Pre-hospital care of frostbite

pre hospital care of frostbite

Management of the injury in the pre hospital phase

• main focus should be about resolving any potentially life threatening conditions such as hypothermia, dehydration, or severe trauma
  • rewarming of hypothermic patients
    • mild hypothermia may be treated concurrently with the frostbite injury while moderate and severe hypothermia should be treated effectively before treating the frostbite injury
  • stabilisation of traumatic injuries before transport to a health facility
    
    
• remove jewellery or other extraneous material from the body
  
  
• wet clothing must be removed immediately, warm drinks and clothing should be provided
  
  
• warm the body part
  • regional cold injuries should be rewarmed only if the risk of refreezing is minimal since freeze-thaw-refreeze cycle causes more damage than waiting for definitive treatment.
  • the decision of thawing a frostbitten tissue in the field should take into account pain control, adequate warming, hydration, and subsequent protection of frostbitten tissue from further injury during evacuation (rewarmed extremities cannot be used for ambulation)
  • guidelines recommend rapid rewarming. If rewarming cannot be achieved in the field, spontaneous or slow thawing should be allowed
    • slow thawing is a reasonable course of action to initiate the rewarming process if it is the only means available.
    • slow rewarming can be accomplished by
      • moving into a warmer location (eg, tent or hut)
      • warming with adjacent body heat from the patient or a caregiver (eg, axilla or abdomen)
• do not
  • apply direct heat e.g. - heater
  • rub the frozen area
  • allow to smoke or take alcohol
  • apply skin ointment (1,2,3,4)

Rewarming an affected area

• once a diagnosis of freezing cold injury is made and the patient is in a safe environment, rapid rewarming of the area(s) can be carried out
• use a whirlpool bath containing a mild antiseptic such as chlorhexidine (without the affected region touching the device’s hard sides) at 40-41°C for at least 30 minutes to rewarm the frostbitten area (until all tissues are thoroughly rewarmed and pliable, with a red-purple colour)
• continue rewarming for 30 minutes twice daily till there is clear demarcation of necrotic tissues or evidence of tissue healing e.g. - epidermal regeneration and the emergence of normal skin colour
• the affected area should be kept warm and dry in between treatments
• give adequate pain relief since rewarming can be acutely painful
  • ibuprofen (400 mg orally (adult dose), every 12 hours) is recommended
• if possible elevate the thawed extremity above the level of the heart to decrease the formation of dependant oedema

Reference:

• (1) Hallam MJ et al. Managing frostbite. BMJ. 2010;341:c5864.
• (2) Heil K et al. Freezing and non-freezing cold weather injuries: a systematic review. Br Med Bull. 2016;117(1):79-93.
• (3) McIntosh SE et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Wilderness Environ Med. 2014;25(4 Suppl):S43-54
• (4) Government of UK. Ministry of defence. Joint Service Publication (JSP). Heat illness and cold injury: prevention and management (JSP 539) 2017