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Frostbite

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Updated 2024 WMS guidelines for the prevention and management of frostbite.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of frostbite are prepared by our editorial team based on guidelines from the Wilderness Medical Society (WMS 2024), the American Academy of Family Physicians (AAFP 2019), and the American College of Chest Physicians (ACCP 2014). ...
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Diagnostic investigations

Diagnostic imaging
As per WMS 2024 guidelines:
Obtain appropriate imaging if available to assess tissue viability and guide timing and extent of amputation.
B
Consider obtaining angiography, technetium-99m bone scan, or MRI to assist in determining surgical margins, in conjunction with clinical findings.
B
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Respiratory support

Suplemental oxygen
As per WMS 2024 guidelines:
Do not administer routine supplemental oxygen in non-hypoxic patients.
D
Consider administering supplemental oxygen in the field by face mask or nasal cannula in patients with hypoxia (oxygen saturation < 88%) or at high altitudes (> 4,000 m).
C

More topics in this section

  • Hyperbaric oxygen therapy

Medical management

Setting of care: as per WMS 2024 guidelines, decide on hospital admission and discharge on an individual basis, taking into account factors such as severity of the injury, coexisting injuries, comorbidities, and need for hospital-based interventions (tissue plasminogen activator, vasodilators, surgery) or supportive therapy, as well as ease of access to appropriate community medical and nursing support.
B
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  • Hydration

  • Analgesics

  • Thrombolytic therapy

  • LMWH

  • Low molecular weight dextran

  • Vasodilators

  • Antibiotics

  • Management of hypothermia

  • Management of corneal frostbite

Nonpharmacologic interventions

Protection: as per WMS 2024 guidelines, advise not to use the frozen extremity for walking, climbing, or other maneuvers, if possible, until definitive care is reached. Assess the potential for further trauma and possible poorer outcome through a risk-benefit analysis when considering the use of a frozen extremity for mobility.
B
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  • Passive thawing

  • Active rewarming

  • Aloe vera

  • Hydrotherapy

Surgical interventions

Dressing: as per WMS 2024 guidelines, insufficient evidence to support applying a dressing to a frostbitten part intended to remain frozen until rewarming can safely be achieved.
I
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  • Debridement

  • Fasciotomy

  • Sympathectomy

  • Amputation

Preventative measures

Maintaining peripheral perfusion
As per WMS 2024 guidelines:
Advise the following preventative measures to ensure local tissue perfusion:
maintaining adequate core temperature and body hydration
minimizing the effects of known diseases, medications, and substances that might decrease perfusion (including awareness and symptoms of alcohol and drug use)
covering all skin and the scalp to insulate from the cold
minimizing blood flow restriction, such as occurs with constrictive clothing, footwear, or immobility
ensuring adequate nutrition
using supplemental oxygen in severely hypoxic conditions (such as > 7,500 m)
B
Consider advising exercises to maintain peripheral perfusion and prevent frostbite, recognizing that exercise can lead to exhaustion, with subsequent profound systemic heat loss should exhaustion occur.
B

More topics in this section

  • Protection from cold

  • Tetanus prophylaxis

Follow-up and surveillance

Recovery
As per WMS 2024 guidelines:
Offer appropriate footwear and orthotics to provide optimal function in patients with insensate affected limb.
B
Offer early multidisciplinary rehabilitation for better long-term functional results.
B