, it may be appropriate not to transport the
patient to a medical
facility. This should only be done in consultation with a physician who is knowledgeable
about the treatment of frostbite. The decision not to transport should be carefully
documented by the prehospital provider, as with any such decision. J.)
Cautions: 1.
do not rub the frozen part; 2.
do not allow the patient to have alcohol or tobacco; 3.
do not apply ice or snow; 4.
do not attempt to thaw the frostbitten part in cold water; 5.
do not attempt to thaw the frostbitten part with high temperatures such as those generated
by stoves, exhaust, etc.; and 6.
do not break blisters which may form. K).
Frostbitten tissues should be handled extremely gently before, during, and after
rewarming L).
When moving patients with frostbite by helicopter, care must be taken to protect
the patient
from additional exposure to cold due to the increased windchill caused by rotorwash.
Rotorwash can be minimized if the helicopter shuts down while loading and unloading.
If this is unsafe from an aviation standpoint, the patient must be packaged carefully
to avoid any additional loss of heat or skin exposure that can cause or worsen frostbite
and hypothermia. FROSTBITE First
Responder/Emergency Medical Technician-I, II, III/Paramedic Small/Bush
Clinic Evaluation
and Treatment A.
Anticipate, assess and treat the patient for hypothermia, if present. B.
Assess the frostbitten area carefully since the loss of sensation may cause the
patient to be unaware
of soft tissue injuries in that area. C.
Obtain a complete set of vital signs and the patient's temperature. D.
Remove jewelry and clothing, if present, from the affected area. E.
Obtain a patient history, including the date of the patient's last tetanus
immunization. F.
If there is frostbite distal to a fracture, attempt to align the limb unless
there is resistance. Splint
the fracture in a manner which does not compromise distal circulation. G.
Determine whether rewarming the frostbitten tissue can be accomplished in a
medical facility.
If it can, transport the patient while protecting the tissue from further injury
from cold
or impacts. H.
If the decision is made to rewarm frostbitten tissue in the field, you should
prepare a warm water
bath in a container large enough to accommodate the frostbitten tissues without
them touching
the sides or bottom of the container. The temperature of the water bath should
be 99°
- 102 °F
(37-39° C). Generally
patients with frostbite do not require opiates for pain relief; they
occasionally need
non-opiate pain medication or anxiolytics. If possible, consult a physician
regarding the
administration of oral analgesics, such as acetaminophen, ibuprofen or aspirin.
Aspirin or
ibuprofen may help improve outcomes by blocking the arachadonic acid pathway. Immersion
injury or frostbite with other associated injuries may produce significant edema and
high pain levels. These patients may need opiate pain medications for initial
treatment. In
this case, advanced life support personnel should administer morphine or other
analgesics in
accordance with physician signed standing orders or on- line medical control. I. A
source of additional warm water must be available. J.
Water should be maintained at approximately at 99-102 °F (37-39 oC)* and gently circulated around
the frostbitten tissue until the distal tip of the frostbitten part becomes
flushed. K.
Pain after rewarming usually indicates that viable tissue has been successfully
rewarmed. L.
After rewarming, let the frostbitten tissues dry in the warm air. Do not towel
dry M.
After thawing, tissues that were deeply frostbitten may develop blisters or
appear cyanotic. Blisters
should not be broken and must be protected from injury. *
Please note that the new temperatures are
lower than previously recommended, this decreases pain for the patient, while
only slightly slowing rewarming.
Avoid
putting undue pressure on the affected parts. O.
Rewarmed extremities should be kept at a level above the heart, if possible. P.
Protect the rewarmed area from refreezing and other trauma during transport. A
frame around
the frostbitten area should be constructed to prevent blankets from pressing
directly on
the injured area. Q.
Do not allow an individual who has frostbitten feet to walk except when the life
of the patient
or rescuer is in danger. Once frostbitten feet are rewarmed, the patient becomes nonambulatory. FROSTBITE Hospital The
following section covers general points and gives an overview of hospital
treatment for frostbite.
This section is not intended to give complete information. Medical care
providers who are
not experienced in the management of frostbite should consult a physician who
regularly manages
frostbite and should consider transfer of the patient to a facility experienced
in the care of frostbite after the
patient has been stabilized, if possible. Evaluation
and Treatment A.
Anticipate hypothermia. Assess and treat accordingly. Treat moderate to severe hypothermia
before treating the frostbitten areas, but don’t take so long that the
extremities thaw
spontaneously. It may be possible to thaw the extremities and treat hypothermia simultaneously,
by combining peritoneal dialysis with rapid rewarming in a tub. B.
Assess frostbitten areas carefully, since the loss of sensation may cause the
patient to be unaware
of soft tissue injuries in that area. C.
Obtain a complete set of vital signs and the patient's temperature D.
Obtain a patient history, including the date of the patient's last tetanus
immunization if possible.
Give anti-tetanus therapy when indicated. E.
Remove jewelry and clothing, if present, from the affected area. F. Give aspirin or ibuprofen. G.
Water should be maintained at approximately 99-102°F (37-39oC) and gently circulated around
the frostbitten tissue until the distal tip of the frostbitten part becomes
flushed.8 H.
Pain after rewarming usually indicates that viable tissue has been successfully
rewarmed. I.
Pain relief: ·
*Generally patients with frostbite
do not require opiates for pain relief; they occasionally need
anxiolytics or aspirin. ·
*Sympathectomy has been performed
in some patients. Patients who received sympathectomy
have reported less pain, had a marked decrease in swelling, and tissue separation
occurred earlier and was more distal. Treatment with this method is still controversial,
and the results are variable. ·
*Immersion injury, or frostbite
with other associated injuries, may produce significant edema
and high pain levels. These patients may need epidural blockade (occasionally for
several days). J.
After re-warming, let the frostbitten tissues dry in the warm air. Do not towel
dry. K.
After thawing, tissues that were deeply frostbitten may develop blisters or
appear cyanotic. L.
Do not allow an individual who has frostbitten feet to walk except when the life
of the 8
Please note that the new temperatures are
lower than previously recommended. This decreases pain for the patient,
while only slightly slowing rewarming. patient
or rescuer is in danger. Once frostbitten feet are rewarmed, the patient becomes nonambulatory. M.
Wound Care: ·
*After thawing, if the injury is
deep, use sterile sheets with cradles over extremity to prevent
additional trauma. Cotton pledgets between affected fingers/toes without excessive
pressure on the digital vessels helps prevent decreased circulation. ·
*The clinician must decide if the
extremity should be elevated (e.g. hanging frostbitten arms
in stockinette dressings) to reduce swelling or kept at the level of the heart
to assist blood
flow in the small arterioles. Avoid keeping the tissues in a dependent position. Examine
the blood flow into the extremity at consistent intervals. ·
*Blisters are generally left
intact (usually sterile). Some experts aspirate small blisters that
contain reddish or bluish material using sterile technique to remove toxins. ·
*Treatment is open; no wet
dressings, ointments, occlusive dressings etc. If the patient has
severe pain, silver nitrate 0.5% can be used on the frostbitten area. If there
are open wounds
secondary to the freezing injury 1% silver sulfadizine cream may be used. ·
*Whirlpool baths twice daily. The
water temperature should be body temperature (98oF
/ 37oC)
which allows the part to be cleansed and removes superficial bacteria without surgical
debridement. Surgical soaps should be used in the baths (e.g. Betadine®,
etc.). ·
*When an eschar (scab) forms
(usually on day 10-14), it is split manually to relieve stiffness.
Patients should perform bedside exercises of all small joints. ·
*Delay debridement or amputations
for at least 21 days, unless it is absolutely necessary. There
is less tissue retraction after this time (Premature amputation may cause the
loss of
up to 3-5 cm) ·
*Cover the wounds as soon as
possible with split thickness (mesh) skin grafts ·
*Antibiotics are not usually
necessary unless deep infection is diagnosed. ·
*Hyperbaric oxygen has not yet
been shown to be beneficial in the final outcome of frostbite,
but may hasten wound healing. M.
If the lower extremity is frozen for a great length of time, the patient may
develop a compartment
syndrome, most commonly in the anterior tibial compartment and the foot. If compartment
pressures are greater than 37-40 mm Hg, the skin may need to be split or the patient
may require a fasciotomy. Delay in performing fasciotomies can be disastrous. useful). O.
Smoking is discouraged as it causes small arterioles to constrict; alcohol is
permitted. P.
Biofeedback may increase hand and foot circulation. Q.
Dibenzyline 10 mg once daily, which can be increased up to 20-60 mg, helps to
treat vasospasm
and is a very effective alpha-adrenergic blocking agent. R.
TPA has not been found to be useful in these patients. S.
If there are associated fractures and dislocations: ·
*Reduce dislocations immediately
after thawing. ·
*Treat fractures conservatively
until thawed and placed in splint. Reduction or open reduction
can be done afterwards. These injuries tend to do poorly as the vascular blood supply
was embarrassed twice. T.
Children’s’ cartilage is more susceptible to cold injury. This is especially
true in the carpal and
tarsal bones. This is due to the epiphyseal growth plates being still open.
Injury may occur
in a child at any age at which the cartilage still persists. U.
If treatment has failed, and an amputation is needed, do modified guillotine
amputations, even
in the digits.
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