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

stimulate increased circulation. Rewarming can be exceptionally painful, and parental opioids are frequently required.

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

CHAPTER 62

Table 62-1. Adj unctive therapies for frostbite.

Debride clear bl isters.

Leave hemorrhagic blisters intact.

Apply aloe vera cream (Dermaide) every 6 hours to affected

tissue.

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

48-72 hours.

Admit to hospital for daily hydrotherapy at 40°C.

Strictly prohibit smoking.

development of large clear blisters. Persistent tissue

cyanosis, firm insensate skin, and the delayed formation of

small hemorrhagic blisters all portent a poor prognosis.

DISPOSITION

� Admission

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.

� Discharge

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.

SUGGESTED READING

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

Group. Cold damage to the extremities: Frostbite and nonfreezing cold injuries. Postgrad Med ]. 2009;85:48 1--488.