Definitions
Superficial frostbite is similar to first and second degree burns. These patients present with clear or no vesicles in the affected areas and have limited dermal involvement.
Deep frostbite may also be described as third and fourth degree. The vesicles tend to be hemorrhagic and subdermal injury is present. Injury may extend to tendon and bone, and a thick black eschar develops over the 1-2 weeks following a deep frostbite injury.
Acute frostbite is frostbite that presents for definitive care within 24 hours of rewarming, and that has not been through multiple freeze/ thaw cycles.
Delayed frostbite presentation occurs greater than 24 hours post-rewarming.
This distinction is important because it impacts our management options for patients with frostbite.
Basic care of frostbite
First and foremost, the patient needs to be warm! Systemic hypothermia is more detrimental than cold injury to soft tissues.
Rewarming should occur using a warm water bath. Rewarming is painful, so patients will often require pain control during this process.
The key principles of basic care for frostbite wounds are the following:
- Gentle daily cleansing
- Mechanical protection with padding/ splints/ elevation
- Topical aloe vera to affected areas
- NO prophylactic antibiotics (just like burns!)
In addition, our pharmacologic management includes:
- Scheduled ibuprofen
- Pentoxyfilline
- Pain management
- Acute pain with opioids as appropriate
- Neuropathic pain is common as well, use of GABA analogues for this
Thrombolytics- yes or no?
Our current practice is to urgently obtain a 99Tc scan from nuclear medicine and initiate IV tPA if digits/ hands/ feet are threatened based upon the scan findings. In addition, the patient absolutely must be less than 24 hours from rewarming, not have more than a 24 hour period of “freeze” AND not have a contraindication to TPA.
The OSUWMC Burn Center Thrombolysis protocol can be found here: