Frostbite

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This article is about a medical condition. For other uses, see Frostbite (disambiguation).

Frostbite

Frostbitten toes two to three days after mountain climbing

Specialty Emergency medicine, orthopedics

Symptoms Numbness, feeling cold, clumsy,

pale color[1]

Complications Hypothermia, compartment

syndrome[2][1]

Types Superficial, deep[2]

Causes Temperatures below freezing[1]

Risk factors Alcohol, smoking, mental health

problems, certain medications, prior
 cold injury[1]

Diagnostic method Based on symptoms[3]

Differential Frostnip, pernio, trench foot[4]

diagnosis

Prevention Avoid cold, wear proper clothing,

maintain hydration and nutrition,
stay active without becoming
exhausted[2]

Treatment Rewarming, medication, surgery[2]

Medication Ibuprofen, tetanus vaccine, iloprost,

thrombolytics[1]

Frequency Unknown[5]

Frostbite occurs when exposure to low temperatures causes freezing of the skin or other
tissues.[1] The initial symptom is typically numbness.[1] This may be followed by clumsiness with
a white or bluish color to the skin.[1] Swelling or blistering may occur following treatment.[1] The
hands, feet, and face are most commonly affected.[4] Complications may include hypothermia or
compartment syndrome.[2][1]

People who are exposed to low temperatures for prolonged periods, such as winter sports
enthusiasts, military personnel, and homeless individuals, are at greatest risk.[6][1] Other risk
factors include drinking alcohol, smoking, mental health problems, certain medications, and
prior injuries due to cold.[1] The underlying mechanism involves injury from ice crystals and
blood clots in small blood vessels following thawing.[1] Diagnosis is based on symptoms.[3]
Severity may be divided into superficial (1st and 2nd degree) or deep (3rd and 4th degree).[2] A
bone scan or MRI may help in determining the extent of injury.[1]

Prevention is through wearing proper clothing, maintaining hydration and nutrition, avoiding low
temperatures, and staying active without becoming exhausted.[2] Treatment is by rewarming.[2]
This should be done only when refreezing is not a concern.[1] Rubbing or applying snow to the
affected part is not recommended.[2] The use of ibuprofen and tetanus toxoid is typically
recommended.[1] For severe injuries iloprost or thrombolytics may be used.[1] Surgery is
sometimes necessary.[1] Amputation, however, should generally be delayed for a few months to
allow determination of the extent of injury.[2]
The number of cases of frostbite is unknown.[5] Rates may be as high as 40% a year among those
who mountaineer.[1] The most common age group affected is those 30 to 50 years old.[4] Evidence
of frostbite occurring in people dates back 5,000 years.[1] Frostbite has also played an important
role in a number of military conflicts.[1] The first formal description of the condition was in 1814
by Dominique Jean Larrey, a physician in Napoleon's army.[1]

Contents
 1Signs and symptoms
o 1.1First degree
o 1.2Second degree
o 1.3Third degree
o 1.4Fourth degree
 2Causes
o 2.1Risk factors
 3Mechanism
o 3.1Freezing
o 3.2Rewarming
o 3.3Non-freezing cold injury
o 3.4Pathophysiology
 4Diagnosis
 5Prevention
 6Treatment
o 6.1Rewarming
o 6.2Medications
o 6.3Surgery
 7Prognosis
o 7.1Grades
 8Epidemiology
 9History
 10Society and culture
 11Research directions
 12References
 13External links

Signs and symptoms[edit]

Frostbite

Areas that are usually affected include cheeks, ears, nose and fingers and toes. Frostbite is often
preceded by frostnip.[2] The symptoms of frostbite progress with prolonged exposure to cold.
Historically, frostbite has been classified by degrees according to skin and sensation changes,
similar to burn classifications. However, the degrees do not correspond to the amount of long
term damage.[7] A simplification of this system of classification is superficial (first or second
degree) or deep injury (third or fourth degree).[8]

First degree[edit]

 First degree frostbite is superficial, surface skin damage that is usually not permanent.
 Early on, the primary symptom is loss of feeling in the skin. In the affected areas, the skin
is numb, and possibly swollen, with a reddened border.
 In the weeks after injury, the skin's surface may slough off.[7]

Second degree[edit]

 In second degree frostbite, the skin develops clear blisters early on, and the skin's surface
hardens.
 In the weeks after injury, this hardened, blistered skin dries, blackens, and peels.
 At this stage, lasting cold sensitivity and numbness can develop.[7]

Third degree[edit]

 In third degree frostbite, the layers of tissue below the skin freeze.
 Symptoms include blood blisters and "blue-grey discoloration of the skin".[citation needed]
 In the weeks after injury, pain persists and a blackened crust (eschar) develops.
 There can be longterm ulceration and damage to growth plates.[7]

Fourth degree[edit]
Frostbite 12 days later

 In fourth degree frostbite, structures below the skin are involved like muscles, tendon,
and bone.
 Early symptoms include a colorless appearance of the skin, a hard texture, and painless
rewarming.
 Later, the skin becomes black and mummified. The amount of permanent damage can
take one month or more to determine. Autoamputation can occur after two months.[7]

Causes[edit]
Risk factors[edit]

The major risk factor for frostbite is exposure to cold through geography, occupation and/or
recreation. Inadequate clothing and shelter are major risk factors. Frostbite is more likely when
the body's ability to produce or retain heat is impaired. Physical, behavioral, and environmental
factors can all contribute to the development of frostbite. Immobility and physical stress (such as
malnutrition or dehydration) are also risk factors.[6] Disorders and substances that impair
circulation contribute, including diabetes, Raynaud's phenomenon, tobacco and alcohol use.[8]
Homeless individuals and individuals with some mental illnesses may be at higher risk.[6]

Mechanism[edit]
Freezing[edit]

In frostbite, cooling of the body causes narrowing of the blood vessels (vasoconstriction).
Temperatures below −4 °C are required to form ice crystals in the tissues.[8] The process of
freezing causes ice crystals to form in the tissue, which in turn causes damage at the cellular
level. Ice crystals can damage cell membranes directly.[9] In addition, ice crystals can damage
small blood vessels at the site of injury.[8] Scar tissue forms when fibroblasts replace the dead
cells.[9]

Rewarming[edit]

Rewarming causes tissue damage through reperfusion injury, which involves vasodilation,
swelling (edema), and poor blood flow (stasis). Platelet aggregation is another possible
mechanism of injury. Blisters and spasm of blood vessels (vasospasm) can develop after
rewarming.[8]

Non-freezing cold injury[edit]

The process of frostbite differs from the process of non-freezing cold injury (NFCI). In NFCI,
temperature in the tissue decreases gradually. This slower temperature decrease allows the body
to try to compensate through alternating cycles of closing and opening blood vessels
(vasoconstriction and vasodilation). If this process continues, inflammatory mast cells act in the
area. Small clots (microthrombi) form and can cut off blood to the affected area (known as
ischemia) and damage nerve fibers. Rewarming causes a series of inflammatory chemicals such
as prostaglandins to increase localized clotting.[9]

Pathophysiology[edit]

The pathological mechanism by which frostbite causes body tissue injury can be characterized
by four stages: Prefreeze, freeze-thaw, vascular stasis, and the late ischemic stage.[10]

1. Prefreeze phase: involves the cooling of tissues without ice crystal formation.[10]
2. Freeze-thaw phase: ice-crystals form, resulting in cellular damage and death.[10]
3. Vascular stasis phase: marked by blood coagulation or the leaking of blood out of the
vessels.[10]
4. Late ischemic phase: characterized by inflammatory events, ischemia and tissue death.[10]

Diagnosis[edit]
Frostbite is diagnosed based on signs and symptoms as described above, and by patient history.
Other conditions that can have a similar appearance or occur at the same time include:

 Frostnip is similar to frostbite, but without ice crystal formation in the skin. Whitening of
the skin and numbness reverse quickly after rewarming.
 Trench foot is damage to nerves and blood vessels that results exposure to wet, cold (non-
freezing) conditions. This is reversible if treated early.
 Pernio or chillbains are inflammation of the skin from exposure to wet, cold (non-
freezing) conditions. They can appear as various types of ulcers and blisters.[7]
 Bullous pemphigoid is a condition that causes itchy blisters over the body that can mimic
frostbite.[11] It does not require exposure to cold to develop.
 Levamisole toxicity is a vasculitis that can appear similar to frostbite.[11] It is caused by
contamination of cocaine by levamisole. Skin lesions can look similar those of frostbite,
but do not require cold exposure to occur.

People who have hypothermia often have frostbite as well.[7] Since hypothermia is life-
threatening this should be treated first. Technetium-99 or MR scans are not required for
diagnosis, but might be useful for prognostic purposes.[12]
Prevention[edit]
The Wilderness Medical Society recommends covering the skin and scalp, taking in adequate
nutrition, avoiding constrictive footwear and clothing, and remaining active without causing
exhaustion. Supplemental oxygen might also be of use at high elevations. Repeated exposure to
cold water makes people more susceptible to frostbite.[13] Additional measures to prevention
frostbite include:[2]

 Avoiding temperatures below −15 °C

 Avoiding moisture, including in the form of sweat and/or skin emollients
 Avoiding alcohol and drugs that impair circulation or natural protective responses
 Layering clothing
 Using chemical or electric warming devices
 Recognizing early signs of frostnip and frostbite[2]

Treatment[edit]
Individuals with frostbite or potential frostbite should go to a protected environment and get
warm fluids. If there is no risk of re-freezing, the extremity can be exposed and warmed in the
groin or underarm of a companion. If the area is allowed to refreeze, there can be worse tissue
damage. If the area cannot be reliably kept warm, the person should be brought to a medical
facility without rewarming the area. Rubbing the affected area can also increase tissue damage.
Aspirin and ibuprofen can be given in the field[6] to prevent clotting and inflammation. Ibuprofen
is often preferred to aspirin because aspirin may block a subset of prostaglandins that are
important in injury repair.[14]

The first priority in people with frostbite should be to assess for hypothermia and other life-
threatening complications of cold exposure. Before treating frostbite, the core temperature
should be raised above 35C. Oral or intravenous (IV) fluids should be given.[6]

Other considerations for standard hospital management include:

 wound care: blisters can be drained by needle aspiration, unless they are bloody
(hemorrhagic). Aloe vera gel can be applied before breathable, protective dressings or
bandages are put on.
 antibiotics: if there is trauma, skin infection (cellulitis) or severe injury
 tetanus toxoid: should be administered according to local guidelines. Uncomplicated
frostbite wounds are not known to encourage tetanus.
 pain control: NSAIDs or opioids are recommended during the painful rewarming process.

Rewarming[edit]

If the area is still partially or fully frozen, it should be rewarmed in the hospital with a warm bath
with povidone iodine or chlorhexidine antiseptic.[6] Active rewarming seeks to warm the injured
tissue as quickly as possible without burning. The faster tissue is thawed, the less tissue damage
occurs.[15] According to Handford and colleagues, "The Wilderness Medical Society and State of
Alaska Cold Injury Guidelines recommend a temperature of 37–39 °C, which decreases the pain
experienced by the patient whilst only slightly slowing rewarming time." Warming takes 15
minutes to 1 hour. Rewarming can be very painful, so pain management is important.[6]

Medications[edit]

People with potential for large amputations and who present within 24 hours of injury can be
given TPA with heparin.[1] These medications should be withheld if there are any
contraindications. Bone scans or CT angiography can be done to assess damage.[16]

Blood vessel dilating medications such as iloprost may prevent blood vessel blockage.[6] This
treatment might be appropriate in grades 2–4 frostbite, when people get treatment within 48
hours.[16] In addition to vasodilators, sympatholytic drugs can be used to counteract the
detrimental peripheral vasoconstriction that occurs during frostbite.[17]

Surgery[edit]

Various types of surgery might be indicated in frostbite injury, depending on the type and extent
of damage. Debridement or amputation of necrotic tissue is usually delayed unless there is
gangrene or systemic infection (sepsis).[6] This has led to the adage "Frozen in January, amputate
in July".[18] If symptoms of compartment syndrome develop, fasciotomy can be done to attempt to
preserve blood flow.[6]

Prognosis[edit]

3 weeks after initial frostbite

Tissue loss and autoamputation are potential consequences of frostbite. Permanent nerve damage
including loss of feeling can occur. It can take several weeks to know what parts of the tissue
will survive.[8] Time of exposure to cold is more predictive of lasting injury than temperature the
individual was exposed to. The classification system of grades, based on the tissue response to
initial rewarming and other factors is designed to predict degree of longterm recovery.[6]

Grades[edit]

Grade 1: if there is no initial lesion on the area, no amputation or lasting effects are expected
Grade 2: if there is a lesion on the distal body part, tissue and fingernails can be destroyed

Grade 3: if there is a lesion on the intermediate or near body part, autoamputation and loss of
function can occur

Grade 4: if there is a lesion very near the body (such as the carpals of the hand), the limb can be
lost. Sepsis and/or other systemic problems are expected.[6]

A number of long term sequelae can occur after frostbite. These include transient or permanent
changes in sensation, paresthesia, increased sweating, cancers, and bone destruction/arthritis in
the area affected.[19]

Epidemiology[edit]
There is a lack of comprehensive statistics about the epidemiology of frostbite. In the United
States, frostbite is more common in northern states. In Finland, annual incidence was 2.5 per
100,000 among civilians, compared with 3.2 per 100,000 in Montreal. Research suggests that
men aged 30–49 are at highest risk, possibly due to occupational or recreational exposures to
cold.[20]

History[edit]
Frostbite has been described in military history for millennia. The Greeks encountered and
discussed the problem of frostbite as early as 400 BCE.[8] Researchers have found evidence of
frostbite in humans dating back 5,000 years, in an Andean mummy. Napoleon's Army was the
first documented instance of mass cold injury in the early 1800s.[6] According to Zafren, nearly 1
million combatants fell victim to frostbite in the First and Second World Wars, and the Korean
War.[8]

Society and culture[edit]

Notable cases of frostbite include Captain Lawrence Oates, an English army captain and
Antarctic explorer, who died of complications of frostbite in 1912.[21] In 1982, noted American
rock climber Hugh Herr lost both legs below the knee to frostbite after being stranded on Mount
Washington in a blizzard.[22] In addition, many Mount Everest explorers have lost digits and
limbs to frostbite. Beck Weathers, a survivor of the 1996 Mount Everest disaster, lost his nose
and hands to frostbite.[23] In 1999, Scottish mountaineer, Jamie Andrew had all four limbs
amputated due to sepsis from frostbite sustained climbing the Mont Blanc massif.[24]

Research directions[edit]
Evidence is insufficient to determine whether or not hyperbaric oxygen therapy as an adjunctive
treatment can assist in tissue salvage.[25] Cases have been reported, but no randomized control
trial has been performed on humans.[26][27][28][29][30]
Medical sympathectomy using intravenous reserpine has also been attempted with limited
success.[19] Studies have suggested that administration of tissue plasminogen activator (tPa) either
intravenously or intra-arterially may decrease the likelihood of eventual need for amputation.[31]