FROSTBITE MANAGEMENT AT

EMERGENCY DEPARTMENT
Kristina A. Wiraputri
Emergency Department EKA Hospital Pekanbaru
2nd ASM on EM - Malang 2014
Topics
 Definition
 Epidemiology
 Pathophysiology
 Clinical Presentation
 ED Evaluation
 ED Management
 Disposition
 Common Pitfalls
Definition
 the freezing and crystallizing of fluids in the
interstitial and cellular spaces as a
consequence of prolonged exposure to
freezing temperatures

Mechem CC. Frostbite. http://emedicine.medscape.com/article/926249-

overview. updated November 2014
Epidemiology
 Mostly in military personnel (until late 50s)
 Winter
 Novel causes

◦ Homelessness
◦ Work related injuries
◦ Recreational
Risk Factors
 Inadequate shelter
 Inadequate or constrictive clothing
 Winter season
 Wind chill factor
 High altitude
 Prolonged exposure to cold
 Prolonged exposure to moisture
 Immobilization
 Malnutrition and exhaustion
 Previous cold injury
 Acclimatization to tropical climates
 Improper behavioral response to cold ambient temperature
 Extremes of age
 Homelessness
 Altered mental status
 Exposure to drugs with vasoconstrictive effects
 Exposure to chronic hand or arm vibration
• negligible cutaneous blood flow <00C
• skin starts freezingfrostbite injury cascade initiated
• neurapraxia occurs 100C
• loss of cutaneous sensation
• vasoconstriction interrupted by rhythmic bursts of vasodilatation occurring <150C
3-5 times per hour and lasting 5-10 minutes (hunter’s response)
• Maximal vasoconstriction reached 150C
• Cutaneous blood flow 20-50 ml/min
(1) Pathophysiology
Pathophysiology (2)

 Prefreeze State
◦ Tissue cooling
◦ Increased viscosity
◦ Capillary constriction-dilation cycle
 Frozen State
◦ Extracellular ice crystal formation
◦ Intracellular dehydration & hyperosmolarity
◦ Fluid shifts across cell membranes
◦ Intracellular ice crystal formation
Pathophysiology (3)

 Ischemic and Vascular Complications

◦ Reperfusion injury
◦ Endothelium leakage
◦ Coagulation from vascular stasis
◦ Leakage of destructive prostaglandins & oxygen
free radicals
◦ Vasoconstriction and arteriovenous shunting
◦ Necrosis demarcation and gangrene
Clinical Presentation
 Limited to nose, ears, face, hands and feet
 Other regions reported:

◦ Penis
◦ Scrotum
◦ Cornea
ED Evaluation (1)

 Survey for systemic hypothermia

 Detailed history
◦ Exposure temperature & duration
◦ Wind & moisture condition
◦ History of thawing & refreezing
◦ Previous frostbite injury
◦ Health-related risk factors
 Physical examination
◦ Core temperature
◦ Neurologic &
 Laboratory studies
ED Evaluation (2)

 Physical examination
◦ Core temperature
◦ Neurologic & vascular exam
◦ Wound description
 Laboratory studies
◦ Not for frostbite per se
◦ Evaluating concomittant illness or associated
conditions
 Radiology studies
◦ Limited for trauma
ED Management (1)
 Rapid rewarming
◦ Gently circulating water at 40-42 0C for 15-30 mins or until
thawing is complete (soft, flushed & pliable)
 Adequate analgesia with iv opiates
 Blisters care
 Tetanus prophylaxis
 Anti-inflammatory agents
◦ Topical aloe vera cream (Dermaide) q 6 hours
◦ Ibuprofen 12 mg/kg PO in divided doses
 Elevate injured extremity
 Benzyl penicillin 600 mg q 6 hours for 48-72h or
Penicillin G 500.000 U IV
 Photographic records of wounds
McCauley RL, Hing DN, Robson MC, et al. Frostbite injuries: a rational
approach based on the pathophysiology. J Trauma 1983.
ED Management (2)

 Early surgical intervention is not indicated

◦ Assessing depth is difficult at early stage
◦ Mummified carapace is protective of the underlying
regenerating tissue
 Limited early escharotomy may be indicated if
the eschar is preventing adequate range of
motion or circulation
 Amputation may be unavoidable

◦ Only after full demarcation occur (3-4 weeks)

ED Management (3)

 IV prostaglandin E1
 Topical bacitracin or silver sulfadiazine
 Oral methimazole (a thromboxane synthetase

inhibitor)
 Topical methylprednisolone acetate (a

phospholipase A2 inhibitor)
 Sympathetic blockade with reserpine
 Low-molecular-weight dextran
 Intraarterial rtPA
Disposition
 Goal: ensure that patient will not re-enter the
same environment causing injury
 Frostnip may be discharged to follow-up with

PHC provider
 All frostbite to be admitted, need specialized

care (Burn Unit)

Common Pitfalls
 Discharging patient into the injury causing
environment without arranging proper
protection
 Failing to recognize sumperimposed vascular

injury or compartment syndrome after

rewarming
 Failing to use a thermometer to accurately

measure the temperature of warm water bath

Thank You