Frostbite Definition
Frostbite is a localized injury caused by exposure to freezing temperatures, leading to the freezing of skin and underlying tissues. The condition primarily affects areas with limited blood flow, such as the fingers, toes, ears, and nose. Common risk factors include extreme cold exposure, inadequate clothing, dehydration, alcohol use, and mental illness.
Frostbite Etiology
Frostbite results from prolonged exposure to cold, which triggers peripheral vasoconstriction and reduces blood flow to distal tissues. Two primary phases of tissue injury are observed:
Freezing Phase
Formation of extracellular ice crystals and fluid shifts lead to cellular dehydration and membrane damage.
Reperfusion Phase
Upon rewarming, inflammatory mediators such as thromboxane exacerbate ischemia and contribute to tissue necrosis.
Diagnostic Criteria for Frostbite
Frostbite is diagnosed based on symptoms such as pallor, cyanosis, blistering, and the degree of tissue damage observed post-rewarming.
Bone scintigraphy, angiography, or single photon emission computed tomography-computed tomography (SPECT/CT) can be used in severe frostbite to evaluate perfusion and guide surgical decisions.
Frostbite is classified as:
Grade 1
No cyanosis seen and no risk for amputation.
Grade 2
Superficial tissue damage, typically in the distal phalanx. This may require soft tissue amputation.
Grade 3
Deeper tissue injury with cyanosis extending to the level of the metacarpophalangeal (MCP) joints at the base of the fingers or the metatarsophalangeal (MTP) joints in the midfoot. This has a high risk of amputation.
Grade 4
Cyanosis is seen proximal to the MCP or MTP joint with extensive necrosis. This has almost 100% amputation risk.
Common Signs and Symptoms of Frostbite
Early symptoms of frostbite include:
- Numbness, tingling, and loss of sensation occur in the affected areas, often progressing to a burning or aching sensation.
- Skin initially appears pale or waxy, transitioning to hard and cold upon palpation.
During frostbite progression, signs and symptoms include:
- Skin becomes mottled, cyanotic, or red, depending on the depth of tissue damage.
- There is a loss of flexibility as deeper structures begin to freeze.
- Clumsiness or loss of dexterity in hands and feet may result from tissue stiffness and nerve involvement.
After rewarming, the person may experience:
- Intense pain, edema, and vesicle formation. Blisters may be clear (indicating superficial damage) or hemorrhagic (indicative of deeper injury).
- Necrosis and gangrene, which may develop over days to weeks post-injury, with demarcation between viable and non-viable tissue.
Red Flags
Some symptoms of frostbite require more specialized medical treatments, such as:
- Hemorrhagic blisters indicate deep tissue damage and an increased risk of necrosis or amputation. These require close monitoring and possible referral for advanced wound care.
- Severe cyanosis or blackened tissue suggests ischemia and irreversible tissue death. Cyanosis extending beyond distal joints signals advanced frostbite (Grade 3 to 4) with a high likelihood of amputation.
- Neurological deficits such as numbness, loss of sensation, or inability to move the affected area could indicate nerve involvement or critical ischemia.
- Progressive swelling or severe pain are signs of compartment syndrome, which may necessitate emergent fasciotomy to prevent permanent functional loss.
Potential Complications
Short-term complications may include:
- Tissue necrosis requires prompt surgical debridement or amputation to prevent systemic infection.
- Compartment syndrome leading to severe swelling in enclosed compartments of the hands or feet may cause ischemia, requiring urgent intervention.
- Open wounds or blistered areas are prone to secondary bacterial infections, cellulitis, or even sepsis if untreated.
Long-term complications may include:
- Chronic neuropathy, which is characterized by persistent pain, numbness, or hypersensitivity to cold, often limits functionality.
- Individuals may experience discomfort or rapid onset of frostnip symptoms in mildly cold environments.
- As a result of deep tissue damage or scarring, affected joints may lose range of motion, requiring physical therapy.
- Amputation or disfigurement may occur.
Treatments
Pharmacological treatment may include:
- Iloprost (Ventavis®) acts as a vasodilator, reducing the risk of amputation by restoring perfusion in frostbite grades 2 to 4 when administered within 72 hours.
- Thrombolytics such as tissue plasminogen activator (tPA) can be used within 24 hours to dissolve microvascular clots and improve tissue salvage in severe frostbite.
- Non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen (Advil®) can mitigate inflammation and reduce thromboxane synthesis, limiting tissue damage.
Non-pharmacological treatment may include:
- For rapid rewarming, immerse affected areas in water at 98.6 to 102.2°F (37 to 39°C) for 15 to 30 minutes until tissue softens and becomes pliable.
- Drain clear blisters but preserve hemorrhagic blisters to minimize infection risk. Use aloe vera gel for its anti-inflammatory effects.
- Hyperbaric oxygen therapy (HBOT) can improve tissue oxygenation in delayed presentations.
Surgical debridement or amputation may be necessary for Grade 4 frostbite, with imaging to determine tissue viability and guide intervention.
Nursing Management of Frostbite
Assessment and Interventions
Managing frostbite requires rapid assessment, targeted interventions, and interdisciplinary collaboration.
Skin
Evaluate skin integrity, circulation, and the depth of injury. Remove constrictive clothing and jewelry to prevent further ischemia. Avoid refreezing tissues.
Interventions
Helpful interventions include:
Rapid rewarming
Submerge the affected area in warm water 98.6 to 102.2°F (37°C to 39°C) for 15 to 30 minutes or until skin appears red or pliable. Avoid dry heat or rubbing the area to prevent further tissue damage.
Pain Management
Use opioids during rewarming for severe pain. Follow with NSAIDs for anti-inflammatory benefits.
Wound Care
Drain large, clear blisters under aseptic conditions; hemorrhagic blisters should remain intact to protect underlying tissue. Apply aloe vera gel for its anti-thromboxane properties and cover with non-adherent dressings.
Pharmacological Therapy
Start ibuprofen or aspirin for inflammation and thromboxane inhibition. Administer iloprost or thrombolytics based on injury severity and timing.
Ongoing Monitoring
Regularly assess for signs of infection, worsening tissue necrosis, or the need for surgical intervention.
Preventive education
Teach individuals to avoid refreezing thawed tissue, as this exacerbates ischemia and increases the risk of complications.
Psychosocial and Cultural Considerations
Managing frostbite goes beyond physical symptoms, requiring attention to emotional, psychological, and cultural needs to ensure adequate care and prevention.
Psychosocial Support
A person with frostbite experiences fear and anxiety. Provide support, including:
- Educate people about frostbite’s long-term sequelae, including pain, sensory deficits, and potential functional impairments.
- Provide resources such as counseling and peer support for coping with physical and emotional challenges following severe frostbite.
- Amputation or disfigurement can cause significant emotional distress, depression, and anxiety.
Cultural Considerations
Cultural beliefs and practices may influence adherence to treatment and prevention modifications. Encourage the use of protective clothing and community-based resources for those at increased risk, such as unhoused populations.
Home Management
Self-Care
Monitor the person daily for:
- Changes in the frostbitten areas, such as changes in color, swelling, or signs of infection (increased redness, pus, or odor).
- Use prescribed topical agents such as aloe vera to promote healing and reduce inflammation.
- Evaluate pain and provide over-the-counter or prescribed medications.
- Keep affected areas moisturized to prevent drying and cracking during the healing process.
Safety Measures
Encourage the person to:
- Wear multiple layers of loose, insulated clothing to maintain warmth and protect exposed areas. For extreme conditions, use windproof and waterproof materials.
- Invest in thermal gloves, socks, and face coverings for adequate insulation.
- Avoid alcohol use during cold exposure since alcohol consumption increases vasodilation and heat loss, heightening the risk of frostbite.
- Always carry essential survival gear such as extra clothing, emergency blankets, and heating pads when engaging in outdoor activities.
- Schedule regular appointments to monitor healing and address complications like joint stiffness or long-term pain.
Additional Information
Course Contributor
The content for this course was revised by Kathleen Koopmann, RN, BSN.
Kathleen is a subject matter expert in post-acute care, with over 37 years of clinical and teaching experience spanning both acute and post-acute care settings. She earned her Bachelor of Science in Nursing from Western Governors University and received specialized infection control training through the North Carolina Statewide Program for Infection Control and Epidemiology, in collaboration with NCDHHS and the University of North Carolina. Kathleen's diverse career includes roles in long-term care, acute care, occupational health, and nursing education. Most recently, she served as a Staff Development Coordinator and Infection Control Practitioner in long-term care, where she played a pivotal role in staff education and infection prevention.
Resource
- Centers for Disease Control and Prevention: Preventing Frostbite: https://www.cdc.gov/winter-weather/prevention/preventing-frostbite.html(opens in a new tab)
References
- Eberle, U. (2024). The fight against frostbite progresses. ACS Central Science, 10, 1976-1979. https://pmc.ncbi.nlm.nih.gov/articles/PMC11623224/
- McNichol, L., Ratliff, C., & Yates, S. (2021). Wound, ostomy and continence nurses society core curriculum: Wound management (2nd ed., pp. 714–720). Wolters Kluwer Health.
- Zaramo, T. Z., Green, J. K., & Janis, J. E. (2022). Practical review of the current management of frostbite injuries. PRS Global Open, 10(e4618). https://pmc.ncbi.nlm.nih.gov/articles/PMC9592504/