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Frostbite

Frostbites

Frostbite is a type of freezing injury, often accompanied by irreversible tissue damage.


Presentation

Depending upon the depth of tissue damage, frostbite has been classified into various categories, each of which has its own characteristic clinical manifestations. These include:

First-degree frostbite

Commonly known as “frost nip”. Involves only the superficial part of skin. Presents as:

Second-degree frostbite

It is also called “superficial frost bite”. The skin freezes without the involvement of deeper soft tissues. It manifests as:

Third- and fourth-degree frostbite

All the layers of the skin are involved at this stage. Permanent and irreversible tissue damage occurs. Deeper tissues like muscles, tendons, nerves get involved at this point. If left untreated, gangrene might set in, which is a major indication for amputation of the affected organs. It presents as:

  • Loss of sensations as a result of destruction of nerve endings
  • Purplish blisters formation
  • Formation of a black eschar after about 2 weeks
Pain
  • Abstract After frostbite injury, the phases of rewarming and progressive injury may cause intense pain for the patient.[ncbi.nlm.nih.gov]
  • A pain specialist may be needed to advise about pain relief. Chilblains [ 3 ] Most idiopathic chilblains resolve spontaneously without treatment. Careful protection from further exposure should be advised.[patient.info]
  • This was caused by the inappropriate application of a bag of frozen chips to the foot in an attempt to ease non-specific pain. No specific acute traumatic injury was identified.[ncbi.nlm.nih.gov]
  • If stronger pain measures are needed, contact a physician. CONTINUE SCROLLING OR CLICK HERE FOR RELATED ARTICLE Reviewed on 12/12/2018[medterms.com]
Gangrene
  • Gangrene of the extremities in the neonatal period is rare. Etiology is not identified in most cases and management is usually conservative.[ncbi.nlm.nih.gov]
  • Surgical interventions Excision of the areas affected by wet gangrene should be done. Surgical amputation of the parts affected by necrosis and gangrene is essential. However, prompt amputation is not recommended.[symptoma.com]
  • The usual treatment is observation for demarcation of the injury before amputation or autoamputation of the dry gangrene that may set in between 1 and 3 weeks. In some instances, tissue viability is assessed by a pyrophosphate nuclear scan.[ncbi.nlm.nih.gov]
  • The patient presented with changes consistent with distal bilateral forefoot frostbite, along with gangrenous changes to the distal tuft of each hallux.[ncbi.nlm.nih.gov]
  • Gangrene may occur. This may require removal of the affected body part (amputation). A person with frostbite on the arms or legs may also have hypothermia (lowered body temperature). Check for hypothermia and treat those symptoms first.[nlm.nih.gov]
Raynaud Phenomenon
  • You are more likely to develop frostbite if you: Take medicines called beta-blockers Have poor blood supply to the legs Smoke Have diabetes Have Raynaud phenomenon Symptoms of frostbite may include: Pins and needles feeling, followed by numbness Hard,[nlm.nih.gov]
  • Impaired thermoregulation in Raynaud’s phenomenon. Angiology. 1995 ;46: 603 - 611. Google Scholar SAGE Journals ISI 11. Haririchi, I, Arvin, A, Vash, JH, Zafarmand, V. Frostbite: incidence and predisposing factors in mountaineers.[doi.org]
  • People who have Raynaud's phenomenon (a condition where the small blood vessels of the fingers constrict) also have an increased risk of developing frostbite. See separate leaflet called Raynaud's Phenomenon for more details .[patient.info]
  • People who have Raynaud's phenomenon (a condition where the small blood vessels of the fingers constrict) also have an increased risk of developing frostbite. See separate leaflet called Raynaud's Phenomenon for more details.[patient.info]
Lymphedema
  • […] gram-negative bacilli, or anaerobes and may present with the following: Increased pain, swelling, redness, and fever Red streaks extending from area Pus discharge Other complications may include the following: Tetanus Tissue loss and gangrene Bacteremia Lymphedema[web.archive.org]
Chest Pain
  • He also experienced increasing breathlessness and went on to develop pleuritic chest pain. A CT pulmonary angiogram performed upon return to sea level revealed multiple small sub-segmental pulmonary emboli.[ncbi.nlm.nih.gov]
Foot Pain
  • Pius II, a 15th century Pope, developed chronic foot pain following frostbite at age 30. Later in life he was progressively disabled by arthritis elsewhere and by colic, which may have been due to kidney stones.[ncbi.nlm.nih.gov]
  • You stop outside of a room to listen to the ambulance report about a homeless patient who has been brought in for foot pain. He is intoxicated and was found asleep in a snow bank.[epmonthly.com]
Blister
  • Blisters form, and prostaglandins and thromboxanes in the blister fluid cause platelet aggregation. Rapid rewarming of the part is now the acceptable practice.[ncbi.nlm.nih.gov]
  • The approach to blisters is debated.[emedicine.com]
  • This type of injury generally blisters 1-2 days after freezing. The blisters may become hard and blackened. However, they usually look worse than they are.[medterms.com]
Tropical Ulcer
Alopecia
  • […] encounter Or: 2015/16 ICD-10-CM T34.90XA Frostbite with tissue necrosis of unspecified sites, initial encounter Or: 2015/16 ICD-10-CM T34.99XA Frostbite with tissue necrosis of other sites, initial encounter Approximate Synonyms Frostbite Frostbite alopecia[icd9data.com]
Denial
  • Denial by the patient can lead to a further delay in diagnosis. This case is especially notable since frostbite injury involving the upper aerodigestive tract is extremely rare.[ncbi.nlm.nih.gov]
Motor Disturbances
  • He developed sensory-motor disturbances and cold hypersensitivity. Angiography and thermography revealed impaired blood flow while Quantitative Sensory Testing indicated impaired somato-sensory nerve function.[ncbi.nlm.nih.gov]

Workup

The diagnosis of frostbite is made with through the following elements [4].

  • Physical examination
  • Tissue biopsy
  • Complete blood count (CBC)
  • Blood urea nitrogen (BUN)
  • Blood electrolytes
  • Serum creatinine levels
  • Blood glucose levels
  • Liver function tests (LFTs)
  • Urinalysis
  • Gram staining of cultures obtained from the tissues
  • Radiography
  • Angiography
  • Technetium-99m (99m Tc) scintigraphy
  • Bone scans
  • Laser Doppler flowmetry
  • Magnetic resonance imaging
Staphylococcus Aureus
  • Wound infection, which is observed in 30% of patients, may be caused by Staphylococcus aureus, beta-hemolytic streptococci, gram-negative bacilli, or anaerobes and may present with the following: Increased pain, swelling, redness, and fever Red streaks[web.archive.org]

Treatment

The management of frostbite consists of the following [5].

Field care

  • Immediate removal of the patient from the cold environment.
  • Removal of wet, soaked clothing.
  • Airway, breathing and circulation of the patient must be checked.
  • Thawing for about 20 to 40 minutes for superficial frost bite and for almost an hour in case of deep tissue involvement [6].
  • Splinting or wrapping of the affected part to avoid movements and damage caused by ice crystals
  • Heating and rewarming by using circulating water at 40° to 42° C. Rewarming may be passive or active.

Medical treatment

Surgical interventions

  • Excision of the areas affected by wet gangrene should be done.
  • Surgical amputation of the parts affected by necrosis and gangrene is essential. However, prompt amputation is not recommended.
  • Needle aspiration of blisters can also be done.
  • Escharotomy may be needed to lessen the pull of the affected part on the surrounding tissues.
  • Routine hydrotherapy for 30 to 45 min at 40° C is done as a rehabilitative measure.
  • Skin grafting may be needed.

Long-term therapy

  • Physiotherapy is recommended to enable proper use of the affected limb.
  • Psychotherapy is recommended for the patients who undergo amputation of the limb.
  • Cosmetic reconstruction of nose, ears, toes that have been amputated may also be done according to the patients’ demands.

Prognosis

Irreversible tissue damage is common after frostbite. The mortality rate related with frost bite is about 11%.

Etiology

Inadequate blood supply to the extremities when exposed to hypothermic environmental conditions as a result of vasoconstriction leading to inadequate tissue perfusion is the basic cause of frostbite.

Various risk factors associated with frostbite are:

Epidemiology

Frostbite is common at the altitudes of 11,000-22,000 feet above sea level. It is common in military personnel, mountaineers and in people who engage in activities like high altitude camping. Any racial, gender or age association has not been established as yet.

Sex distribution
Age distribution

Pathophysiology

Body responds to hypothermia by directing the flow of blood from extremities towards the core organs like heart and lungs in an effort to maintain body’s homeostasis. This is done by peripheral vasoconstriction. The body parts likely to be exposed are affected the worst. These include earlobes, tip of nose, chin, fingers, knuckles and toes. Decrease in the flow of blood in the peripheral parts decreases the already falling temperature even further.

If exposure to the cold continues, cellular changes start taking place. Ice crystal formation occurs around the cell membrane [2]. Dehydration of cells causes them to shrink and they begin to die as a result of loss of cellular architecture [3]. Capillary endothelium is also affected which causes leakage of blood out of the blood vessels into the tissue spaces. Blood also begins to clot inside the small vessels, initiating the recruitment of the mediators of inflammation which cause further tissue damage.

Prevention

Frostbite can be prevented by the following measures [8] [9] [10].

  • The affected part of the body should not be excessively moved as the ice crystals that have formed around the cells can cause further damage.
  • The affected part should not be rubbed or massaged for the purpose of warming.
  • Education of soldiers who are more susceptible to frostbite.
  • While going to high altitudes, appropriate warm clothing must be chosen.
  • Clothing should be protected from getting wet.
  • Position should be changed every few minutes or so in extremely cold conditions to maintain the circulation.
  • Skin should be examined every 20 minutes or so for signs of frost bite.
  • Smoking and drinking for the purpose of keeping warm should be avoided in cold weather as it slows the circulation and aggravates the condition.

Summary

Frostbite refers to the damage to the tissues caused by prolonged exposure to cold environment [1]. Exposure to minus 10 °C for even a few minutes is enough to cause frostbite. The parts of the body that are normally exposed to the external environment are likely to be affected the most.

The condition goes unnoticed at first as numbness sets in almost immediately. A form of frostbite, the “trench foot”, is common in soldiers. It is however, a preventable condition that can be avoided with proper precautionary measures.

Patient Information

Freezing of the body tissues when exposed to cold environmental conditions for prolonged time period is known as frost bite. It commonly occurs in hands, feet, toes, earlobes and tip of nose.

Initially, it is limited to the superficial layer of skin only but later on, it proceeds to deeper tissues. Tingling is followed by numbness. Skin becomes initially red, then white and yellow, ultimately becoming black. Infection of the affected tissues may lead to the need for amputation. That is why frost bite should be given prompt medical attention.

References

Article

  1. Reamy BV. Frostbite: review and current concepts. The Journal of the American Board of Family Practice / American Board of Family Practice. Jan-Feb 1998;11(1):34-40.
  2. Laroche GP. [Frostbite: review and new concepts]. L'union medicale du Canada. Dec 1978;107(12):1155-1157.
  3. Rasmusen DL, Zook EG. frostbite: a review of pathophysiology and newest treatments. The Journal of the Indiana State Medical Association. Dec 1972;65(12):1237-1241.
  4. Iukhtin VI, Klimiashvili AD, Smel'nitskii PS. [Diagnosis and treatment of frostbite]. Khirurgiia. Aug 1988(8):93-97.
  5. Grieve AW, Davis P, Dhillon S, Richards P, Hillebrandt D, Imray CH. A clinical review of the management of frostbite. Journal of the Royal Army Medical Corps. Mar 2011;157(1):73-78.
  6. Fuhrman FA, Fuhrman GJ. The treatment of experimental frostbite by rapid thawing; a review and new experimental data. Medicine. Dec 1957;36(4):465-487.
  7. Gavinskaia NM. [Use of fibrinolysin and anticoagulants in complex treatment of frostbite]. Khirurgiia. Apr 1972;48(4):42-46.
  8. Kotel'nikov VP. [Prevention and treatment of frostbite]. Meditsinskaia sestra. Mar 1981;40(3):13-16.
  9. AIa G. [Prevention and treatment of frostbite]. Vestnik khirurgii imeni I. I. Grekova. Feb 1958;80(2):126-135.
  10. Friberg O. [Prevention and treatment of frostbite injuries]. Duodecim; laaketieteellinen aikakauskirja. 1989;105(5):471-479.

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Last updated: 2019-07-11 22:38