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<!-- Definition and symptoms --> | <!-- Definition and symptoms --> | ||
'''Frostbite''' is | '''Frostbite''' is an [[injury]] to [[skin]] or other living tissue that is allowed to [[freezing|freeze]],<ref name=Han2017/> especially affecting the [[finger]]s, [[toe]]s, [[nose]], [[ear]]s, [[cheek]]s and [[chin]].<ref>{{Cite web|title=Frostbite - Symptoms and causes|url=https://www.mayoclinic.org/diseases-conditions/frostbite/symptoms-causes/syc-20372656|access-date=19 February 2021|website=Mayo Clinic}}</ref> Most often, frostbite occurs in the hands and feet,<ref name="Handford 7">{{Cite journal|last1=Handford|first1=Charles|last2=Buxton|first2=Pauline|last3=Russell|first3=Katie|last4=Imray|first4=Caitlin EA|last5=McIntosh|first5=Scott E|last6=Freer|first6=Luanne|last7=Cochran|first7=Amalia|last8=Imray|first8=Christopher HE|date=22 April 2014|title=Frostbite: a practical approach to hospital management|journal=Extreme Physiology & Medicine|volume=3|article-number=7|doi=10.1186/2046-7648-3-7|issn=2046-7648|pmc=3994495|pmid=24764516 |doi-access=free }}</ref><ref>{{Cite journal|last1=Millet|first1=John D.|last2=Brown|first2=Richard K. J.|last3=Levi|first3=Benjamin|last4=Kraft|first4=Casey T.|last5=Jacobson|first5=Jon A.|last6=Gross|first6=Milton D.|last7=Wong|first7=Ka Kit|date=November 2016|title=Frostbite: Spectrum of Imaging Findings and Guidelines for Management|journal=Radiographics|volume=36|issue=7|pages=2154–2169|doi=10.1148/rg.2016160045|issn=0271-5333|pmc=5131839|pmid=27494386}}</ref> often preceded by '''frostnip''', a paling or reddening of a body part as its blood vessels constrict that [[tingling|tingles]], feels very cold, or simply feels [[numbing|numb]].<ref>{{cite web |title=Frostbite and Frostnip in Children |url=https://www.ummhealth.org/health-library/frostbite-and-frostnip-in-children |website=UMass Memorial Health |location= |publisher=UMass Memorial Health Care |access-date=7 August 2025}}</ref><ref name=Mc2014/><ref>{{cite web |last=Williamson |first=Laura |date=3 January 2025 |title=What cold weather does to the body and how to protect yourself this winter |url=https://www.heart.org/en/news/2025/01/03/what-cold-weather-does-to-the-body-and-how-to-protect-yourself-this-winter#:~:text=Cold%20and%20the%20cardiovascular%20system,blood%20around%20the%20body's%20core. |website=American Heart Association |access-date=7 August 2025}}</ref> This may be followed by the clumsiness and white or bluish, waxy-looking skin that evidence full-blown frostbite.<ref name=Han2017/><ref>{{cite web |title=Frostbite |url=https://www.mayoclinic.org/diseases-conditions/frostbite/symptoms-causes/syc-20372656 |website=Mayo Clinic |access-date=7 August 2025}}</ref> Swelling or [[Blister|blistering]] may occur following treatment.<ref name=Han2017/> Complications may include [[hypothermia]] or [[compartment syndrome]].<ref name=Mc2014/><ref name=Han2017/> | ||
<!-- Cause and diagnosis--> | <!-- Cause and diagnosis--> | ||
People who are exposed to low temperatures for prolonged periods, such as winter sports enthusiasts, military personnel, and homeless | People who are exposed to low temperatures for prolonged periods, such as winter sports enthusiasts, military personnel, and the [[Homelessness|homeless]], are at greatest risk.<ref name="Handford 7"/><ref name=Han2017/> Other risk factors include drinking [[Alcoholic beverage|alcohol]], [[smoking]], [[mental health problems]], certain medications, and prior injuries due to cold.<ref name=Han2017>{{cite journal|last1=Handford|first1=C|last2=Thomas|first2=O|last3=Imray|first3=CHE|title=Frostbite.|journal=Emergency Medicine Clinics of North America|date=May 2017|volume=35|issue=2|pages=281–299|doi=10.1016/j.emc.2016.12.006|pmid=28411928}}</ref> The underlying mechanism involves injury from ice crystals and [[blood clot]]s in small [[blood vessel]]s following thawing.<ref name=Han2017/> Diagnosis is based on symptoms.<ref name=Sin2014>{{cite book|last1=Singleton|first1=Joanne K.|last2=DiGregorio|first2=Robert V.|last3=Green-Hernandez|first3=Carol|title=Primary Care, Second Edition: An Interprofessional Perspective|date=2014|publisher=Springer Publishing Company|isbn=978-0-8261-7147-4|page=172|url=https://books.google.com/books?id=jJCKBQAAQBAJ&pg=PA172}}</ref> Severity may be divided into superficial (first and second degree) and deep (third and fourth degree).<ref name=Mc2014/> A [[bone scan]] or [[MRI]] may help in determining the extent of injury.<ref name=Han2017/> | ||
<!-- Prevention and treatment --> | <!-- Prevention and treatment --> | ||
Prevention | Prevention consists of wearing proper, fully-covering clothing, avoiding low temperatures and wind, maintaining [[management of dehydration|hydration]] and nutrition, and sufficient physical activity to maintain [[Human body temperature#Core temperature|core temperature]] without exhaustion.<ref name=Mc2014/> Treatment is by rewarming, immersion in warm water (near body temperature), or body contact, and should be done only when a consistent temperature can be maintained so that refreezing is not a risk.<ref name=Mc2014/><ref name=Han2017/> Rapid heating or cooling should be avoided since it could potentially cause burning or heart stress.<ref>{{Cite web|title=Frostbite and Hypothermia|url=https://portal.ct.gov/dph/communications/crisis-and-emergency-risk-communication/frostbite-and-hypothermia|access-date=2 July 2021|website=CT.gov - Connecticut's Official State Website}}</ref> Rubbing or applying force to the affected areas should be avoided as it may cause further damage such as [[Abrasion (medicine)|abrasions]].<ref name=Mc2014/> The use of [[ibuprofen]] and [[tetanus vaccine|tetanus toxoid]] is recommended for pain relief or to reduce swelling or inflammation.<ref name=Han2017/> For severe injuries, [[iloprost]] or [[thrombolytic]]s may be used.<ref name=Han2017/> Surgery, including [[amputation]], is sometimes necessary.<ref name=Han2017/><ref name=Mc2014>{{Cite journal|last1=McIntosh|first1=Scott E.|last2=Opacic|first2=Matthew|last3=Freer|first3=Luanne|last4=Grissom|first4=Colin K.|last5=Auerbach|first5=Paul S.|last6=Rodway|first6=George W.|last7=Cochran|first7=Amalia|last8=Giesbrecht|first8=Gordon G.|last9=McDevitt|first9=Marion|date=1 December 2014|title=Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update|journal=Wilderness & Environmental Medicine|volume=25|issue=4 Suppl|pages=S43–54|doi=10.1016/j.wem.2014.09.001|issn=1545-1534|pmid=25498262|doi-access=free}}</ref> | ||
<!-- Epidemiology and history --> | <!-- Epidemiology and history --> | ||
Evidence of frostbite occurring in | Evidence of frostbite occurring in humans dates back 5,000 years.<ref name="Han2017" /> Evidence was documented in a pre-Columbian mummy discovered in the Andes.<ref name="Handford 7"/> The number of annual cases of frostbite is unknown.<ref name=Au2011>{{cite book|last1=Auerbach|first1=Paul S.|title=Wilderness Medicine E-Book: Expert Consult Premium Edition - Enhanced Online Features|date=2011|publisher=Elsevier Health Sciences|isbn=978-1-4557-3356-9|page=181|url=https://books.google.com/books?id=tdTInPqMCjMC&pg=PA181}}</ref> Rates may be as high as 40% a year among those who [[mountaineer]].<ref name=Han2017/> The most common age group affected is those 30 to 50 years old.<ref name="Fer2018">{{cite book|last1=Ferri|first1=Fred F.|url=https://books.google.com/books?id=wGclDwAAQBAJ&pg=PA502|title=Ferri's Clinical Advisor 2018 E-Book: 5 Books in 1|date=2017|publisher=Elsevier Health Sciences|isbn=978-0-323-52957-0|page=502}}</ref> Frostbite has also played an important role in a number of military conflicts.<ref name=Han2017/> Its first formal description was in 1813 by [[Dominique Jean Larrey]], a physician in [[Napoleon]]'s army, during its [[French invasion of Russia|invasion of Russia]].<ref name=Han2017/> Frostbite reports were largely military until the late 1950s.<ref>{{cite web |last=Zonnoor |first=Bobak |date=29 February 2024 |title=Frostbite |url=https://emedicine.medscape.com/article/926249-overview#:~:text=When%20external%20warmth%20is%20applied,resulting%20in%20greater%20tissue%20loss. |website= Medscape |publisher= WebMD LLC|access-date=7 August 2025}}</ref> | ||
==Signs and symptoms== | ==Signs and symptoms== | ||
[[File:Frostbite.png|thumb|upright=1.3|Frostbite]] | [[File:Frostbite.png|thumb|upright=1.3|Frostbite]] | ||
Areas that are usually affected include cheeks, ears, nose and fingers and toes. Frostbite is often preceded by frostnip.<ref name=Mc2014/> 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.<ref name=":2">{{Cite web|url=http://emedicine.medscape.com/article/926249-clinical|title=Frostbite Clinical Presentation|website=emedicine.medscape.com|access-date=2 March 2017|url-status=live|archive-url=https://web.archive.org/web/20170302113905/http://emedicine.medscape.com/article/926249-clinical|archive-date=2 March 2017}}</ref> A simplification of this system of classification is superficial (first or second degree) or deep injury (third or fourth degree).<ref name=Zaf2012 /> | Areas that are usually affected include cheeks, ears, nose and fingers and toes. Frostbite is often preceded by frostnip.<ref name=Mc2014/><ref>{{cite web |title=Frostbite and Frostnip in Children |url=https://www.ummhealth.org/health-library/frostbite-and-frostnip-in-children |website=UMass Memorial Health |location= |publisher=UMass Memorial Health Care |access-date=7 August 2025}}</ref> 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.<ref name=":2">{{Cite web|url=http://emedicine.medscape.com/article/926249-clinical|title=Frostbite Clinical Presentation|website=emedicine.medscape.com|access-date=2 March 2017|url-status=live|archive-url=https://web.archive.org/web/20170302113905/http://emedicine.medscape.com/article/926249-clinical|archive-date=2 March 2017}}</ref> A simplification of this system of classification is superficial (first or second degree) or deep injury (third or fourth degree).<ref name=Zaf2012 /> | ||
===First degree=== | ===First degree=== | ||
* First degree frostbite is superficial, surface skin damage that is usually not permanent. | * First-degree frostbite is superficial, surface skin damage that is usually not permanent. | ||
* Early on, the primary symptom is loss of feeling in the skin. In the affected areas, the skin is numb, and possibly swollen, with a reddened border. | * Early on, the primary symptom is loss of feeling in the skin. In the affected areas, the skin is numb, waxy, and possibly swollen, with a reddened border. | ||
* In the weeks after injury, the skin's surface may slough off.<ref name=":2" /> | * In the weeks after injury, the skin's surface may slough off.<ref name=":2" /> | ||
[[File:Right foot third degree frostbite.png|thumb|Third-degree frostbite developing. Doppler arterial ultrasound showed adequate perfusion to the foot with no blood flow to the toes. Gangrene was still demarcating, i.e., separating dead from living tissue.]] | |||
===Second degree=== | ===Second degree=== | ||
* In second degree frostbite, the skin develops clear [[blister]]s early on, and | * In second-degree frostbite, the skin develops clear [[blister]]s early on, and its surface hardens. | ||
* In the weeks after injury, this hardened, blistered skin dries, blackens, and peels. | * In the weeks after injury, this hardened, blistered skin dries, blackens, and peels. | ||
* At this stage, lasting cold sensitivity and numbness can develop.<ref name=":2" /> | * At this stage, lasting cold sensitivity and numbness can develop.<ref name=":2" /> | ||
[[File:Left foot third degree frostbite.png|thumb|Third-degree frostbite. No surgical interventions recommended as the gangrenous portion of the wound was still demarcating.]] | |||
===Third degree=== | ===Third degree=== | ||
* In third degree frostbite, the layers of tissue below the skin freeze. | * In third-degree frostbite, the layers of tissue below the skin freeze. | ||
* Symptoms include blood blisters and "blue-grey discoloration of the skin".<ref>{{cite web | vauthors = Zonnoor B | title = What are the characteristics of third-degree frostbite? | publisher = Medscape | date = 29 July 2019 | url = https://www.medscape.com/answers/926249-117029/what-are-the-characteristics-of-third-degree-frostbite | access-date = 10 May 2020}}</ref> | * Symptoms include blood blisters and "blue-grey discoloration of the skin".<ref>{{cite web | vauthors = Zonnoor B | title = What are the characteristics of third-degree frostbite? | publisher = Medscape | date = 29 July 2019 | url = https://www.medscape.com/answers/926249-117029/what-are-the-characteristics-of-third-degree-frostbite | access-date = 10 May 2020}}</ref> | ||
* In the weeks after injury, pain persists and a blackened crust ([[eschar]]) develops. | * In the weeks after injury, pain persists and a blackened crust ([[eschar]]) develops. | ||
* There can be | * There can be long-term [[ulcer]]ation and damage to [[Epiphyseal plate|growth plates]]. | ||
=== Fourth degree === | === Fourth degree === | ||
[[File:Human toes, 12 days post-frostbite.jpg|thumb|Frostbite 12 days later]] | [[File:Human toes, 12 days post-frostbite.jpg|thumb|Frostbite 12 days later]] | ||
* In fourth degree frostbite, structures below the skin | * In fourth-degree frostbite, structures below the skin, like muscles, tendon, and bone, are involved. | ||
* Early symptoms include a colorless appearance of the skin, a hard texture, and painless rewarming. | * Early symptoms include a colorless appearance of the skin, a hard texture, and painless rewarming. | ||
* Later, the skin becomes black and [[Mummy|mummified]]. The amount of permanent damage can take one month or more to determine. [[Autoamputation]] can occur after two months.<ref name=":2" /> | * Later, the skin becomes black and [[Mummy|mummified]]. The amount of permanent damage can take one month or more to determine. [[Autoamputation]] can occur after two months.<ref name=":2" />[[File:Frostbite dorsal surface feet.jpg|thumb|Fourth-degree frostbite in a homeless patient five days after freezing conditions. Patient developed [[trench foot]] and was unable to properly dry feet.]][[File:Frostbite palmar surface feet.jpg|thumb|Plantar surface of frostbitten feet five days after a freeze. Patient was homeless with poor footwear.]] | ||
==Causes== | ==Causes== | ||
===Risk factors=== | ===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.<ref name= | 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.<ref name="Handford 7"/> Disorders and substances that impair circulation contribute, including [[Diabetes mellitus|diabetes]], [[Raynaud syndrome|Raynaud's phenomenon]], [[tobacco]] and [[Alcoholic drink|alcohol]] use.<ref name=Zaf2012 /> Homeless individuals and individuals with some mental illnesses may be at higher risk.<ref name="Handford 7"/> | ||
==Mechanism== | ==Mechanism== | ||
===Freezing=== | ===Freezing=== | ||
In frostbite, cooling of the body causes narrowing of the blood vessels ([[vasoconstriction]]). | In frostbite, cooling of the body causes narrowing of the blood vessels ([[vasoconstriction]]). Prolonged exposure to temperatures below {{convert|-2|C|F}} may cause ice crystals to form in the tissues, and prolonged exposure to temperatures below {{convert|-4|C|F}} may cause ice crystals to form in the blood.<ref name="knap">{{cite journal |vauthors=Knapik JJ, Reynolds KL, Castellani JW |title=Frostbite: Pathophysiology, Epidemiology, Diagnosis, Treatment, and Prevention |journal=Journal of Special Operations Medicine|volume=20 |issue=4 |pages=123–135 |date=2020 |pmid=33320326 |doi=10.55460/PDX9-BG8G |s2cid=229171926 |url=}}</ref> Ice crystals can damage small blood vessels at the site of injury.<ref name=Zaf2012>{{Cite journal|last=Zafren|first=Ken|s2cid=3036889|title=Frostbite: Prevention and Initial Management|journal=High Altitude Medicine & Biology|volume=14|issue=1|pages=9–12|doi=10.1089/ham.2012.1114|pmid=23537254|year=2013}}</ref> Typically, prolonged exposure to temperatures below {{convert|-0.55|C|F}} may cause frostbite.<ref>{{cite web | url=https://www.nhs.uk/conditions/frostbite/ | title=Frostbite|publisher=UK National Health Service | access-date=16 July 2023|date=24 August 2021}}</ref> | ||
===Rewarming=== | ===Rewarming=== | ||
Rewarming causes tissue damage through [[reperfusion injury]], which involves vasodilation, swelling (edema), and poor blood flow (stasis). [[Platelet|Platelet aggregation]] is another possible mechanism of injury. Blisters and spasm of blood vessels ([[vasospasm]]) can develop after rewarming.<ref name=Zaf2012 /> | Rewarming, though vital, causes tissue damage through [[reperfusion injury]], which involves [[vasodilation]], swelling (edema), and poor blood flow (stasis). [[Platelet|Platelet aggregation]] is another possible mechanism of injury. Blisters and spasm of blood vessels ([[vasospasm]]) can develop after rewarming.<ref name=Zaf2012 /> | ||
===Non-freezing cold injury=== | ===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 cell]]s act in the area. Small [[Thrombus|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 [[prostaglandin]]s to increase localized clotting.<ref name=":0" /> | 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 cell]]s act in the area. Small [[Thrombus|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 [[prostaglandin]]s to increase localized clotting.<ref name=":0">{{Cite journal|last1=Sachs|first1=Christoph|last2=Lehnhardt|first2=Marcus|last3=Daigeler|first3=Adrien|last4=Goertz|first4=Ole|date=1 March 2017|title=The Triaging and Treatment of Cold-Induced Injuries|journal=Deutsches Ärzteblatt International|volume=112|issue=44|pages=741–747|doi=10.3238/arztebl.2015.0741|issn=1866-0452|pmc=4650908|pmid=26575137}}</ref> | ||
===Pathophysiology=== | ===Pathophysiology=== | ||
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== Diagnosis == | == Diagnosis == | ||
Frostbite is diagnosed | Frostbite is diagnosed on the basis of signs and symptoms as described above, and by [[Medical history|patient history]]. Other conditions that can have a similar appearance or occur at the same time include: | ||
* Frostnip | * Frostnip, a precursor to frostbite with a similar appearance, but without ice crystal formation in the skin. Whitening of the skin and numbness reverse quickly after rewarming. | ||
* [[Trench foot]] | * [[Trench foot]], damage to nerves and blood vessels that results from exposure to cold wet (non-freezing) conditions.<ref>{{Cite journal |last=Jurkovich |first=Gregory J. |date=February 2007 |title=Environmental cold-induced injury |journal=The Surgical Clinics of North America |volume=87 |issue=1 |pages=247–267, viii |doi=10.1016/j.suc.2006.10.003 |issn=0039-6109 |pmid=17127131}}</ref> This is reversible if treated early. | ||
* [[Chilblains|Pernio]] or chilblains | * [[Chilblains|Pernio]] or chilblains, inflammation of the skin from exposure to wet, cold (non-freezing) conditions. They can appear as various types of ulcers and blisters.<ref name=":2" /> | ||
* [[Bullous pemphigoid]] | * [[Bullous pemphigoid]], a condition that causes itchy blisters over the body that can mimic frostbite.<ref name=":4">{{Cite news|url=https://www.visualdx.com/visualdx/diagnosis/frostbite?diagnosisId=51593&moduleId=8|title=VisualDx - Frostbite|work=VisualDx|access-date=3 March 2017|url-status=live|archive-url=https://web.archive.org/web/20170303123454/https://www.visualdx.com/visualdx/diagnosis/frostbite?diagnosisId=51593&moduleId=8|archive-date=3 March 2017}}</ref> It does not require exposure to cold to develop. | ||
* [[Levamisole-induced vasculitis|Levamisole toxicity]] | * [[Levamisole-induced vasculitis|Levamisole toxicity]], a [[vasculitis]] that can appear similar to frostbite.<ref name=":4" /> It is caused by contamination of cocaine by [[levamisole]]. Skin lesions can look similar to those of frostbite, but do not require cold exposure to occur. | ||
People who have [[hypothermia]] often have frostbite as well.<ref name=":2" /> Since hypothermia is life-threatening this should be treated first. [[Technetium-99m|Technetium-99]] or [[Magnetic resonance imaging|MR]] scans are not required for diagnosis, but might be useful for prognostic purposes.<ref>{{Cite web|url=http://us.bestpractice.bmj.com/best-practice/monograph/997.html|title=Frostbite|website=us.bestpractice.bmj.com | People who have [[hypothermia]] often have frostbite as well.<ref name=":2" /> Since hypothermia is life-threatening this should be treated first. [[Technetium-99m|Technetium-99]] or [[Magnetic resonance imaging|MR]] scans are not required for diagnosis, but might be useful for prognostic purposes.<ref>{{Cite web|url=http://us.bestpractice.bmj.com/best-practice/monograph/997.html|title=Frostbite|website=us.bestpractice.bmj.com|access-date=4 March 2017|url-status=live|archive-url=https://web.archive.org/web/20170304193415/http://us.bestpractice.bmj.com/best-practice/monograph/997.html|archive-date=4 March 2017}}</ref> | ||
== Prevention == | == Prevention == | ||
[[File:CDC winter safety infographic.ogg|thumb|A [[Centers for Disease Control and Prevention]] infographic video about frostbite prevention | [[File:CDC winter safety infographic.ogg|thumb|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 | 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 may also be of use at high elevations. Repeated exposure to cold water makes people more susceptible to frostbite.<ref name="pmid26857732">{{cite journal | vauthors = Fudge J | title = Preventing and Managing Hypothermia and Frostbite Injury | journal = Sports Health | volume = 8 | issue = 2 | pages = 133–9 | date = 2016 | pmid = 26857732 | pmc = 4789935 | doi = 10.1177/1941738116630542 }}</ref> Additional measures to prevent frostbite include:<ref name=Mc2014 /> | ||
* Avoiding temperatures below | * Avoiding temperatures below −23 °C (-9 °F) | ||
* Avoiding moisture, including in the form of [[Perspiration|sweat]] and/or skin [[Moisturizer|emollients]] | * Avoiding moisture, including in the form of [[Perspiration|sweat]] and/or skin [[Moisturizer|emollients]] | ||
* Avoiding alcohol and drugs that impair circulation or natural protective responses | * Avoiding alcohol and drugs that impair circulation or natural protective responses | ||
| Line 108: | Line 110: | ||
==Treatment== | ==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 | 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 underarm of a companion or the groin. 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<ref name="Handford 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.<ref>{{cite journal|last1=Heil|first1=K|last2=Thomas|first2=R|last3=Robertson|first3=G|last4=Porter|first4=A|last5=Milner|first5=R|last6=Wood|first6=A|title=Freezing and non-freezing cold weather injuries: a systematic review.|journal=British Medical Bulletin|date=March 2016|volume=117|issue=1|pages=79–93|doi=10.1093/bmb/ldw001|pmid=26872856|doi-access=free}}</ref> | ||
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 [[Human body temperature|core temperature]] should be raised above 35 °C. Oral or [[Intravenous therapy|intravenous (IV)]] fluids should be given.<ref name= | 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 [[Human body temperature|core temperature]] should be raised above 35 °C. Oral or [[Intravenous therapy|intravenous (IV)]] fluids should be given.<ref name="Handford 7"/> | ||
Other considerations for standard hospital management include: | Other considerations for standard hospital management include: | ||
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=== Rewarming === | === Rewarming === | ||
If the area is still partially or fully frozen, it should be rewarmed in the hospital with a warm bath with [[Povidone-iodine|povidone iodine]] or [[chlorhexidine]] [[antiseptic]].<ref name= | If the area is still partially or fully frozen, it should be rewarmed in the hospital with a warm bath with [[Povidone-iodine|povidone iodine]] or [[chlorhexidine]] [[antiseptic]].<ref name="Handford 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.<ref name="mistovich506">{{cite book|title=Prehospital Emergency Care|last2=Haffen|first2=Brent|last3=Karren|first3=Keith|publisher=Pearson Education|year=2004|isbn=0-13-049288-4|location=Upsaddle River, NJ|page=506|last1=Mistovich|first1=Joseph}}</ref> 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.<ref>{{Cite web|last=Laderer|first=Ashley|title=How to treat frostbite and when you should seek emergency medical help|url=https://www.insider.com/how-to-treat-frostbite|access-date=30 September 2021|website=Insider}}</ref> Rewarming can be very painful, so pain management is important.<ref name="Handford 7"/> | ||
=== Medications === | === Medications === | ||
People with potential for large amputations and who present within 24 hours of injury can be given [[Tissue plasminogen activator|TPA]] with [[heparin]].<ref name=Han2017/> These medications should be withheld if there are any contraindications. [[Bone scintigraphy|Bone scans]] or [[Computed tomography angiography|CT angiography]] can be done to assess damage.<ref name=":6">{{Cite web|url=https://www.uptodate.com/contents/frostbite|title=Frostbite|website=www.uptodate.com|access-date=3 March 2017|url-status=live|archive-url=https://web.archive.org/web/20170304120126/https://www.uptodate.com/contents/frostbite|archive-date=4 March 2017}}</ref> | People with potential for large amputations and who present within 24 hours of injury can be given [[Tissue plasminogen activator|TPA]] with [[heparin]].<ref name=Han2017/> These medications should be withheld if there are any contraindications. [[Bone scintigraphy|Bone scans]] or [[Computed tomography angiography|CT angiography]] can be done to assess damage.<ref name=":6">{{Cite web|url=https://www.uptodate.com/contents/frostbite|title=Frostbite|website=www.uptodate.com|access-date=3 March 2017|url-status=live|archive-url=https://web.archive.org/web/20170304120126/https://www.uptodate.com/contents/frostbite|archive-date=4 March 2017}}</ref> | ||
Blood vessel dilating medications such as [[iloprost]] may prevent blood vessel blockage.<ref name= | Blood vessel dilating medications such as [[iloprost]] may prevent blood vessel blockage.<ref name="Handford 7"/> This treatment might be appropriate in grades 2–4 frostbite, when people get treatment within 48 hours.<ref name=":6" /> In addition to vasodilators, [[sympatholytic]] drugs can be used to counteract the detrimental peripheral [[vasoconstriction]] that occurs during frostbite.<ref>{{cite journal|last1=Sachs|first1=C|last2=Lehnhardt|first2=M|last3=Daigeler|first3=A|last4=Goertz|first4=O|title=The Triaging and Treatment of Cold-Induced Injuries.|journal=Deutsches Ärzteblatt International|date=30 October 2015|volume=112|issue=44|pages=741–7|doi=10.3238/arztebl.2015.0741|pmid=26575137|pmc=4650908}}</ref> | ||
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.<ref>{{Cite journal|last1=Lorentzen|first1=Anne Kathrine|last2=Davis|first2=Christopher|last3=Penninga|first3=Luit|date=20 December 2020|title=Interventions for frostbite injuries | 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.<ref>{{Cite journal|last1=Lorentzen|first1=Anne Kathrine|last2=Davis|first2=Christopher|last3=Penninga|first3=Luit|date=20 December 2020|title=Interventions for frostbite injuries|journal=Cochrane Database of Systematic Reviews|volume=2020|issue=12|article-number=CD012980|doi=10.1002/14651858.cd012980.pub2|pmid=33341943|pmc=8092677|issn=1465-1858}}</ref> | ||
===Surgery=== | ===Surgery=== | ||
Various types of surgery might be indicated in frostbite injury, depending on the type and extent of damage. [[Debridement]] or amputation of [[Necrosis|necrotic]] tissue is usually delayed unless there is [[gangrene]] or systemic infection ([[sepsis]]).<ref name= | Various types of surgery might be indicated in frostbite injury, depending on the type and extent of damage. [[Debridement]] or amputation of [[Necrosis|necrotic]] tissue is usually delayed unless there is [[gangrene]] or systemic infection ([[sepsis]]).<ref name="Handford 7"/> This has led to the adage "Frozen in January, amputate in July".<ref name=2008rev>{{Cite journal | last1 = Golant | first1 = A | last2 = Nord | first2 = RM | last3 = Paksima | first3 = N | last4 = Posner | first4 = MA | title = Cold exposure injuries to the extremities. | journal = J Am Acad Orthop Surg | volume = 16 | issue = 12 | pages = 704–15 |date=Dec 2008 | pmid = 19056919 | doi = 10.5435/00124635-200812000-00003 | s2cid = 19274894 }}</ref> If symptoms of compartment syndrome develop, [[fasciotomy]] can be done to attempt to preserve blood flow.<ref name="Handford 7"/> | ||
== Prognosis == | == Prognosis == | ||
[[File:Human toes, 3 weeks post-frostbite.jpg|thumb|3 weeks after initial frostbite]] | [[File:Human toes, 3 weeks post-frostbite.jpg|thumb|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.<ref name=Zaf2012 /> 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.<ref name= | 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.<ref name=Zaf2012 /> 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.<ref name="Handford 7"/> | ||
=== Grades === | === Grades === | ||
| Line 143: | Line 145: | ||
Grade 3: if there is a lesion on the intermediate or near body part, auto-amputation and loss of function can occur | 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.<ref name= | 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.<ref name="Handford 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.<ref name= | 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.<ref name=marx1866>{{cite book |title=Rosen's emergency medicine: concepts and clinical practice |edition=7th |last=Marx |first=John |year=2010 |publisher=Mosby/Elsevier |location=Philadelphia, PA |isbn=978-0-323-05472-0 |page=1866}}</ref> | ||
== Epidemiology == | == 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 (epidemiology)|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 | 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 (epidemiology)|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 because of occupational or recreational exposures to cold.<ref>{{Cite web |date=2 February 2017|title=Frostbite: Background, Pathophysiology, Etiology |website=Medscape |publisher=Medscape, LLC|url=http://emedicine.medscape.com/article/926249-overview#a5 |url-status=live |archive-url=https://web.archive.org/web/20170302112845/http://emedicine.medscape.com/article/926249-overview#a5 |archive-date=2 March 2017}}</ref> | ||
== History == | == History == | ||
Frostbite has been described in military history for millennia. The Greeks encountered and discussed the problem of frostbite as early as 400 | Frostbite has been described in military history for millennia. The Greeks encountered and discussed the problem of frostbite as early as 400 BC.<ref name=Zaf2012 /> 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.<ref name="Handford 7"/> According to Zafren, nearly 1 million combatants fell victim to frostbite in the First and Second World Wars and the Korean War.<ref name=Zaf2012 /> | ||
== Society and culture == | == Society and culture == | ||
[[File:Nigel Vardy Frostbite.jpg|thumb|Mountaineer [[Nigel Vardy]] in hospital after | [[File:Nigel Vardy Frostbite.jpg|thumb|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: [[Lawrence Oates|Captain Lawrence Oates]], an English army captain and [[Antarctic]] explorer who in 1912 died of complications of frostbite | Several notable cases of frostbite include: | ||
* [[Lawrence Oates|Captain Lawrence Oates]], an English army captain and [[Antarctic]] explorer who in 1912 died of complications of frostbite<ref>{{Cite web|url=https://www.bbc.co.uk/history/british/britain_wwone/race_pole_01.shtml|website=BBC - History |title= British History in depth: The Race to the South Pole|access-date=4 March 2017|url-status=live|archive-url=https://web.archive.org/web/20170213052907/http://www.bbc.co.uk/history/british/britain_wwone/race_pole_01.shtml|archive-date=13 February 2017}}</ref> | |||
* [[Harold Bride]], the junior wireless operator of {{RMS|Titanic}}, who suffered severe frostbite on his feet as he and other survivors stood for over an hour on the back of a capsized lifeboat knee-deep in freezing water—Bride had to be carried off from the rescue vessel {{RMS|Carpathia}} after it arrived in New York | |||
* Noted American rock climber [[Hugh Herr]], who in 1982 lost both legs below the knee to frostbite after being stranded on [[Mount Washington (New Hampshire)]] in a blizzard<ref>{{Cite news|url=http://www.bostonmagazine.com/2009/02/best-foot-forward-february/|title=Hugh Herr's Best Foot Forward {{!}} Boston Magazine|date=18 February 2009|work=Boston Magazine|access-date=4 March 2017|url-status=live|archive-url=https://web.archive.org/web/20170330102917/http://www.bostonmagazine.com/2009/02/best-foot-forward-february/|archive-date=30 March 2017}}</ref> | |||
* [[Beck Weathers]], a survivor of the [[1996 Mount Everest disaster]] who lost his nose and hands to frostbite<ref>{{Cite news|url=http://people.com/movies/beck-weathers-says-fateful-everest-climb-saved-his-marriage/|title=Beck Weathers Says Fateful Everest Climb Saved His Marriage|date=16 September 2015|work=PEOPLE|access-date=4 March 2017|url-status=live|archive-url=https://web.archive.org/web/20170304114431/http://people.com/movies/beck-weathers-says-fateful-everest-climb-saved-his-marriage/|archive-date=4 March 2017}}</ref> | |||
* Scottish mountaineer [[Jamie Andrew]], who in 1999 had all four limbs amputated as a result of sepsis from frostbite sustained after becoming trapped for four nights whilst climbing [[Les Droites]] in the [[Mont Blanc massif]]<ref>{{Cite news|url=https://www.theguardian.com/books/2004/mar/28/biography.sportandleisure|title=I'll get there, even if it kills...|last=Heawood|first=Jonathan|date=27 March 2004|work=The Guardian|access-date=4 March 2017|issn=0261-3077|url-status=live|archive-url=https://web.archive.org/web/20170304115505/https://www.theguardian.com/books/2004/mar/28/biography.sportandleisure|archive-date=4 March 2017}}</ref> | |||
{{clear}} | {{clear}} | ||
==Research directions== | ==Research directions== | ||
Evidence is insufficient to determine whether or not [[hyperbaric oxygen therapy]] as an adjunctive treatment can assist in tissue salvage.<ref>{{harvnb|Marx|2010}}</ref> Cases have been reported, but no [[Randomized controlled trial|randomized control trial]] has been performed on humans.<ref>{{cite journal |vauthors=Finderle Z, Cankar K |title=Delayed treatment of frostbite injury with hyperbaric oxygen therapy: a case report |journal=Aviat Space Environ Med |volume=73 |issue=4 |pages=392–4 |date=April 2002|pmid=11952063 }}</ref><ref>{{cite journal |vauthors=Folio LR, Arkin K, Butler WP |title=Frostbite in a mountain climber treated with hyperbaric oxygen: case report|journal=Mil Med |volume=172 |issue=5 |pages=560–3 |date=May 2007 |pmid=17521112 |doi=10.7205/milmed.172.5.560|doi-access=free }}</ref><ref>{{cite journal |vauthors=Gage AA, Ishikawa H, Winter PM |title=Experimental frostbite. The effect of hyperbaric oxygenation on tissue survival |journal=Cryobiology |volume=7 |issue=1 |pages=1–8 |year=1970 |pmid=5475096 |doi= 10.1016/0011-2240(70)90038-6}}</ref><ref>{{cite journal |vauthors=Weaver LK, Greenway L, Elliot CG |title=Controlled Frostbite Injury to Mice: Outcome of Hyperbaric Oxygen Therapy. |journal=J. Hyperbaric Med |volume=3 |issue=1 |pages=35–44 |year=1988 |url=http://archive.rubicon-foundation.org/4363 |access-date=20 June 2008 |url-status= | Evidence is insufficient to determine whether or not [[hyperbaric oxygen therapy]] as an adjunctive treatment can assist in tissue salvage.<ref>{{harvnb|Marx|2010}}</ref> Cases have been reported, but no [[Randomized controlled trial|randomized control trial]] has been performed on humans.<ref>{{cite journal |vauthors=Finderle Z, Cankar K |title=Delayed treatment of frostbite injury with hyperbaric oxygen therapy: a case report |journal=Aviat Space Environ Med |volume=73 |issue=4 |pages=392–4 |date=April 2002|pmid=11952063 }}</ref><ref>{{cite journal |vauthors=Folio LR, Arkin K, Butler WP |title=Frostbite in a mountain climber treated with hyperbaric oxygen: case report|journal=Mil Med |volume=172 |issue=5 |pages=560–3 |date=May 2007 |pmid=17521112 |doi=10.7205/milmed.172.5.560|doi-access=free }}</ref><ref>{{cite journal |vauthors=Gage AA, Ishikawa H, Winter PM |title=Experimental frostbite. The effect of hyperbaric oxygenation on tissue survival |journal=Cryobiology |volume=7 |issue=1 |pages=1–8 |year=1970 |pmid=5475096 |doi= 10.1016/0011-2240(70)90038-6}}</ref><ref>{{cite journal |vauthors=Weaver LK, Greenway L, Elliot CG |title=Controlled Frostbite Injury to Mice: Outcome of Hyperbaric Oxygen Therapy. |journal=J. Hyperbaric Med |volume=3 |issue=1 |pages=35–44 |year=1988 |url=http://archive.rubicon-foundation.org/4363 |access-date=20 June 2008 |url-status=usurped |archive-url=https://web.archive.org/web/20090710074430/http://archive.rubicon-foundation.org/4363 |archive-date=10 July 2009 }}</ref><ref>{{cite journal |vauthors=Ay H, Uzun G, Yildiz S, Solmazgul E, Dundar K, Qyrdedi T, Yildirim I, Gumus T |title=The treatment of deep frostbite of both feet in two patients with hyperbaric oxygen |journal=Undersea Hyperb. Med. |volume=32 |issue=1 Suppl |year=2005 |issn=1066-2936 |oclc=26915585 |url=http://archive.rubicon-foundation.org/1629 |access-date=30 June 2008 |url-status=usurped |archive-url=https://web.archive.org/web/20080915070147/http://archive.rubicon-foundation.org/1629 |archive-date=15 September 2008 }}</ref> | ||
Medical [[sympathectomy]] using intravenous [[reserpine]] has also been attempted with limited success.<ref name=marx1866 /> Studies have suggested that administration of [[tissue plasminogen activator]] (tPa) either intravenously or intra-arterially may decrease the likelihood of eventual need for amputation.<ref>{{cite journal|last=Bruen|first=KJ|author2=Ballard JR |author3=Morris SE |author4=Cochran A |author5=Edelman LS |author6=Saffle JR |title=Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy|journal=Archives of Surgery|year=2007|volume=142|pages=546–51|doi=10.1001/archsurg.142.6.546 |pmid=17576891 |issue=6|doi-access= | Medical [[sympathectomy]] using intravenous [[reserpine]] has also been attempted with limited success.<ref name=marx1866 /> Studies have suggested that administration of [[tissue plasminogen activator]] (tPa) either intravenously or intra-arterially may decrease the likelihood of eventual need for amputation.<ref>{{cite journal|last=Bruen|first=KJ|author2=Ballard JR |author3=Morris SE |author4=Cochran A |author5=Edelman LS |author6=Saffle JR |title=Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy|journal=Archives of Surgery|year=2007|volume=142|pages=546–51|doi=10.1001/archsurg.142.6.546 |pmid=17576891 |issue=6|doi-access=}}</ref> | ||
==References== | ==References== | ||
| Line 190: | Line 198: | ||
[[Category:Mountaineering and health]] | [[Category:Mountaineering and health]] | ||
[[Category:Skin conditions resulting from physical factors]] | [[Category:Skin conditions resulting from physical factors]] | ||
[[Category: | [[Category:Thermal medicine]] | ||
[[Category: | [[Category:Weather and health]] | ||
[[Category:Causes of amputation]] | |||
[[Category:Bharatpedia medicine articles ready to translate]] | |||
[[Category:Wilderness medical emergencies]] | [[Category:Wilderness medical emergencies]] | ||
Latest revision as of 03:25, 21 March 2026
| Frostbite | |
|---|---|
| Other names | Frostnip |
 | |
| 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] |
| Types | Superficial, deep[2] |
| Causes | Temperatures 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] |
| Prevention | Avoid cold, wear proper clothing, maintain hydration and nutrition, stay active without becoming exhausted[2] |
| Treatment | Rewarming, medication, surgery[2] |
| Medication | Ibuprofen, tetanus vaccine, iloprost, thrombolytics[1] |
| Frequency | Unknown[5] |
Frostbite is an injury to skin or other living tissue that is allowed to freeze,[1] especially affecting the fingers, toes, nose, ears, cheeks and chin.[6] Most often, frostbite occurs in the hands and feet,[7][8] often preceded by frostnip, a paling or reddening of a body part as its blood vessels constrict that tingles, feels very cold, or simply feels numb.[9][2][10] This may be followed by the clumsiness and white or bluish, waxy-looking skin that evidence full-blown frostbite.[1][11] Swelling or blistering may occur following treatment.[1] Complications may include hypothermia or compartment syndrome.[2][1]
People who are exposed to low temperatures for prolonged periods, such as winter sports enthusiasts, military personnel, and the homeless, 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 (first and second degree) and deep (third and fourth 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, immersion in warm water (near body temperature), or body contact, and should be done only when a 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.[12] 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, including amputation, is sometimes necessary.[1][2]
Evidence of frostbite occurring in humans dates back 5,000 years.[1] Evidence was documented in a pre-Columbian mummy discovered in the Andes.[7] The number of annual 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] Its first formal description was in 1813 by Dominique Jean Larrey, a physician in Napoleon's army, during its invasion of Russia.[1] Frostbite reports were largely military until the late 1950s.[13]
Signs and symptoms[edit | edit source]
Areas that are usually affected include cheeks, ears, nose and fingers and toes. Frostbite is often preceded by frostnip.[2][14] 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.[15] A simplification of this system of classification is superficial (first or second degree) or deep injury (third or fourth degree).[16]
First degree[edit | edit source]
- First-degree frostbite is superficial, surface skin damage that is usually not permanent.
- Early on, the primary symptom is loss of feeling in the skin. In the affected areas, the skin is numb, waxy, and possibly swollen, with a reddened border.
- In the weeks after injury, the skin's surface may slough off.[15]
Second degree[edit | edit source]
- In second-degree frostbite, the skin develops clear blisters early on, and its surface hardens.
- In the weeks after injury, this hardened, blistered skin dries, blackens, and peels.
- At this stage, lasting cold sensitivity and numbness can develop.[15]
Third degree[edit | edit source]
- In third-degree frostbite, the layers of tissue below the skin freeze.
- Symptoms include blood blisters and "blue-grey discoloration of the skin".[17]
- In the weeks after injury, pain persists and a blackened crust (eschar) develops.
- There can be long-term ulceration and damage to growth plates.
Fourth degree[edit | edit source]
- In fourth-degree frostbite, structures below the skin, like muscles, tendon, and bone, are involved.
- Early symptoms include a colorless appearance of the skin, a hard texture, and painless rewarming.
- Later, the skin becomes black and mummified. The amount of permanent damage can take one month or more to determine. Autoamputation can occur after two months.[15]
Fourth-degree frostbite in a homeless patient five days after freezing conditions. Patient developed trench foot and was unable to properly dry feet. Plantar surface of frostbitten feet five days after a freeze. Patient was homeless with poor footwear.
Causes[edit | edit source]
Risk factors[edit | edit source]
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.[16] Homeless individuals and individuals with some mental illnesses may be at higher risk.[7]
Mechanism[edit | edit source]
Freezing[edit | edit source]
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.[18] Ice crystals can damage small blood vessels at the site of injury.[16] Typically, prolonged exposure to temperatures below −0.55 °C (31.01 °F) may cause frostbite.[19]
Rewarming[edit | edit source]
Rewarming, though vital, 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.[16]
Non-freezing cold injury[edit | edit source]
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.[20]
Pathophysiology[edit | edit source]
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.[21]
- Prefreeze phase: involves the cooling of tissues without ice crystal formation.[21]
- Freeze-thaw phase: ice-crystals form, resulting in cellular damage and death.[21]
- Vascular stasis phase: marked by blood coagulation or the leaking of blood out of the vessels.[21]
- Late ischemic phase: characterized by inflammatory events, ischemia and tissue death.[21]
Diagnosis[edit | edit source]
Frostbite is diagnosed on the basis of 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:
- Frostnip, a precursor to frostbite with a similar appearance, but without ice crystal formation in the skin. Whitening of the skin and numbness reverse quickly after rewarming.
- Trench foot, damage to nerves and blood vessels that results from exposure to cold wet (non-freezing) conditions.[22] This is reversible if treated early.
- Pernio or chilblains, inflammation of the skin from exposure to wet, cold (non-freezing) conditions. They can appear as various types of ulcers and blisters.[15]
- Bullous pemphigoid, a condition that causes itchy blisters over the body that can mimic frostbite.[23] It does not require exposure to cold to develop.
- Levamisole toxicity, a vasculitis that can appear similar to frostbite.[23] It is caused by contamination of cocaine by levamisole. Skin lesions can look similar to those of frostbite, but do not require cold exposure to occur.
People who have hypothermia often have frostbite as well.[15] 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.[24]
Prevention[edit | edit source]
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 may also be of use at high elevations. Repeated exposure to cold water makes people more susceptible to frostbite.[25] Additional measures to prevent frostbite include:[2]
- Avoiding temperatures below −23 °C (-9 °F)
- Avoiding moisture, including in the form of sweat and/or skin emollients
- Avoiding alcohol and drugs that impair circulation or natural protective responses
- Layering clothing
- Using chemical or electric warming devices
- Recognizing early signs of frostnip and frostbite[2]
Treatment[edit | edit source]
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 underarm of a companion or the groin. 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.[26]
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:
- wound care: blisters can be drained by needle aspiration, unless they are bloody (hemorrhagic). Aloe vera gel can be applied before breathable, protective dressings or bandages are put on.
- antibiotics: if there is trauma, skin infection (cellulitis) or severe injury
- tetanus toxoid: should be administered according to local guidelines. Uncomplicated frostbite wounds are not known to encourage tetanus.
- pain control: NSAIDs or opioids are recommended during the painful rewarming process.
Rewarming[edit | edit source]
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.[27] 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.[28] Rewarming can be very painful, so pain management is important.[7]
Medications[edit | edit source]
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.[29]
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.[29] In addition to vasodilators, sympatholytic drugs can be used to counteract the detrimental peripheral vasoconstriction that occurs during frostbite.[30]
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.[31]
Surgery[edit | edit source]
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".[32] If symptoms of compartment syndrome develop, fasciotomy can be done to attempt to preserve blood flow.[7]
Prognosis[edit | edit source]
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.[16] 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[edit | edit source]
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.[33]
Epidemiology[edit | edit source]
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 because of occupational or recreational exposures to cold.[34]
History[edit | edit source]
Frostbite has been described in military history for millennia. The Greeks encountered and discussed the problem of frostbite as early as 400 BC.[16] 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.[16]
Society and culture[edit | edit source]
Several notable cases of frostbite include:
- Captain Lawrence Oates, an English army captain and Antarctic explorer who in 1912 died of complications of frostbite[35]
- Harold Bride, the junior wireless operator of Template:RMS, who suffered severe frostbite on his feet as he and other survivors stood for over an hour on the back of a capsized lifeboat knee-deep in freezing water—Bride had to be carried off from the rescue vessel Template:RMS after it arrived in New York
- Noted American rock climber Hugh Herr, who in 1982 lost both legs below the knee to frostbite after being stranded on Mount Washington (New Hampshire) in a blizzard[36]
- Beck Weathers, a survivor of the 1996 Mount Everest disaster who lost his nose and hands to frostbite[37]
- Scottish mountaineer Jamie Andrew, who in 1999 had all four limbs amputated as a result of sepsis from frostbite sustained after becoming trapped for four nights whilst climbing Les Droites in the Mont Blanc massif[38]
Research directions[edit | edit source]
Evidence is insufficient to determine whether or not hyperbaric oxygen therapy as an adjunctive treatment can assist in tissue salvage.[39] Cases have been reported, but no randomized control trial has been performed on humans.[40][41][42][43][44]
Medical sympathectomy using intravenous reserpine has also been attempted with limited success.[33] Studies have suggested that administration of tissue plasminogen activator (tPa) either intravenously or intra-arterially may decrease the likelihood of eventual need for amputation.[45]
References[edit | edit source]
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 Handford, C; Thomas, O; Imray, CHE (May 2017). "Frostbite". Emergency Medicine Clinics of North America. 35 (2): 281–299. doi:10.1016/j.emc.2016.12.006. PMID 28411928.
- ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 McIntosh, Scott E.; Opacic, Matthew; Freer, Luanne; Grissom, Colin K.; Auerbach, Paul S.; Rodway, George W.; Cochran, Amalia; Giesbrecht, Gordon G.; McDevitt, Marion (1 December 2014). "Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update". Wilderness & Environmental Medicine. 25 (4 Suppl): S43–54. doi:10.1016/j.wem.2014.09.001. ISSN 1545-1534. PMID 25498262.
- ↑ 3.0 3.1 Singleton, Joanne K.; DiGregorio, Robert V.; Green-Hernandez, Carol (2014). Primary Care, Second Edition: An Interprofessional Perspective. Springer Publishing Company. p. 172. ISBN 978-0-8261-7147-4.
- ↑ 4.0 4.1 Ferri, Fred F. (2017). Ferri's Clinical Advisor 2018 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 502. ISBN 978-0-323-52957-0.
- ↑ 5.0 5.1 Auerbach, Paul S. (2011). Wilderness Medicine E-Book: Expert Consult Premium Edition - Enhanced Online Features. Elsevier Health Sciences. p. 181. ISBN 978-1-4557-3356-9.
- ↑ "Frostbite - Symptoms and causes". Mayo Clinic. Retrieved 19 February 2021.
- ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 7.12 7.13 7.14 Handford, Charles; Buxton, Pauline; Russell, Katie; Imray, Caitlin EA; McIntosh, Scott E; Freer, Luanne; Cochran, Amalia; Imray, Christopher HE (22 April 2014). "Frostbite: a practical approach to hospital management". Extreme Physiology & Medicine. 3 7. doi:10.1186/2046-7648-3-7. ISSN 2046-7648. PMC 3994495. PMID 24764516.
- ↑ Millet, John D.; Brown, Richard K. J.; Levi, Benjamin; Kraft, Casey T.; Jacobson, Jon A.; Gross, Milton D.; Wong, Ka Kit (November 2016). "Frostbite: Spectrum of Imaging Findings and Guidelines for Management". Radiographics. 36 (7): 2154–2169. doi:10.1148/rg.2016160045. ISSN 0271-5333. PMC 5131839. PMID 27494386.
- ↑ "Frostbite and Frostnip in Children". UMass Memorial Health. UMass Memorial Health Care. Retrieved 7 August 2025.
- ↑ Williamson, Laura (3 January 2025). "What cold weather does to the body and how to protect yourself this winter". American Heart Association. Retrieved 7 August 2025.
- ↑ "Frostbite". Mayo Clinic. Retrieved 7 August 2025.
- ↑ "Frostbite and Hypothermia". CT.gov - Connecticut's Official State Website. Retrieved 2 July 2021.
- ↑ Zonnoor, Bobak (29 February 2024). "Frostbite". Medscape. WebMD LLC. Retrieved 7 August 2025.
- ↑ "Frostbite and Frostnip in Children". UMass Memorial Health. UMass Memorial Health Care. Retrieved 7 August 2025.
- ↑ 15.0 15.1 15.2 15.3 15.4 15.5 "Frostbite Clinical Presentation". emedicine.medscape.com. Archived from the original on 2 March 2017. Retrieved 2 March 2017.
- ↑ 16.0 16.1 16.2 16.3 16.4 16.5 16.6 Zafren, Ken (2013). "Frostbite: Prevention and Initial Management". High Altitude Medicine & Biology. 14 (1): 9–12. doi:10.1089/ham.2012.1114. PMID 23537254. S2CID 3036889.
- ↑ Zonnoor B (29 July 2019). "What are the characteristics of third-degree frostbite?". Medscape. Retrieved 10 May 2020.
- ↑ Knapik JJ, Reynolds KL, Castellani JW (2020). "Frostbite: Pathophysiology, Epidemiology, Diagnosis, Treatment, and Prevention". Journal of Special Operations Medicine. 20 (4): 123–135. doi:10.55460/PDX9-BG8G. PMID 33320326. S2CID 229171926.
- ↑ "Frostbite". UK National Health Service. 24 August 2021. Retrieved 16 July 2023.
- ↑ Sachs, Christoph; Lehnhardt, Marcus; Daigeler, Adrien; Goertz, Ole (1 March 2017). "The Triaging and Treatment of Cold-Induced Injuries". Deutsches Ärzteblatt International. 112 (44): 741–747. doi:10.3238/arztebl.2015.0741. ISSN 1866-0452. PMC 4650908. PMID 26575137.
- ↑ 21.0 21.1 21.2 21.3 21.4 McIntosh, SE; Opacic, M; Freer, L; Grissom, CK; Auerbach, PS; Rodway, GW; Cochran, A; Giesbrecht, GG; McDevitt, M; Imray, CH; Johnson, EL; Dow, J; Hackett, PH; Wilderness Medical, Society. (December 2014). "Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update". Wilderness & Environmental Medicine. 25 (4 Suppl): S43-54. doi:10.1016/j.wem.2014.09.001. PMID 25498262.
- ↑ Jurkovich, Gregory J. (February 2007). "Environmental cold-induced injury". The Surgical Clinics of North America. 87 (1): 247–267, viii. doi:10.1016/j.suc.2006.10.003. ISSN 0039-6109. PMID 17127131.
- ↑ 23.0 23.1 "VisualDx - Frostbite". VisualDx. Archived from the original on 3 March 2017. Retrieved 3 March 2017.
- ↑ "Frostbite". us.bestpractice.bmj.com. Archived from the original on 4 March 2017. Retrieved 4 March 2017.
- ↑ Fudge J (2016). "Preventing and Managing Hypothermia and Frostbite Injury". Sports Health. 8 (2): 133–9. doi:10.1177/1941738116630542. PMC 4789935. PMID 26857732.
- ↑ Heil, K; Thomas, R; Robertson, G; Porter, A; Milner, R; Wood, A (March 2016). "Freezing and non-freezing cold weather injuries: a systematic review". British Medical Bulletin. 117 (1): 79–93. doi:10.1093/bmb/ldw001. PMID 26872856.
- ↑ Mistovich, Joseph; Haffen, Brent; Karren, Keith (2004). Prehospital Emergency Care. Upsaddle River, NJ: Pearson Education. p. 506. ISBN 0-13-049288-4.
- ↑ Laderer, Ashley. "How to treat frostbite and when you should seek emergency medical help". Insider. Retrieved 30 September 2021.
- ↑ 29.0 29.1 "Frostbite". www.uptodate.com. Archived from the original on 4 March 2017. Retrieved 3 March 2017.
- ↑ Sachs, C; Lehnhardt, M; Daigeler, A; Goertz, O (30 October 2015). "The Triaging and Treatment of Cold-Induced Injuries". Deutsches Ärzteblatt International. 112 (44): 741–7. doi:10.3238/arztebl.2015.0741. PMC 4650908. PMID 26575137.
- ↑ Lorentzen, Anne Kathrine; Davis, Christopher; Penninga, Luit (20 December 2020). "Interventions for frostbite injuries". Cochrane Database of Systematic Reviews. 2020 (12) CD012980. doi:10.1002/14651858.cd012980.pub2. ISSN 1465-1858. PMC 8092677. PMID 33341943.
- ↑ Golant, A; Nord, RM; Paksima, N; Posner, MA (Dec 2008). "Cold exposure injuries to the extremities". J Am Acad Orthop Surg. 16 (12): 704–15. doi:10.5435/00124635-200812000-00003. PMID 19056919. S2CID 19274894.
- ↑ 33.0 33.1 Marx, John (2010). Rosen's emergency medicine: concepts and clinical practice (7th ed.). Philadelphia, PA: Mosby/Elsevier. p. 1866. ISBN 978-0-323-05472-0.
- ↑ "Frostbite: Background, Pathophysiology, Etiology". Medscape. Medscape, LLC. 2 February 2017. Archived from the original on 2 March 2017.
- ↑ "British History in depth: The Race to the South Pole". BBC - History. Archived from the original on 13 February 2017. Retrieved 4 March 2017.
- ↑ "Hugh Herr's Best Foot Forward | Boston Magazine". Boston Magazine. 18 February 2009. Archived from the original on 30 March 2017. Retrieved 4 March 2017.
- ↑ "Beck Weathers Says Fateful Everest Climb Saved His Marriage". PEOPLE. 16 September 2015. Archived from the original on 4 March 2017. Retrieved 4 March 2017.
- ↑ Heawood, Jonathan (27 March 2004). "I'll get there, even if it kills..." The Guardian. ISSN 0261-3077. Archived from the original on 4 March 2017. Retrieved 4 March 2017.
- ↑ Marx 2010
- ↑ Finderle Z, Cankar K (April 2002). "Delayed treatment of frostbite injury with hyperbaric oxygen therapy: a case report". Aviat Space Environ Med. 73 (4): 392–4. PMID 11952063.
- ↑ Folio LR, Arkin K, Butler WP (May 2007). "Frostbite in a mountain climber treated with hyperbaric oxygen: case report". Mil Med. 172 (5): 560–3. doi:10.7205/milmed.172.5.560. PMID 17521112.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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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