Frostbite

Epidemiology
Frostbite is the inability to physiologically
compensate for cold that produces injury.
Duration of exposure, humidity, wind, altitude,
clothing, medical conditions, behavior, and
individual variability are contributing factors.
Inadequate clothing is the most preventable cause of
cold related injuries with exposed head and neck
accounting for 80% of heat loss.
Alcoholic or drug-intoxicated persons acount for the
majority of frostbite cases in the US.

Epidemiology
Disease states as atherosclerosis, arteritis,
hypovolemia, diabetes, vascular injury may
predispose to cold-related injury.
Dark-skinned people and those from
warmer climates are more susceptible to
frostbite.
Local cold-related injuries are classified
into nonfreezing and freezing injuries

Nonfreezing cold
injuries:chilblains and trench foot
Chilblains is characterized by mild but uncomfortably
inflammatory lesions of the skin of bared body areas
caused by intermittent exposure to damp, nonfreezing
ambient temperatures.
Hands, ears, lower legs, and feet are most commonly
affected.
Cutaneous manifestations which appear 12 h after
exposure include localized edema, erythema, cyanosis,
plaques , nodules , ulcerations, and vesicles.

Chilblains
Pt may complain of pruritus and burning
paresthesias.
Rewarming may result in formation of
tender blue nodules.
More common in children and women ,
especially the ones with Raynaud
phenomenon.

Trench Foot
It involves direct injury to soft tissue sustained from
prolonged cooling and is accelerated by wet
conditions
Peripheral nerves are more sensitive to this form of
injury.
It develops over hours to days and is reversible
initially.
On physical exam, the foot is pale, mottled,
anesthetic , pulseless, and immobile which does not
change after rewarming.

Trench Foot
A hyperemic phase begins within hours after
rewarming and is associated with severe burning
pain and reappearance of proximal sensation.
Perfusion returns to the foot over 2 to 3days, edema
and bulla form, and the hyperemia may worsen.
In severe cases, tissue sloughing and gangrene may
develop.
Hyperhidrosis and cold sensitivity are common late
features and may persist for months to years.

Treatment
Treatment of chilblains is supportive affected skin should be rewarmed, gently
bandaged, and elevated. -Some European
studies suggest
nifedipine,
pentoxifylline, or an oral analogue of PGE1,
limaprost.
-Topical corticosteroids or
even oral
corticosteroids have been
shown to be useful.

Treatment
Treatment for trench foot includes
-keeping warm, good boot fit
changing out wet socks several times
a day
-dry, elevate feet
pentoxifylline or limaprost can be used

Freezing Cold injuries:Frostnip

and frostbite
At 10 0Cof skin temperature cutaneous blood flow
becomes negligible, with occurrence of 5-10 min cycles
of vasodilation and vasoconstriction.
As cooled blood is carried back from the extremities, the
core temperature falls.
The body attempts to maintain thermal integrity by
shutting down flow to the coldest extremities.
This begins the phase I of frostbite with ice crystal
formation in the extracellular space that leads to an
intacellular dehydration and hyperosmolarity by pulling
of fluids.

Freezing cold injuries:Frostnip

and Frostbite
As proteins get denatured , intracellular ice
crystals form.
Phase II is characterized by reperfusion injury as
the extremity gets rewarmed which leads to
endothelium leakage, leakage of destructive
prostaglandins and oxygen free radicals,
vasoconstriction an arteriovenous shunting, and
finally necrosis and gangrene.

Freezing Cold Injuries:Frostnip

and Frostbite
Frostbite can be divided in three zones:
zone of coagulation is the most severe, usually
distal and irreversible
zone of hyperemia is the most superficial,
typically proximal with the least cellular damage
and recovers with no treatment.
zone of stasis is characterized by severe, but
possibly reversibly cell damage that can benefit
from treatment.

Clinical features
Classification of frostbite
-first degree is characterized by partial skin
freezing, erythema, mild edema, lack of blisters,
and occasional skin desquamation, has excellent
prognosis.
-second degree is characterized by fullthickness skin freezing, formation of substantial
edema over 3 to 4 h, and formation of clear
blisters that desquamate to form black eschars and
has good prognosis.

Clinical Features
Classifications (continued) third degree injury is
characterized by damage that extends into the
subdermal plexus and leads to formation of
hemorrhagic blisters, skin necrosis and a blue-gray
discoloration of skin, has poor prognosis -fourth
degree injury is characterized by extension into
subcutaneous tissues, muscle, bone, and tendon,
there is little edema, nonblanching cyanosis, bloody
blebs, has extrememly poor prognosis.

Treatment in the field

Remove wet and
constrictive clothing.
Elevate and wrap in dry
sterile gauze the involved
extremities.
Rapid rewarming if rapid
access to hospital
400 to 420 C clean water
should be used

There is controversy with

regards to debridement of
clear blisters on the field
Pain management should
start with NSAIDS to
counteract the arachidonic
acid cascade, in addition
to opioids
Smoking should be
discouraged

Treatment in the ED
Injured extremity should
be placed in circulating
water at a temperature of
400 to 420 C for
approximately 10-30 min
until the distal extremity is
pliable and erythematous
Pain should be treated
with parenteral antibiotics
Clear blisters should be
debrided or aspirated

Hemorrhagic blisters
should not be debrided
Alo vera cream should be
applied to the blisters
Role of antibiotics is
unclear.
Staph aureus, Staph epi,
beta-hemolytic Strep,
Pseudomonas, and
Enterococus are important
pathogens.

Treatment in ED
Infection prophylaxis
using topical
bacitracin is as good
as IV penicillin.
Tetanus immunization
status should be
assessed.
Ibuprofen

Early surgical
intervention is not
indicated in treatment
of frostbite
Amputation if needed
within 3 weeks

Disposition
Admit all but the most isolated and
superficial frostbite cases.
Homeless or elderly should never be
discharged into subfreezing temperatures.
If hospital is not equipped to treat the
degree of severity, transfer pt after the
initial rewarming.

Thank

you!