• Tissue injury because of freezing
  • The level of involvement is like an iceberg!


  • Annual incidence: 1.1 %
  • Gender: Men > Women (A little more)
  • Mean age: < 65 (Frequency diminishes after this age)
  • Most targeted population:
    • Occupational groups
      • Skilled agricultural
      • Fishery workers
      • Craft
      • Related trades workers
      • Plant and machine operators
      • Assemblers
      • Echnicians
      • Associate professionals



  • Tissue injury (Vasoconstriction => Tissue hypo-perfusion => Tissue ischemia => Necrosis => Gangrene) because of freezing and extreme cold mostly in high altitudes

Risk factors

  • Exposing a bare skin (Unprotected) to extreme cold and freezing condition for reasonable amount of time
  • Working in certain industries
  • Weekly cold exposure at work
  • Individual risk factors:
    • Diabetes Mellitus
    • White fingers in the cold
    • Cardiac insufficiency
    • Angina pectoris
    • Stroke
    • Depression
    • Heavy alcohol users
    • Homeless
    • Hunters
    • Bikers
    • Babies sleeping in cold room temperature
    • Elderlies with no good support


  • Rewarming causes enormous pain
  • Necrosis
  • 2nd bacterial infection
  • Superimposed Cellulitis
  • Local vasoconstriction and tissue ischemia
  • Tissue necrosis
  • Tissue gangrene
  • +/- Auto-amputation
  • Compartment syndrome
  • Prolonged neuropathic symptoms
  • Complex regional pain syndrome


  • Cold skin
  • Erythematous skin
  • Numb skin
  • Pain
  • Shivering
  • Exhaustion
  • Slurred speech
  • Decreased level of consciousness
  • Drowsiness
  • Confusion
  • Fatigue


  • Most common sites:
    • Exposed skin
    • Distal of upper and lower extremities
  • Skin numbness
  • Swollen
  • Hypothermic skin
  • +/- White skin
  • +/- Blisters
    • Clear serum: Indicates superficial damage (Better prognosis)
    • Contains blood: Indicates deeper level of damage and worse prognosis

Red flags

  • Frost bite is can be similar to burn and both act like an iceberg
  • When rewarming begin, patient might develop with a significant severe pain
  • Tissue rewarming may leads to release of inflammatory cytokines in blood steam, Prostaglandins, Thromboxans, which add up to the injury

Lab work ups

  • Diagnosis is mostly by Hx and P/E
  • Lab work up as indicated by history and physical findings and for monitoring the treatment success


  • Diagnosis is mostly by Hx and P/E
  • To assess circulation, tissue viability and address treatment:
    • Radionuclide scanning
    • MRI
    • Microwave thermography
    • Laser-Doppler flowmetry


  • It is an emergency
  • Call 911
  • Remove the wet clothing
  • Administer Opioids: Morphine Sulfate IV prior to rewarming due to severe pain afterwards
  • Quickly rewarming/ immersing the affected tissue in 40-42 C water
  • Local wound management
  • Consult with general surgeon
  • Caution:
    • Do not attempt to rewarm the tissue with a dry warmer. Since the tissue is numb, it can case a secondary burn!
    • Avoid rubbing the tissue
    • Do not use electric blanket for warming
    • Do not walk on an injured tissue
    • If no warm water around, keep the tissue warm by a blanket till help arrives
  • Blister management:
    • Large and serous/ clear blisters: Either drained in a sterile setting or left to be absorbed
    • Hemorrhagic blisters: Left intact=> increase the chance or tissue dissection and 2nd bacterial infection if manipulated
    • Broken blisters: Debridement in a sterile setting
  • Anti-inflammatory topical/Po/IV medications:
    • Aloe Vera topical q6h
    • Ibuprofen 400 mg po q8h
    • Ketorolac 30-60 mg IV
  • +/- Phenoxybenzamine (Alfa- Blocker): 10-60 mg po qd hinders vasoconstriction and increases blood flow
  • Antibiotic prophylaxis: MANDATORY step!
    • Penicillin: To avoid Streptococcal infection
    • In any sign of wet gangrene: broad spectrum antibiotics must be initiated
  • DO NOT forget to administer Tetanus Toxoid! (Vaccination) if the patient’s hx if not reliable, not informative or vaccination is not updated.
    • Act as tetanus vaccination/Toxoid wound injury prophylaxis guidelines
  • Intra tissue pressure measurement: If suspicious to compartment syndrome
  • Consult with a nutritionist for adequate nutrition to keep the metabolism produce more body heat
  • Whirlpool baths:
    • 37 C 3/day
    • Gently dry the tissue after the bath
  • Severe frost bite with gangrene: Emergency consult with general surgeon for possible surgical debridement / Amputation:
    • Do MRI as a helpful indicator to assess the level of injury and need for level of surgical debridement
  • May have a prolonged hospitalization to monitor the level of tissue damage (As previously said, frost bite is like an iceberg and the true level of injury may take several day to weeks to show up!)


  • Mäkinen TM, Jokelainen J, Näyhä S, Laatikainen T, Jousilahti P, Hassi J. Occurrence of frostbite in the general population–work-related and individual factors. Scand J Work Environ Health. 2009 Oct;35(5):384-93. PubMed PMID: 19730758.
  • 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. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S43-54. doi: 10.1016/j.wem.2014.09.001. PubMed PMID: 25498262.
  • Handford, C., Buxton, P., Russell, K., Imray, C. E., McIntosh, S. E., Freer, L., Cochran, A., … Imray, C. H. (2014). Frostbite: a practical approach to hospital management. Extreme physiology & medicine, 3, 7. doi:10.1186/2046-7648-3-7
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