Frostbite

Paul Kraincuk1, Maike Keck2, David Lumenta2, Lars-Peter Kamolz2

1 Universitätsklinik für Anästhesie, Allgemeine Intensivmedizin und Schmerztherapie, Vienna, Austria, 2 Universitätsklinik für Chirurgie, Vienna, Austria

Frostbite (congelatio in medical terminology) is the medical condition, where a damage is caused to skin and other tissues due to extreme cold. Frostbite is most likely to happen in body parts farthest from the heart and those with large exposed areas. The initial stages of frostbite are sometimes called “frostnip”.

Classification

Cold injuries can result in a number of distinct conditions including: Frostnip is a superficial cooling of tissues without cellular destruction [1]. Chilblains are superficial ulcers of the skin that occur when a predisposed individual is repeatedly exposed to cold. Frostbite, on the other hand, involves tissue destruction. Hypothermia is a decrease in core body temperature below 35 C. Trench foot or immersion foot is due to repetitive exposure to wet non-freezing temperatures.

Mechanism

At or below 0 °C (32 °F), blood vessels close to the skin start to constrict. The same response may also be a result of exposure to high winds. This constriction helps to preserve core body temperature. In extreme cold, or when the body is exposed to cold for long periods, this protective strategy can reduce

blood flow in some areas of the body to dangerously low levels. This lack of blood leads to the eventual freezing and death of skin tissue in the affected areas. There are four degrees of frostbite. Each of these degrees has varying degrees of pain [2].

First degree

This is called frostnip and this only affects the surface of the skin, which is frozen. On onset there is itching and pain, and then the skin develops white and yellow patches and becomes numb. The area affected by frostnip usually does not become permanently damaged as only the skin’s top layers are affected. Long-term hypersensitivity to both heat and cold can sometimes happen after suffering from frostnip.

Second degree

If freezing continues, the skin may freeze and harden, but the deep tissues are not affected and remain soft and normal. Second-degree injury usually blisters 1–2 days after becoming frozen. The blisters may become hard and blackened, but usually appear worse than they are. Most of the injuries heal in one month but the area may become permanently sensitive to both heat and cold.

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Third and fourth degrees

If the area freezes further, deep frostbite occurs. The muscles, tendons, blood vessels, and nerves will all freeze. The skin is hard, it feels waxy, and use of the area is lost temporarily, in severe cases permanently. The deep frostbite results in areas of purplish blisters, which turn black and, which are generally blood-filled. Nerve damage in the area can result in a loss of feeling. This extreme frostbite may result in fingers and toes being amputated, if the area becomes infected. If the frostbite has gone on untreated they may fall off. The damage done to the area by the freezing process of the frostbite may take several months to find out and this often delays surgery to remove the dead tissue [3].

Risk factors

Risk factors for frostbite include using beta-blockers and having conditions such as diabetes and peripheral neuropathy.

Causes

Factors that contribute to frostbite include extreme cold, inadequate clothing, wet clothes, wind chill, and poor circulation. Tight clothing or boots, cramped positions and fatigue can cause poor circulation. Certain medications, smoking, alcohol use, and diseases that affect the blood vessels like diabetes can do the same. Liquid nitrogen and other cryogenic liquids can cause frostbite to people working in chemical laboratories even under brief exposure. If the weather is very cold and it is windy, wind chill can greatly reduce the time it takes for frostbite to set in. Diabetes can also sometimes lead to frostbite, if diabetics take trips to ice-cold places[4].

Diagnosis

Plain radiographs, angiography, laser doppler, digital plethysmography, infrared thermography, magnetic resonance imaging, magnetic resonance angiography and triple phase bone scanning can help to predict the severity of frostbite injuries. The most promising studies have used triple phase bone

scanning [5] and MRI/MRA [6]. Triple phase bone scanning using 99technetium assesses tissue viability in an effort to allow early debridement of soft tissue and early coverage of ischaemic bony structures [7].

Treatment

Treatment of frostbite centers on rewarming (and possibly thawing) of the affected tissue. The decision to thaw is based on proximity to a stable, warm environment. If rewarmed tissue ends up refreezing, more damage to tissue will be done. Excessive movement of frostbitten tissue can cause ice crystals that have formed in the tissue to do further damage. Splinting and/or wrapping frostbitten extremities is therefore recommended to prevent such movement. For this reason, rubbing, massaging, shaking, or otherwise applying physical force to frostbitten tissues in an attempt to rewarm them can be harmful [8]. Caution should be taken not to rapidly warm up the affected area until further refreezing is prevented. Warming can be achieved in one of two ways.

Rewarming

Passive rewarming [9] involves using body heat or ambient room temperature to aid the person’s body in rewarming itself. This includes wrapping in blankets or moving to a warmer environment [10]. Active rewarming [9] is the direct addition of heat to a person, usually in addition to the treatments included in passive rewarming. Active rewarming requires more equipment and therefore may be difficult to perform in the prehospital environment [8]. When performed, active rewarming seeks to warm the injured tissues as quickly as possible without burning them. This is desirable as the faster tissue is thawed, the less tissue damage occurs [8]. Active rewarming is usually achieved by immersing the injured tissue in a water-bath that is held between 40 – 42 ˚C. Warming of peripheral tissues can increase blood flow from these areas back to the bodies’ core. This may produce a degree in the bodies’ core temperature and increase the risk of cardiac dysrhythmias [11].

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