Question

Create an algorithm for treatment of frostbite in the emergency department.

Answer 1

Frostbite is a freezing injury that happen when tissues are show to temperatures below their freezing point, resulting in direct ice crystal formation and cellular lysis with microvascular occlusion. Most of the damage from frostbite occurs as a result of a freeze thaw cycle with endothelial damage and cellular death resulting in osmotic gradient changes, initiation of the arachidonic acid cascade, vasoconstriction, and hematologic abnormalities which including  thrombosis.The seriousness of irreversible damage is most closely associated to ambient temperature and length of time the tissue remains frozen. The handhands, feet, ears, nose, and cheeks are the most common locations.

The starting treatment in the Emergency Department for all degrees of frostbite is the same.

• Addressing ABCs
• truama evaluation
• remove wet and constructive clothing
• treatment of concomitant hypothermia
• identification of other injuries should be confirmed in all cold injury cases if warented
• Active rewarming is best performed in a circulating water bath around 37°C to 39°C.
• fostbiten faces can be thawed using warm water commpresses
• ears may be thawed with small bowels of warm water
• Thermal injuries can occur when rewarming is performed with an uncontrollable heat source outside a monitored temperature range.
• absorption  rewarming can be discontinued when the affected area developed a red or purple appearance and becomes pliable to the touch.
• smoothly dry, raise, and put in bulky dressing to the affected area. The rewarming process is incredibly painful, and symptomatic treatment including aggressive pain control should be initiated early.
• Tetanus status should be determined and updated as needed. Empiric prophylactic antibiotics are not need
• plan NSAIDs are recommended for both pain and inflammatory control.2 Blister treatment is controversial
• Blister treatment is controversial. Common practice is to selectively drain clear blisters with needle aspiration to reduce tissue exposure to thromboxane and prostaglandin rich fluid, while leaving hemorrhagic blisters intact to prevent desiccation.
• Surgical management including debridement and amputation is reserved for late frostbite management after the rewarming phase in days to weeks.
• However, escharotomy/fasciotomy or initial debridement is warranted if there are signs of compartment syndrome or significant concomitant infection not responsive to antibiotic therapy.
• There is gradual demarcation of the injured area and delineation of non-viable tissue over time. Early surgical intervention is avoided as the permanent tissue loss is often much less than originally suspected.

Following the initial emergency department  management of frostbite, it is best to be conservative when determining disposition as well as recognition of social and concomitant medical issues. Patients unable to care for themselves adequately should never be discharged into subfreezing temperatures. Consultation with the surgical team is also warranted for significant injury or concerning features. If injury is minor, shared decision making may be utilized. Patients must be provided with sufficient recommendation for self-care including outlining cold injury prevention strategies. They must also receive clear instructions for close short-term and long-term follow-up

• ABC’s, then treat hypothermia or serious trauma.
• Rewarm in water heated and maintained between 37-39°C for approximately 30 minutes until the area becomes soft and pliable to the touch
• Pain medication including scheduled NSAIDs
• Tetanus prophylaxis.
• Selectively drain by needle aspiration clear blisters and leave hemorrhagic blisters intact.
• Dry, bulky dressings and elevate the affected body part if possible.
• Early consultation with surgical team to discuss TPA for deep frostbite if less than 24 hours after thawing, as well as additional strategies for definitive management.