Do not use water warmed above 42°C to avoid
superimposed thermal injury. Never initiate rewarming in
the prehospital setting if there is any potential for refreezing,
as this can worsen tissue injury.
A rewarming period of between 15 and 60 minutes
is adequate for most patients. Use the appearance of the
affected tissues to guide the duration of therapy. Appropriately
rewarmed tissue should appear erythematous and pliable.
Encourage active movement of the affected extremity to
Numerous adjunctive therapies have been proposed, although
the evidence supporting their use is lacking ( Table 62- 1).
It may take many weeks for the full extent of the
patient's injuries to declare. That said, certain early findings
do suggest better or worse outcomes. Findings associated
with a better prognosis include the rapid re-establishment
of normal skin temperature and sensation and the
Table 62-1. Adj unctive therapies for frostbite.
Leave hemorrhagic blisters intact.
Apply aloe vera cream (Dermaide) every 6 hours to affected
Dress affected areas in soft, dry bandages.
Elevate and splint affected extremity.
Administer tetanus prophylaxis.
Administer NSAID (ibuprofen 400 mg every 8 hours).
Administer penicillin orally or intravenously every 6 hours for
Admit to hospital for daily hydrotherapy at 40°C.
development of large clear blisters. Persistent tissue
cyanosis, firm insensate skin, and the delayed formation of
small hemorrhagic blisters all portent a poor prognosis.
Admit all patients with acute frostbite for a minimum of
24-48 hours, as the full extent of tissue injury may not be
evident on initial presentation. Transfer to a specialized
burn center may be required in severe cases where
significant tissue necrosis will necessitate surgical
debridement. Consider admission for all high-risk patients
(young children, elderly, and homeless) with NFCI and
most patients with significant immersion foot to limit
further progression of disease.
Most patients with frostnip, chilblains, and mild cases of
immersion foot can be safely discharged home provided
they have access to adequate cold-weather clothing and a
warm, dry environment. All discharged patients require
clear instructions on proper wound care and further injury
prevention. Ensure adequate outpatient analgesia and
arrange for close surgical follow-up as necessary.
Ikaheimo TM, Junila J, Hirvonen J, Hassi J. Frostbite and other
localized cold injuries. In: Tintinalli JE, Stapczynski JS, Cline
DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's
Emergency Medicine: A Comprehensive Study Guide. 7th ed.
New York, NY: McGraw-Hill, 201 1.
Irnray C, Grieve A, Shillon S, Caudwell Xtreme Everest Research
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