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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 2019; 2012), the American Academy of Family Physicians (AAFP 2019), and the American College of Chest Physicians (ACCP 2014).


1.Diagnostic investigations

Diagnostic imaging
As per WMS 2019 guidelines:
Obtain noninvasive imaging with technetium pyrophosphate or MRA, if available, at an early stage in patients with delayed presentation of frostbite (4-24 hours from the time of the frostbite thawing) to assess tissue viability and guide timing and extent of amputation.
Consider obtaining angiography, technetium-99m bone scan, and/or MRI in conjunction with clinical findings to assist in determining surgical margins.
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2.Respiratory support

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

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  • Hyperbaric oxygen therapy

3.Medical management

Setting of care: as per WMS 2019 guidelines, decide on hospital admission and discharge on an individual basis, including 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.
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  • Hydration

  • Analgesics

  • Thrombolytic therapy

  • Heparin

  • Low molecular weight dextran

  • Vasodilators

  • Antibiotics

  • Management of hypothermia

  • Management of corneal frostbite

4.Nonpharmacologic interventions

Protection: as per WMS 2019 guidelines, protect the frozen tissue from further damage if a body part is frozen in the field. Remove jewelry or other constrictive extraneous material from the body part. Do not rub or apply ice or snow to the affected area.
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  • Passive thawing

  • Active rewarming

  • Aloe vera

  • Hydrotherapy

5.Surgical interventions

Dressing: as per WMS 2019 guidelines, insufficient evidence to support applying a dressing to a frostbitten part intended to remain frozen until rewarming can safely be achieved.
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  • Debridement

  • Fasciotomy

  • Sympathectomy

  • Amputation

6.Preventative measures

Protection from cold: advise the following measures to minimize the exposure of tissue to cold to prevent frostbite:
avoiding environmental conditions predisposing to frostbite, specifically < -15 °C or 5 °F, even with low wind speeds
protecting skin from moisture, wind, and cold
avoiding perspiration or wet extremities
increasing insulation and skin protection (such as adding clothing layers, changing from gloves to mitts)
ensuring beneficial behavioral responses to changing environmental conditions (such as not being under the influence of illicit drugs, alcohol, or extreme hypoxemia)
using chemical hand and foot warmers and electric foot warmers to maintain peripheral warmth (warmers should be close to body temperature before being activated and must not be placed directly against skin or constrict flow if used within a boot)
regularly checking oneself and the group for extremity numbness or pain and warming the digits and/or extremities as soon as possible if there is concern that frostbite may be developing
recognizing frostnip or superficial frostbite before it becomes more serious
minimizing duration of cold exposure
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  • Maintaining peripheral perfusion

  • Tetanus prophylaxis

7.Follow-up and surveillance

Offer appropriate footwear and orthotics to provide optimal function in patients with insensate affected limb.
Offer early multidisciplinary rehabilitation produces for better long-term functional results.