Frostbite: hospital management

Article Overview: 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 Apr 22;3:7. doi: 10.1186/2046-7648-3-7. PMID: 24764516; PMCID: PMC3994495.

The primary rule in providing assistance for frostbite is the prompt delivery of the affected individual to a medical facility. Upon hospitalization, it is necessary to remove the patient’s clothing and assess their general condition, including:

Presence/absence of consciousness.
Presence/absence of productive contact with the patient.

Simultaneously, it is recommended to free the fingers from rings and the wrists from watch straps and bracelets, as significant swelling can be expected after the thawing of extremities. Subsequently, a comprehensive examination of the patient should be conducted to identify visible injuries due to hypothermia. It is crucial to assess the degree of hypothermia. In the case of deep or moderate hypothermia, it is vital to achieve an internal body temperature above 35 degrees Celsius. Correction of vital functions should be performed before treating frozen parts of the body or limbs.

It is extremely important to gather a detailed medical history:

Duration of exposure to cold (more or less than 24 hours).
Wind chill.
Wet/dry exposure to cold air.
Immersion in water.
Duration and adequacy of thermal protection usage.

All information collected about the cold injury and the warming time should be carefully documented, as it will largely determine the plan for subsequent treatment. The authors of the article Frostbite: a practical approach to hospital management, Charles Handford et al., recommend the widespread use of clinical photography and diagrams to document the depth of damage, facilitating monitoring of the dynamics of damaged tissues’ condition.

Classification

There are several classifications of frostbite:

According to the mechanism of frostbite development.
According to the depth of tissue damage.
According to the degree of frostbite.

Cauchy et al. propose a convenient classification, including 4 degrees of injury. In the first degree of frostbite, hospitalization is not required as changes are completely reversible. For the second, third, and fourth degrees, hospitalization is mandatory, as amputation of the affected limbs may be necessary.

Charles Handford et al. propose the following hospital management for patients with frostbite:

Warming in a jacuzzi for 15 to 60 minutes at a temperature of 38 degrees Celsius with the addition of antiseptic solutions (povidone-iodine or chlorhexidine) until a burgundy-purple color appears in the affected tissues.
Oral or parenteral rehydration with warmed fluids, as cold diuresis is influenced by the suppression of antidiuretic hormone.
Selective drainage of epidermal blisters which must be performed strictly in hospital conditions, often under general anesthesia.
Aloe vera gel to be applied to thawed areas of the skin before dressing.
Application of immobilizing splints and elevated positioning of the lower extremities with protective padding between the toes.
Systemic antibiotics are recommended in case of infection and severe trauma.
Tetanus toxoid should be administered according to standard recommendations.
Analgesia, NSAIDs (non-steroidal anti-inflammatory drugs), or opioids: Ibuprofen up to 2400 mg/day and aspirin 300 mg/day are recommended due to the significant pain associated with warming, blister drainage, and dressing.

Visualization

For adequate surgical wound treatment and amputations, information about the depth of tissue and vascular damage in the affected person is necessary. The most reliable visualization methods include:

Magnetic Resonance Angiography (MRA) directly visualizes occluded vessels and surrounding tissues, providing a clearer differentiation of ischemic tissues.
Scintigraphy is a three-phase bone scanning with technetium-99 (99Tc), performed on the second day after the injury, which shows an 84% accuracy in determining the level of amputations.

Thrombolysis

Administering thrombolytic agents parenterally or intra-arterially within 24 hours reduces the risk of finger amputation. Thrombolysis beyond 24 hours, considering other injuries, should be weighed against the risk of bleeding. rTPA (tissue plasminogen activator) and heparin are used for thrombolysis.

Iloprost

Iloprost, a prostacyclin analog, has vasodilatory properties and inhibits platelet aggregation, adhesion, and activation. It is administered parenterally at a rate of 0.5 to 2 ng/kg/min for 5–8 days, advantageously applicable after 24 hours post-injury compared to rTPA.

Surgical Treatment

Operative intervention requires careful planning, as premature amputation increases disability and leads to loss of function. Fasciotomy on distal parts of the extremities may be necessary in some cases after thawing. Most amputations can be performed 6–12 weeks after demarcation of ischemic tissues.

Tissue Protection

Not only the immediate trauma but also post-frostbite neuropathy can lead to functional impairments. It is crucial to take measures to protect tissues both before and after amputation:

Selection of dressings or footwear during demarcation.
Custom footwear post-amputation, as the biomechanics of the foot/hand can be drastically altered. The normalization of limb function has long-term implications, ultimately reducing the risk of secondary injuries.

Hyperbaric Oxygen Therapy (HBOT)

Although HBOT increases oxygen delivery to tissues and reduces swelling in damaged tissues, its effectiveness is debatable due to insufficiently convincing data.

Long-term Outcomes

Long-term outcomes of frostbite are inadequately studied. Individual tissue susceptibility to cold is a crucial factor. Cold sensitization in recovered tissues makes it impossible for patients to tolerate cold exposure on previously frostbitten areas. Patients should be informed about these risks. Statistical data provided by Charles Handford et al. is illustrative:

53% had hypersensitivity to cold.
40% suffered from numbness of fingers.
33% confirmed a decrease in touch sensitivity.

Among other remote consequences:

Chronic pain in recovered frostbitten areas is the most common complaint, often persisting throughout life.
Local osteoporosis and loss of subchondral bone structure, reflecting the severity of vascular damage.
Early arthritis in bone-affected areas in children.
Secondary malignancy in areas of affected skin.

Conclusion

Frostbite is a severe trauma requiring a multidisciplinary approach.
Young, active individuals who expose themselves to risk are most commonly affected by frostbite.
Frostbite, as a mass trauma, becomes especially relevant during military operations in cold conditions, necessitating hospitals' thorough preparation for a massive influx of casualties.
Timely pre-hospital and adequate hospital care minimize tissue loss and ensure the preservation of function in affected limbs and areas of the patient’s body.