How is frostbite best treated?

Hospital treatment

Re-warming

Re-warming is generally regarded as best done under the supervision of medical professionals so as to reduce the risk of further tissue damage as far as possible.

Re-warming (thawing) can result in the following:

• Oedema (swelling) which typically occurs within 3 hours of treatment and can last at least a week.
• The formation of large, clear blebs (irregular bulges in the plasma membrane of a cell) may appear within 6 to 24 hours. Clear blebs may result in superficial injury to a patient. Some may haemorrhage (also appearing within 24 hours) and cause deeper (scarring) injury.
• Eschar wound formations may appear between 9 and 15 days following re-warming treatment (often resembling a shrunken dark / black carapace shell which covers wounded tissue). New skin may develop beneath the carapace if the injury is superficial.

The thawing process can be a painful experience for the person affected by frostbite, and thus, being treated in a hospital environment can also ensure that pain is managed safely with appropriate medications.

A person who is admitted into the emergency room with hypothermia will need to be treated swiftly and the core body temperature returned to normal before tissues affected by frostbite can be attended to. Medical professionals will remove all wet clothing items (as well as jewellery) and cover a person with warm blankets in order to help restore the core body temperature quickly.

Once this has been achieved, medical doctors may begin the thawing process of frostbitten tissues. A team may make use of circulating warm water (whirlpool) to immerse affected tissues in for between 15 and 40 minutes at a time (at a temperature of 37-39°C / 98.6 – 102.2°F). The patient will be monitored for signs of thawing such as the return of sensation or colour to the skin tissues. He/she will be encouraged to try and move the affected body part as rewarming is taking place in order to help things along. The water temperature will be monitored, so as to be maintained. Superficial frostbite should thaw within 20 to 40 minutes. Severe or deep frostbite may thaw within 1 hour.

The process needs to be controlled, taking into consideration that premature termination of rewarming, or warming at higher temperatures for extended periods of time can contribute to destroying other viable tissues. One of the main aims of medical re-warming is to preserve as much body tissue as possible.

Pain medications may also be given during the rewarming process to manage and control discomfort that occurs during the process. Signs of dehydration will be treated with IV fluids as soon as possible.

A team may also gently wash the affected area with an antiseptic. A person will then be carefully dried, and wrapped in non-adherent gauze dressings, protecting injured tissues from any possible friction. Fingers and toes may be padded, separating each digit. Any blister formations will be left intact. If damage to the muscles or bones has occurred, a doctor may use a brace or splint to immobilise the affected body part and prevent further injury. Dressings will be changed 2 to 3 times a day and wounds closely checked for any signs of infection.

If damage is extensive, skin necrosis (gangrene) is likely to require some skin grafting, and in worst case scenarios, possible surgical amputation of the affected digit or limb. Once gangrene has occurred deterioration can affect the surrounding tissues, causing further tissue death.

Severe frostbite which leads to complex wounds may also be treated with vacuum-assisted closure therapy (wound VAC) wherein a specialised device is used to reduce air pressure on the wound and promote better healing.

Post-rewarming care

Once thawing has taken place, a doctor will likely elevate the digits and/or limbs affected by frostbite, and begin treating other symptoms where necessary. Further treatment may also involve medications, like anti-inflammatories and pain relievers (NSAIDs / nonsteroidal anti-inflammatories), blood thinning drugs, thrombolytics (clot-busting medications) and antibiotics to prevent infection (as necessary). A tetanus shot may also be given to reduce the risk of tetanus (a severe and painful bacterial infection). If blisters that have developed contain blood and are hindering movement they may be drained, but are more likely to be left intact so as not to disturb blood vessels beneath.

A person suffering from frostbite may be hospitalised for at least 1 to 3 days in order to ensure adequate treatment. A doctor may take photographs of the injured tissues periodically during this time, initially after 24 hours, and then on each day thereafter (until the patient is discharged from hospital), to be used for comparison assessment in regard to damage severity. A patient may need to remain in hospital for several weeks, should frostbite associated damage be extensive or complications occur.

During the course of the subsequent weeks or months, debridement may take place. This refers to the removal of damaged, infected or dead tissue. This procedure may take one month, or up to 3 months post incident, and can help the affected tissues to heal properly. Other healing treatments may involve whirlpool therapy (hydrotherapy). This treatment helps to keep the affected skin clean, as well as slowly remove injured tissues while they are immersed in water.

Surgical treatment

When necessary, amputation surgery (removal of part or all of an extremity / limb) is usually reserved for several weeks or months following the initial frostbite treatment. This is because the full extent of the tissue damage is usually only really apparent sometime after freezing and thawing has taken place. Affected tissues typically heal or ‘mummify’ without the need for surgery, but if this does not occur, operative therapy may be necessary.

Initially deep / severe frostbite can look a little worse (on the skin’s surface) than it may really be. Post initial treatment, a patient will be carefully monitored and assessed for the degree of damage caused to be determined, as well as to identify the signs of any other complications like infection, should they arise. Monitoring can take place over the course of 3 to 4 weeks and may extend to a few months if necessary.

If an infection is severe, or a person experiences wet gangrene (resulting in oozing fluid or pus) or pain that does not respond well to other treatment, amputation surgery may be a considered, but will only really be a viable option once the affected tissues have become entirely non-functional and necrotic.

Homecare tips

Caring for damaged skin will continue once the frostbite sufferer is discharged from hospital. A doctor may recommend the following:

• Taking all recommended and prescribed medications exactly as directed (for the treatment of pain and inflammation, as well as antibiotics for the prevention or treatment of infection).
• Treating superficial frostbite with aloe vera gels or lotions several times a day. This helps to alleviate inflammation, and promote healing of the affected tissues.
• Taking precautions when it comes to cold exposure, especially if residing in areas with extreme cold and/or windy climates.
• Refraining from walking if the feet have been affected by frostbite, as this can worsen damaged tissues (potentially permanently).
• Elevating the affected limbs to help reduce swelling.
• Taking care not to rub or place any direct heat on affected tissue areas.
• Leaving all blister formations alone. Blisters are natural protectors for damaged tissue (acting like a bandage). It is better to allow these to heal or break on their own.
• Quitting smoking (if applicable) as this impedes healing and causes further blood vessel constriction (narrowing).
• Consuming a high-protein and high-calorie diet for a healing period as this may help the body’s tissues to repair themselves.
• Undergoing physical therapy after a period of healing so as to help increase limb flexibility and restore nimbleness. Active motion (such as walking), once sufficient healing has taken place and it is safe to do so is generally encouraged.

A doctor will also likely ensure that a patient is aware of any predictable healing patterns. Once tissues have been successfully re-warmed, a person can expect to feel tingling feelings which linger, sometimes with occasional electric shock type sensations. During healing a person will have some sensation / sensory loss, but also chronic pain, as well as a sensitivity to cold. This typically lasts for months, sometimes years following frostbite treatment. A doctor may also make it clear that the affected tissues may be more vulnerable to both heat-related or cold-related injuries going forward, so care will need to be taken accordingly.