Frostbite: Pathogenesis and Treatment

Abstract

Frostbite, once almost exclusively a military problem, is becoming more prevalent among the general population and should now be considered to be within the scope of the civilian physician's practice. Studies into the epidemiology of civilian frostbite have identified several risk factors that may aid the clinician in the diagnosis and management of cold injuries. Research into the pathophysiology has revealed marked similarities in inflammatory processes to those seen in thermal burns and ischemia/reperfusion injury. Evidence of the role of thromboxanes and prostaglandins has resulted in more active approaches to the medical treatment of frostbite wounds. Although the surgical management of frostbite involves delayed debridement 1 to 3 months after demarcation, recent improvements in radiologic assessment of tissue viability have led to the possibility of earlier surgical intervention. In addition, several adjunctive therapies, including vasodilators, thrombolysis, hyperbaric oxygen, and sympathectomy, are discussed.

A retrospective cohort study examining treatments and operative interventions for frostbite in a tertiary care hospital

“…Case reports of tetanus in patients with frostbite do exist 25 and most reviews promote the use of tetanus toxoid prophylaxis. 10,24 The low rates of tetanus vaccination seen in our study were in keeping with previous findings, and may be due to the lack of recognition of frostbite as an open wound at the time of presentation or the lack of recognition of their potential to become an open wound should the blisters burst at a later time. 15 Analgesia is promoted in frostbite treatment reviews 10 and had a relatively good rate of adherence in our study compared to other interventions.…”

“…13,23 These metabolites of arachidonic acid have been heavily implicated as mediators of progressive dermal ischemia in burn, frostbite, or ischemia/reperfusion injuries. 24 Debridement of clear blisters is included in the protocol as a means to remove these inflammatory agents and improve wound healing. However, these benefits must be weighed against the risk of wound desiccation and infection.…”

“…15 Analgesia is promoted in frostbite treatment reviews 10 and had a relatively good rate of adherence in our study compared to other interventions. 12,24,26 This is likely because frostbite injuries can be extremely painful, and probably not due to a conscious effort to follow the treatment protocol.…”

“…1 Despite these limitations, the McCauley protocol is frequently referenced in frostbite literature and medical textbooks as a standard guideline for frostbite treatment. 13,24,27 It should also be noted that as a guideline, it has undergone slight modifications since the original publication in 1983, and is now often quoted as "Treatment protocol for frostbite (after McCauley et al)" 13 or "Treatment protocol for frostbite (adapted from McCauley et al)" 24 . Smoking cessation, and regular ibuprofen (rather than aspirin) were not included in the original paper but are now generally accepted to be part of the protocol and were therefore included in our study.…”

“…Smoking cessation, and regular ibuprofen (rather than aspirin) were not included in the original paper but are now generally accepted to be part of the protocol and were therefore included in our study. 13,24,27 We used the McCauley protocol in our primary objective because we wanted to determine if a common, protocolled approach to treatment led to improved outcomes. Recognizing these limitations prior to beginning our study and the fact that physicians may use treatments outside of the protocol for frostbite injuries, we decided to include any treatments ordered for frostbite and whether they had an impact on operative interventions.…”