By Lauren Lazarevski, RN, BSN, CWOCN

Introduction

Up here in Western New York, we are still “digging out” – literally and metaphorically - from the historic blizzards and freezing temperatures that have hit our area. While we are no strangers to snow and subzero temperatures, the rapid deterioration seen in our recent storm posed a swift and formidable risk to the many residents who quickly found themselves stranded. Predictably, we still are seeing an increase in frostbite cases related to the weather event. I’ve summarized the guiding principles we’ve used to develop treatment guidelines for our patients suffering from the unfortunate effects of frostbite, but first, below is some background on this condition.

Frostbite: Background

As an ischemic vascular injury, frostbite develops as the result of ice crystal formation, which damages the endothelium of blood vessels.^1-3 Currently, no overall incidence rate for this condition exists, although experts theorize that this common military personnel injury is on the rise in civilian populations.^1,2 In fact, it is recorded that certain regions are witnessing substantial decreases in temperatures.² Considering the possible long-term effects of severe injury, wound care professionals in northern regions, in particular, may see incidents of this condition in their facility.

How Does Frostbite Happen?

When frostbite occurs, the following 3 factors will determine the severity of injury¹:

• Low temperature
• Wind chill
• Length of exposure

The upper and lower extremities and the face are usually the most at risk for frostbite. Typically, this injury presents with redness, with more severe forms presenting with scabs, blisters, purple discoloration, swelling, and other features. Generally, frostbite is staged similarly to burns.^1-3 The first 2 grades, partial-thickness and full-thickness, are deemed superficial, while the 2 final stages, full-thickness necrosis and freezing present in bone, may be considered severe.³ If frostbite is severe enough, it may result in long-term sequelae, such as chronic pain, cold hypersensitivity, and neuropathic pain.¹

Management: Frostbite really “BITES”

Our facility has developed several treatment guidelines in light of these events depending on features present in the patient’s condition. Below are guiding principles wound care professionals may use in their facility:

• Blisters are treated differently depending on their contents. Clinicians should evacuate serous-filled blisters as they contain high levels of prostaglandin and thromboxane, which contribute to ischemia. Hemorrhagic (blood-filled) blisters should be left intact to reduce infection risk.⁴
• Ice crystals form in the extracellular fluid, which causes mechanical damage resulting in cell lysis. Rewarming should only occur after the patient is removed from the elements; refreezing thawed tissue is even more harmful than letting it remain frozen.⁴
• Thaw the affected area(s) in a 100.4-104 F bath with water and mild antibacterial soap for 20-40 minutes.⁵
• Edema occurs post-thaw and can be substantial even in superficial frostbite cases. Elevate affected areas. Range of Motion (ROM) exercises should also be performed to preserve function.
• Surgery should be delayed until the necrotic tissue demarcates to clarify which tissues are viable and nonviable.⁴ This may take several weeks or months.

Conclusion

Many clinicians practicing in warm climates may never see a case of frostbite. Those in temperate or colder climates should be prepared for weather emergency-related injuries, including frostbite /cold injury. These wounds aren't caused by ordinary ischemia; the pathophysiology of frostbite is a perfect example of the importance of understanding wound etiology to ensure proper management of these injuries.

References

1. Regil IB, Strapazzon G, Falla M, et al. Long-Term Sequelae of Frostbite—A Scoping Review. Int J Environ Res Public Health. 2021; 18(8):9655. https://doi.org/10.3390/ijerph18189655
2. Joshi K, Goyary D, Mazumder B, et al. Frostbite: Current status and advancements in therapeutics. J Therm Biol. 2020; 93. https://doi.org/10.1016/j.jtherbio.2020.102716
3. Gao Y, Wang F, Zhou W, et al. Research progress in the pathogenic mechanisms and imaging of severe frostbite. Eur J Radiol. 2021; 137. https://doi.org/10.1016/j.ejrad.2021.109605
4. Bryant R A, Nix DP. Chapter 30: Uncommon Wounds and Manifestations of Intrinsic Disease. In: Acute & Chronic Wounds: Current Management Concepts. 5th Edition. Elsevier; 2015: 456–458. https://www.elsevier.com/books/acute-and-chronic-wounds/978-0-323-31621…
5. Murphy JV, Banwell PE, Roberts AHN, McGrouther DA. Frostbite: Pathogenesis and Treatment. J Trauma. 2000; 48(1):171. https://journals.lww.com/jtrauma/toc/2000/01000

About the Author Lauren graduated with a BSN from the University of Buffalo in Western New York, where she was born and raised. She has held various nursing jobs, but continued to work towards a goal of a career in wound care nursing after she was one of only two students who signed up for a wound care clinical during nursing school. She currently works at the Advanced Wound Healing Center in Orchard Park, NY where she once had her nursing clinicals. She became credentialed in Wound, Ostomy, and Continence Nursing in 2019 and is incorporating her knowledge and skills into her busy clinic practice. When not at work, Lauren enjoys indoor spinning, playing guitar, video games, and rooting for the Buffalo Bills NFL team.