Frostbite is damage to the skin and other tissues caused by extreme cold. When it is cold (at or below 0ºC) or there are strong winds, the human body tries to preserve its core body temperature by narrowing the blood vessels close to the skin. In extreme cases, this can reduce the blood flow in some areas of the body to dangerously low levels resulting in frostbite. The fingers and toes are the most vulnerable. Frostbite can lead to permanent damage, but this can be avoided if it is recognised and treated quickly.
Guidelines
Good practice points
- Warming of frozen body parts should be done only if the appropriate resources are available, medical care is more than two hours away and there is no risk of refreezing.
- Warming should be achieved by immersing the affected area in warm water between 37ºC and 39ºC (98.6ºF and 102ºF) until the affected body part takes on a red or purple appearance and becomes soft and pliable to the touch (usually in 30 minutes).
- Other heat sources (e.g., fire, space heater, oven, heated rocks) should be avoided because of the risk of burns.
- During warming, consider giving the person a high dose of ibuprofen (400-800 mg) or if not available, a low dose of acetylsalicylic acid (75-80mg). This may improve healing.
- After warming, the frostbitten area should be protected from refreezing and the person should seek medical care as soon as possible.
- Topical aloe vera may be applied to the frostbite.
- Affected body parts should be dressed in sterile gauze until the person can reach medical care. If fingers or toes are affected, the gauze should be placed between them.
Chain of survival behaviours
Prevent and prepare
- Ensure feet, hands and face are kept warm and covered in cold conditions.
- Pack appropriate equipment and clothing for the weather conditions, including emergency items if conditions worsen.
- Take shelter from extreme cold or strong cold winds.
Early recognition
Early frostbite may be marked by flushed skin, sensation changes such as burning, prickling or numbness, or pain in the exposed cold area. The skin flushing can decrease as the skin cools, and it can appear paler from decreased blood flow. Skin becomes cold, hard to the touch, waxy, and blisters can form. As frostbite progresses, the skin dies and turns dark blue or black.
First aid steps
- Protect the person from hypothermia. Do this by helping them move to a warmer place, removing wet clothing and keeping them warm and dry.
- Carefully remove jewellery if this is possible without causing any damage to the skin.
- Gently warm the affected area by putting it in warm (body temperature) water until it is rewarmed (usually 30 minutes). Avoid rubbing or aggressively handling the affected area as this may damage the skin.
- Dress the affected area with sterile gauze. If multiple digits are affected, place gauze between each digit.
- Consider giving the person a high dose of ibuprofen (400-800 mg) or if not available, a low dose of acetylsalicylic acid (75-80mg). This may improve healing.
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CAUTION
- Only warm a frostbitten area if you have the appropriate resources, there is no risk of refreezing, and medical care is more than two hours away.
- Do not put the affected area near direct heat like a space heater or hot stove.
- Avoid breaking blisters that may occur.
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Access help
- Always access medical care in the case of frostbite.
Education considerations
Context considerations
- It may be useful to explore preparedness and safe behaviour in very cold climates relevant to the learners, for example, being stuck somewhere remote with a broken-down vehicle in winter, working in wilderness areas, or doing winter sports such as skiing.
- Consider covering this topic with learners who are more vulnerable, such as elderly people and people who are homeless.
Facilitation tips and tools
- As frostbite is relatively uncommon, help learners recognise it by including images in your education material.
- Help learners to identify how they would get medical help in an emergency in the extreme cold.
Learning connections
- A person with frostbite may also be experiencing Hypothermia.
Scientific foundation
Systematic review
An evidence summary was conducted by the Centre for Evidence-Based Practice (CEBaP) on active warming for frostbite, but no relevant controlled studies were identified.
A Cochrane systematic review protocol was identified on interventions for frostbite injuries (Lorentzen, 2018).
Non-systematic review
While conducting the evidence summary on active warming for frostbite, CEBaP identified the recently updated guidelines from the Wilderness Medical Society on the prevention and management of frostbite (McIntosh 2019). These guidelines are based on case series and animal studies and contain some recommendations:
- Field rewarming by warm water bath immersion can and should be performed if the proper resources are available and medical care is more than two hours distant. Other heat sources (e.g., fire, space heater, oven, heated rocks) should be avoided because of the risk of thermal burn injury.
- Rapid rewarming by water bath has been found to result in better outcomes than slow rewarming.
- Field rewarming should only be undertaken if the frozen part can be kept thawed and warm until the person arrives at medical care. Water should be heated to 37° to 39° C. Circulation of water around the frozen tissue will help maintain the correct temperature.
Use of medication
Low dose acetylsalicylic acid (75-80mg) and high dose ibuprofen (400-800 mg) appear to be associated with improved healing, although data is poor. However, the risk of acetylsalicylic acid and ibuprofen is very low and providing acetylsalicylic acid or ibuprofen may be considered for significant frostbite (Heggars et al., 1987; McIntosh, 2019).
Aloe vera
There is limited evidence but topical aloe vera may be beneficial when applied to the frostbite (Heggars et al., 1987; McIntosh, 2019; McCauley, 1983).
References
Systematic reviews
Centre for Evidence-Based Practice, Belgian Red Cross-Flanders. (2020). Evidence summary Frostbite – Active rewarming. Available from:
https://www.cebap.org/knowledge-dissemination/first-aid-evidence-summaries/
Lorentzen, A. K., Davis, C., & Penninga, L. (2018). Interventions for frostbite injuries. The Cochrane Database of Systematic Reviews, 2018(3). Retrieved from: https://doi.org/10.1002/14651858.CD012980
Non-systematic reviews
Heggers, J. P., Robson, M. C., Manavalen, K., Weingarten, M. D., Carethers, J. M., Boertman, J. A., … & Sachs, R. J. (1987). Experimental and clinical observations on frostbite. Annals of emergency medicine, 16(9), 1056-1062.
McCauley, R. L., Hing, D. N., Robson, M. C., & Heggers, J. P. (1983). Frostbite injuries: a rational approach based on the pathophysiology. The Journal of trauma, 23(2), 143-147.
McIntosh, S. E., Freer, L., Grissom, C. K., Auerbach, P. S., Rodway, G. W., Cochran, A., … & Pandey, P. (2019). Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2019 Update. Wilderness & environmental medicine, 30(4), S19-S32. Retrieved from https://www.wemjournal.org/article/S1080-6032(19)30097-3/fulltext
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