Treatment of Frostbite

Frostbite occurs (usually to the extremities especially fingers and toes, but can occur in hands, feet and legs) when exposed to subzero temperature and tissue temperature drops below 0°C. Ice crystals are formed which subsequently distorts and destroys the cellular architecture. If not treated very promptly there may be loss of the affected part due to death of cells and the tissues.

The most effective treatment of frostbite is rapid and complete thawing of affected frozen tissues by immersion in circulating water at 37°–40°C. A common error is the premature termination of thawing, because the reestablishment of perfusion is intensely painful and parenteral narcotics will be necessary with deep frostbite. The sign of good prognosis is formation of early, large clear distal blebs and bad prognostic indication is formation of smaller proximal dark hemorrhagic blebs.

The principle of treatment of frostbite can be summarized into three stages before thawing, during thawing and after thawing.

To do Before thawing:

First of all remove the patient from environment (usually cold and dump). After removing from environment, refreezing and partial thawing should be prevented. Stabilize core temperature and treat hypothermia which usually accompanies frostbite. Frozen parts should be properly protected and no friction or massage allowed.

To do During thawing:

Give parentaral analgesics and ketorolac, and also give ibuprofen 400 mg orally. Immerse the frozen part in 37°–40°C (temperature should be monitored with thermometer) circulating water containing an antiseptic soap until there is distal flush (which usually takes 10–45 min). Ask the patient to gently move affected part and if there is refractory pain reduce water temperature to 35°–37°C.

To do After thawing:

Gently dry the affected part, protect it and elevate it. Put cushion in between toes or fingers. If clear vesicles are intact, aspirate sterilely and if broken, debride and dress with antibiotic or sterile aloe vera ointment. Keep giving ibuprofen 400 mg orally (12 mg/kg per day) 2-3 times a day. If there are hemorrhagic vesicles leave them intact to prevent desiccation and infection. Give prophylaxis for streptococcal prophylaxis. Continue giving hydrotherapy at 37°C.

Any decision regarding debridement or amputation should be deferred until there is clear evidence of demarcation, mummification, and sloughing in the affected parts unless there is infection when amputation may have to be done early. Magnetic resonance angiography can demonstrate the line of demarcation earlier than clinical demarcation.

Delayed affects of frostbite include nail deformities, cutaneous carcinomas, and epiphyseal damage (damage to the bone ends due to incomplete growth of bones in children) in children.

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