Treating serious frostbite
Frostbite isn’t just limited to climbers. Many people live in climates where the homeless, mentally ill, or alcoholic patients spend the night outside and have the possibility of developing frostbite. Failure to diagnose or appropriately treat frostbite can lead to increased morbidity and tissue loss. And judging by the chart below, it won’t take long over most of the US this weekend. (Chart possibly not evidence based)
Then how do we treat serious frostbite? Well, we can use this protocol developed by plastic surgeons in Korea using only 17 patients. And it took them 3 years to accumulate these 17 patients. One can surmise that frostbite might not be a problem, at least not around this particular institution.
That being said, their protocol is based on other studies of frostbite, so it isn’t unsound. Basically it goes as follows:
- Rewarm early to 40-42℃
- NSAIDs during rewarming to prevent thrombosis
- Prostaglandin E1 for 24 hours
- Wait until necrotic margins are defined, then operate
The authors also give prophylactic antibiotics during dressing changes, but have no reference for that. They include tPA and hyperbaric oxygen in their discussion, but based on my reading none of their patients actually received it.
The majority (12/17) of the cases occurred in January, with the other 5 coming in December and February. Climbing was the highest risk factor in their case series. The good news was that all the second degree cases, and three of the five third degree cases resolved without operative management. Of course, conservative management of those third degree cases lasted longer than a month on average. As expected, all 4th degree frostbite cases required surgery, with the surgeries occurring 3 weeks after injury.
Certainly this is a reasonable plan to limit the damage of frostbite once it has been identified and the patient is in a hospital environment. The only treatments one could reasonably perform in the wilderness would be rewarming and NSAIDs. As always, don’t rewarm if there is a chance the extremity could freeze again.
Woo EK, Lee JW, Hur GY, Koh JH, Seo DK, Choi JK, Jang YC. Proposed treatment protocol for frostbite: a retrospective analysis of 17 cases based on a 3-year single-institution experience. Arch Plast Surg. 2013 Sep;40(5):510-6. [PMC3785582]
EBM Gone Wild
Emergency physician with interests in wilderness and prehospital medicine. Medical Director of the Texas State Aquarium, Padre Island National Seashore, Robstown EMS, and Code 3 ER | EBM gone Wild | @EBMGoneWild |