Frostbite

Last updated
Frostbite
Other namesFrostnip
Frost bite.jpg
Frostbitten toes two to three days after mountain climbing
Specialty Dermatology, emergency medicine, orthopedics
Symptoms Numbness, feeling cold, clumsiness, pale color [1]
Complications Hypothermia, compartment syndrome [2] [1]
TypesSuperficial, deep [2]
CausesTemperatures below freezing [1]
Risk factors Alcohol, smoking, mental health problems, certain medications, prior cold injury [1]
Diagnostic method Based on symptoms [3]
Differential diagnosis Frostnip, pernio, trench foot [4]
PreventionAvoid cold, wear proper clothing, maintain hydration and nutrition, stay active without becoming exhausted [2]
TreatmentRewarming, medication, surgery [2]
Medication Ibuprofen, tetanus vaccine, iloprost, thrombolytics [1]
FrequencyUnknown [5]

Frostbite is a skin injury that occurs when exposed to extremely low temperatures, causing the freezing of the skin or other tissues, [1] commonly affecting the fingers, toes, nose, ears, cheeks and chin areas. [6] Most often, frostbite occurs in the hands and feet. [7] [8] The initial symptoms are typically a feeling of cold and tingling or numbing. [1] This may be followed by clumsiness with a white or bluish color to the skin. [1] Swelling or blistering may occur following treatment. [1] Complications may include hypothermia or compartment syndrome. [2] [1]

Contents

People who are exposed to low temperatures for prolonged periods, such as winter sports enthusiasts, military personnel, and homeless individuals, are at greatest risk. [7] [1] Other risk factors include drinking alcohol, smoking, mental health problems, certain medications, and prior injuries due to cold. [1] The underlying mechanism involves injury from ice crystals and blood clots in small blood vessels following thawing. [1] Diagnosis is based on symptoms. [3] Severity may be divided into superficial (1st and 2nd degree) or deep (3rd and 4th degree). [2] A bone scan or MRI may help in determining the extent of injury. [1]

Prevention consists of wearing proper, fully-covering clothing, avoiding low temperatures and wind, maintaining hydration and nutrition, and sufficient physical activity to maintain core temperature without exhaustion. [2] Treatment is by rewarming, by immersion in warm water (near body temperature) or by body contact, and should be done only when consistent temperature can be maintained so that refreezing is not a risk. [2] [1] Rapid heating or cooling should be avoided since it could potentially cause burning or heart stress. [9] Rubbing or applying force to the affected areas should be avoided as it may cause further damage such as abrasions. [2] The use of ibuprofen and tetanus toxoid is recommended for pain relief or to reduce swelling or inflammation. [1] For severe injuries, iloprost or thrombolytics may be used. [1] Surgery is sometimes necessary. [1] Amputation should be considered a few months after exposure in order to consider whether the extent of injury is permanent damage and thus necessitates drastic treatment. [2]

Evidence of frostbite occurring in people dates back 5,000 years. [1] Evidence was documented in a pre-Columbian mummy discovered in the Andes. [7] The number of cases of frostbite is unknown. [5] Rates may be as high as 40% a year among those who mountaineer. [1] The most common age group affected is those 30 to 50 years old. [4] Frostbite has also played an important role in a number of military conflicts. [1] The first formal description of the condition was in 1813 by Dominique Jean Larrey, a physician in Napoleon's army, during its invasion of Russia. [1]

Signs and symptoms

Frostbite Frostbite.png
Frostbite

Areas that are usually affected include cheeks, ears, nose and fingers and toes. Frostbite is often preceded by frostnip. [2] The symptoms of frostbite progress with prolonged exposure to cold. Historically, frostbite has been classified by degrees according to skin and sensation changes, similar to burn classifications. However, the degrees do not correspond to the amount of long term damage. [10] A simplification of this system of classification is superficial (first or second degree) or deep injury (third or fourth degree). [11]

First degree

Third degree frostbite developing. Doppler arterial ultrasound showed adequate perfusion to the foot with no blood flow to the toes. Gangrene was still demarcating. Right foot third degree frostbite.png
Third degree frostbite developing. Doppler arterial ultrasound showed adequate perfusion to the foot with no blood flow to the toes. Gangrene was still demarcating.

Second degree

Third degree frostbite. No surgical interventions recommended as the gangrenous portion of the wound was still demarcating. Left foot third degree frostbite.png
Third degree frostbite. No surgical interventions recommended as the gangrenous portion of the wound was still demarcating.

Third degree

Fourth degree

Frostbite 12 days later Human toes, 12 days post-frostbite.jpg
Frostbite 12 days later

Causes

Risk factors

The major risk factor for frostbite is exposure to cold through geography, occupation and/or recreation. Inadequate clothing and shelter are major risk factors. Frostbite is more likely when the body's ability to produce or retain heat is impaired. Physical, behavioral, and environmental factors can all contribute to the development of frostbite. Immobility and physical stress (such as malnutrition or dehydration) are also risk factors. [7] Disorders and substances that impair circulation contribute, including diabetes, Raynaud's phenomenon, tobacco and alcohol use. [11] Homeless individuals and individuals with some mental illnesses may be at higher risk. [7]

Mechanism

Freezing

In frostbite, cooling of the body causes narrowing of the blood vessels (vasoconstriction). Prolonged exposure to temperatures below −2 °C (28 °F) may cause ice crystals to form in the tissues, and prolonged exposure to temperatures below −4 °C (25 °F) may cause ice crystals to form in the blood. [13] Ice crystals can damage small blood vessels at the site of injury. [11] Typically, prolonged exposure to temperatures below −0.55 °C (31.01 °F) may cause frostbite. [14]

Rewarming

Rewarming causes tissue damage through reperfusion injury, which involves vasodilation, swelling (edema), and poor blood flow (stasis). Platelet aggregation is another possible mechanism of injury. Blisters and spasm of blood vessels (vasospasm) can develop after rewarming. [11]

Non-freezing cold injury

The process of frostbite differs from the process of non-freezing cold injury (NFCI). In NFCI, temperature in the tissue decreases gradually. This slower temperature decrease allows the body to try to compensate through alternating cycles of closing and opening blood vessels (vasoconstriction and vasodilation). If this process continues, inflammatory mast cells act in the area. Small clots (microthrombi) form and can cut off blood to the affected area (known as ischemia) and damage nerve fibers. Rewarming causes a series of inflammatory chemicals such as prostaglandins to increase localized clotting. [15]

Pathophysiology

The pathological mechanism by which frostbite causes body tissue injury can be characterized by four stages: Prefreeze, freeze-thaw, vascular stasis, and the late ischemic stage. [16]

  1. Prefreeze phase: involves the cooling of tissues without ice crystal formation. [16]
  2. Freeze-thaw phase: ice-crystals form, resulting in cellular damage and death. [16]
  3. Vascular stasis phase: marked by blood coagulation or the leaking of blood out of the vessels. [16]
  4. Late ischemic phase: characterized by inflammatory events, ischemia and tissue death. [16]

Diagnosis

Frostbite is diagnosed based on signs and symptoms as described above, and by patient history. Other conditions that can have a similar appearance or occur at the same time include:

People who have hypothermia often have frostbite as well. [10] Since hypothermia is life-threatening this should be treated first. Technetium-99 or MR scans are not required for diagnosis, but might be useful for prognostic purposes. [18]

Prevention

A Centers for Disease Control and Prevention infographic video about frostbite prevention

The Wilderness Medical Society recommends covering the skin and scalp, taking in adequate nutrition, avoiding constrictive footwear and clothing, and remaining active without causing exhaustion. Supplemental oxygen might also be of use at high elevations. Repeated exposure to cold water makes people more susceptible to frostbite. [19] Additional measures to prevent frostbite include: [2]

Treatment

Individuals with frostbite or potential frostbite should go to a protected environment and get warm fluids. If there is no risk of re-freezing, the extremity can be exposed and warmed in the groin or underarm of a companion. If the area is allowed to refreeze, there can be worse tissue damage. If the area cannot be reliably kept warm, the person should be brought to a medical facility without rewarming the area. Rubbing the affected area can also increase tissue damage. Aspirin and ibuprofen can be given in the field [7] to prevent clotting and inflammation. Ibuprofen is often preferred to aspirin because aspirin may block a subset of prostaglandins that are important in injury repair. [20]

The first priority in people with frostbite should be to assess for hypothermia and other life-threatening complications of cold exposure. Before treating frostbite, the core temperature should be raised above 35 °C. Oral or intravenous (IV) fluids should be given. [7]

Other considerations for standard hospital management include:

Rewarming

If the area is still partially or fully frozen, it should be rewarmed in the hospital with a warm bath with povidone iodine or chlorhexidine antiseptic. [7] Active rewarming seeks to warm the injured tissue as quickly as possible without burning. The faster tissue is thawed, the less tissue damage occurs. [21] According to Handford and colleagues, "The Wilderness Medical Society and State of Alaska Cold Injury Guidelines recommend a temperature of 37–39 °C, which decreases the pain experienced by the patient whilst only slightly slowing rewarming time." Warming takes 15 minutes to 1 hour. The faucet should be left running so the water can circulate. [22] Rewarming can be very painful, so pain management is important. [7]

Medications

People with potential for large amputations and who present within 24 hours of injury can be given TPA with heparin. [1] These medications should be withheld if there are any contraindications. Bone scans or CT angiography can be done to assess damage. [23]

Blood vessel dilating medications such as iloprost may prevent blood vessel blockage. [7] This treatment might be appropriate in grades 2–4 frostbite, when people get treatment within 48 hours. [23] In addition to vasodilators, sympatholytic drugs can be used to counteract the detrimental peripheral vasoconstriction that occurs during frostbite. [24]

A systematic review and metaanalysis revealed that iloprost alone or iloprost plus recombinant tissue plasminogen activator (rtPA) may decrease amputation rate in case of severe frostbite in comparison to buflomedil alone with no major adverse events reported from iloprost or iloprost plus rtPA in the included studies. [25]

Surgery

Various types of surgery might be indicated in frostbite injury, depending on the type and extent of damage. Debridement or amputation of necrotic tissue is usually delayed unless there is gangrene or systemic infection (sepsis). [7] This has led to the adage "Frozen in January, amputate in July". [26] If symptoms of compartment syndrome develop, fasciotomy can be done to attempt to preserve blood flow. [7]

Prognosis

3 weeks after initial frostbite Human toes, 3 weeks post-frostbite.jpg
3 weeks after initial frostbite

Tissue loss and autoamputation are potential consequences of frostbite. Permanent nerve damage including loss of feeling can occur. It can take several weeks to know what parts of the tissue will survive. [11] Time of exposure to cold is more predictive of lasting injury than temperature the individual was exposed to. The classification system of grades, based on the tissue response to initial rewarming and other factors is designed to predict degree of longterm recovery. [7]

Grades

Grade 1: if there is no initial lesion on the area, no amputation or lasting effects are expected

Grade 2: if there is a lesion on the distal body part, tissue and fingernails can be destroyed

Grade 3: if there is a lesion on the intermediate or near body part, auto-amputation and loss of function can occur

Grade 4: if there is a lesion very near the body (such as the carpals of the hand), the limb can be lost. Sepsis and/or other systemic problems are expected. [7]

A number of long term sequelae can occur after frostbite. These include transient or permanent changes in sensation, paresthesia, increased sweating, cancers, and bone destruction/arthritis in the area affected. [27]

Epidemiology

There is a lack of comprehensive statistics about the epidemiology of frostbite. In the United States, frostbite is more common in northern states. In Finland, annual incidence was 2.5 per 100,000 among civilians, compared with 3.2 per 100,000 in Montreal. Research suggests that men aged 30–49 are at highest risk, possibly due to occupational or recreational exposures to cold. [28]

History

Frostbite has been described in military history for millennia. The Greeks encountered and discussed the problem of frostbite as early as 400 BCE. [11] Researchers have found evidence of frostbite in humans dating back 5,000 years, in an Andean mummy. Napoleon's Army was the first documented instance of mass cold injury in the early 1800s. [7] According to Zafren, nearly 1 million combatants fell victim to frostbite in the First and Second World Wars, and the Korean War. [11]

Society and culture

Mountaineer Nigel Vardy in hospital after developing frostbite when benighted on Denali in 1999. His nose, fingers and toes were subsequently amputated. Nigel Vardy Frostbite.jpg
Mountaineer Nigel Vardy in hospital after developing frostbite when benighted on Denali in 1999. His nose, fingers and toes were subsequently amputated.

Several notable cases of frostbite include:

Research directions

Evidence is insufficient to determine whether or not hyperbaric oxygen therapy as an adjunctive treatment can assist in tissue salvage. [33] Cases have been reported, but no randomized control trial has been performed on humans. [34] [35] [36] [37] [38]

Medical sympathectomy using intravenous reserpine has also been attempted with limited success. [27] Studies have suggested that administration of tissue plasminogen activator (tPa) either intravenously or intra-arterially may decrease the likelihood of eventual need for amputation. [39]

Related Research Articles

<span class="mw-page-title-main">Decompression sickness</span> Disorder caused by dissolved gases forming bubbles in tissues

Decompression sickness is a medical condition caused by dissolved gases emerging from solution as bubbles inside the body tissues during decompression. DCS most commonly occurs during or soon after a decompression ascent from underwater diving, but can also result from other causes of depressurisation, such as emerging from a caisson, decompression from saturation, flying in an unpressurised aircraft at high altitude, and extravehicular activity from spacecraft. DCS and arterial gas embolism are collectively referred to as decompression illness.

<span class="mw-page-title-main">Hypothermia</span> Human body core temperature below 35.0 °C (95.0 °F)

Hypothermia is defined as a body core temperature below 35.0 °C (95.0 °F) in humans. Symptoms depend on the temperature. In mild hypothermia, there is shivering and mental confusion. In moderate hypothermia, shivering stops and confusion increases. In severe hypothermia, there may be hallucinations and paradoxical undressing, in which a person removes their clothing, as well as an increased risk of the heart stopping.

<span class="mw-page-title-main">Gangrene</span> Type of tissue death by infection or lack of blood supply

Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the gangrene is caused by an infectious agent, it may present with a fever or sepsis.

<span class="mw-page-title-main">Blister</span> Small pocket of fluid within the upper layers of the skin

A blister is a small pocket of body fluid within the upper layers of the skin, usually caused by forceful rubbing (friction), burning, freezing, chemical exposure or infection. Most blisters are filled with a clear fluid, either serum or plasma. However, blisters can be filled with blood or with pus.

<span class="mw-page-title-main">Necrotizing fasciitis</span> Infection that results in the death of the bodys soft tissue

Necrotizing fasciitis (NF), also known as flesh-eating disease, is a bacterial infection that results in the death of parts of the body's soft tissue. It is a severe disease of sudden onset that spreads rapidly. Symptoms usually include red or purple skin in the affected area, severe pain, fever, and vomiting. The most commonly affected areas are the limbs and perineum.

<span class="mw-page-title-main">Barotrauma</span> Injury caused by pressure

Barotrauma is physical damage to body tissues caused by a difference in pressure between a gas space inside, or in contact with, the body and the surrounding gas or liquid. The initial damage is usually due to over-stretching the tissues in tension or shear, either directly by an expansion of the gas in the closed space or by pressure difference hydrostatically transmitted through the tissue. Tissue rupture may be complicated by the introduction of gas into the local tissue or circulation through the initial trauma site, which can cause blockage of circulation at distant sites or interfere with the normal function of an organ by its presence. The term is usually applied when the gas volume involved already exists prior to decompression. Barotrama can occur during both compression and decompression events.

<span class="mw-page-title-main">Ischemia</span> Restriction in blood supply to tissues

Ischemia or ischaemia is a restriction in blood supply to any tissue, muscle group, or organ of the body, causing a shortage of oxygen that is needed for cellular metabolism. Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue i.e. hypoxia and microvascular dysfunction. It also implies local hypoxia in a part of a body resulting from constriction.

<span class="mw-page-title-main">Chilblains</span> Medical condition

Chilblains, also known as pernio, is a medical condition in which damage occurs to capillary beds in the skin, most often in the hands or feet, when blood perfuses into the nearby tissue, resulting in redness, itching, inflammation, and possibly blisters.

Cryotherapy, sometimes known as cold therapy, is the local or general use of low temperatures in medical therapy. Cryotherapy may be used to treat a variety of tissue lesions. The most prominent use of the term refers to the surgical treatment, specifically known as cryosurgery or cryoablation. Cryosurgery is the application of extremely low temperatures to destroy abnormal or diseased tissue and is used most commonly to treat skin conditions.

<span class="mw-page-title-main">CREST syndrome</span> Medical condition

CREST syndrome, also known as the limited cutaneous form of systemic sclerosis (lcSSc), is a multisystem connective tissue disorder. The acronym "CREST" refers to the five main features: calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia.

Diving disorders, or diving related medical conditions, are conditions associated with underwater diving, and include both conditions unique to underwater diving, and those that also occur during other activities. This second group further divides into conditions caused by exposure to ambient pressures significantly different from surface atmospheric pressure, and a range of conditions caused by general environment and equipment associated with diving activities.

<span class="mw-page-title-main">Iloprost</span> Pharmaceutical drug

Iloprost, sold under the brand name Ventavis among others, is a medication used to treat pulmonary arterial hypertension (PAH), scleroderma, Raynaud's phenomenon, frostbite, and other conditions in which the blood vessels are constricted and blood cannot flow to the tissues. Iloprost is a prostacyclin mimetic.

Ebullism is the formation of water vapour bubbles in bodily fluids due to reduced environmental pressure, usually at extreme high altitude. It occurs because a system of liquid and gas at equilibrium will see a net conversion of liquid to gas as pressure lowers; for example, liquids reach their boiling points at lower temperatures when the pressure on them is lowered. The injuries and disorder caused by ebullism is also known as ebullism syndrome. Ebullism will expand the volume of the tissues, but the vapour pressure of water at temperatures in which a human can survive is not sufficient to rupture skin or most other tissues encased in skin. Ebullism produces predictable injuries, which may be survivable if treated soon enough, and is often accompanied by complications caused by rapid decompression, such as decompression sickness and a variety of barotrauma injuries. Persons at risk are astronauts and high altitude aviators, for whom it is an occupational hazard.

Deep hypothermic circulatory arrest (DHCA) is a surgical technique in which the temperature of the body falls significantly and blood circulation is stopped for up to one hour. It is used when blood circulation to the brain must be stopped because of delicate surgery within the brain, or because of surgery on large blood vessels that lead to or from the brain. DHCA is used to provide a better visual field during surgery due to the cessation of blood flow. DHCA is a form of carefully managed clinical death in which heartbeat and all brain activity cease.

Cold compression therapy, also known as hilotherapy, combines two of the principles of rest, ice, compression, elevation to reduce pain and swelling from a sports or activity injury to soft tissues and is recommended by orthopedic surgeons following surgery. The therapy is especially useful for sprains, strains, pulled muscles and pulled ligaments.

<span class="mw-page-title-main">Trench foot</span> Injury to the foot due to poor circulation, cold and moisture

Trench foot, also known by other names, is a type of foot damage due to moisture. Initial symptoms often include tingling or itching which can progress to numbness. The feet may become red or bluish in color. As the condition worsens the feet can start to swell and smell of decay. Complications may include skin breakdown or infection.

<span class="mw-page-title-main">Cold injury</span> Medical condition

Cold injury is damage to the body from cold exposure, including hypothermia and several skin injuries. Cold-related skin injuries are categorized into freezing and nonfreezing cold injuries. Freezing cold injuries involve tissue damage when exposed to temperatures below freezing. Nonfreezing cold injuries involve tissue damage when exposed to temperatures often between 0-15 degrees Celsius for extended periods of time. While these injuries have disproportionally affected military members, recreational winter activities have also increased the risk and incidence within civilian populations. Additional risk factors include homelessness, inadequate or wet clothing, alcohol abuse or tobacco abuse, and pre-existing medical conditions that impair blood flow.

<span class="mw-page-title-main">Aerosol burn</span> Medical condition

An aerosol frostbite of the skin is an injury to the body caused by the pressurized gas within an aerosol spray cooling quickly, with the sudden drop in temperature sufficient to cause frostbite to the applied area. Medical studies have noted an increase of this practice, known as "frosting", in pediatric and teenage patients.

Non-freezing cold injuries (NFCI) is a class of tissue damage caused by sustained exposure to low temperature without actual freezing. There are several forms of NFCI, and the common names may refer to the circumstances in which they commonly occur or were first described, such as trench foot, which was named after its association with trench warfare. NFCI is caused by microvascular endothelial damage, stasis and vascular occlusion and is characterised by peripheral neuropathy. NFCI generally affects the hands or feet during exposure to temperatures just above freezing, often wet, and is typically found in soldiers.

Inner ear decompression sickness, (IEDCS) or audiovestibular decompression sickness is a medical condition of the inner ear caused by the formation of gas bubbles in the tissues or blood vessels of the inner ear. Generally referred to as a form of decompression sickness, it can also occur at constant pressure due to inert gas counterdiffusion effects.

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  36. ↑ Gage AA, Ishikawa H, Winter PM (1970). "Experimental frostbite. The effect of hyperbaric oxygenation on tissue survival". Cryobiology. 7 (1): 1–8. doi:10.1016/0011-2240(70)90038-6. PMID   5475096.
  37. ↑ Weaver LK, Greenway L, Elliot CG (1988). "Controlled Frostbite Injury to Mice: Outcome of Hyperbaric Oxygen Therapy". J. Hyperbaric Med. 3 (1): 35–44. Archived from the original on 10 July 2009. Retrieved 20 June 2008.{{cite journal}}: CS1 maint: unfit URL (link)
  38. ↑ Ay H, Uzun G, Yildiz S, Solmazgul E, Dundar K, Qyrdedi T, Yildirim I, Gumus T (2005). "The treatment of deep frostbite of both feet in two patients with hyperbaric oxygen". Undersea Hyperb. Med. 32 (1 Suppl). ISSN   1066-2936. OCLC   26915585. Archived from the original on 15 September 2008. Retrieved 30 June 2008.{{cite journal}}: CS1 maint: unfit URL (link)
  39. ↑ Bruen, KJ; Ballard JR; Morris SE; Cochran A; Edelman LS; Saffle JR (2007). "Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy". Archives of Surgery. 142 (6): 546–51. doi:10.1001/archsurg.142.6.546. PMID   17576891.
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