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Frostbite is a completely preventable injury that can occur with or without hypothermia. Below –10°C, any tissue that feels numb for more than a few minutes may become frostbitten. Progressive symptoms of frostbitten areas are as follows:
Coldness
Stinging, burning, and throbbing
Numbness followed by complete loss of sensation (This history of anesthesia suggests a frostbite injury.)
Loss of fine muscle dexterity (ie, clumsiness of fingers)
Loss of large muscle dexterity (ie, difficulty ambulating)
Severe joint pain
Numbness over the affected area is the initial symptom of frostbite. After rewarming, severe throbbing and hyperemia begin and may last for weeks. Many patients complain of paresthesias. Long-term symptoms include cold sensitivity, sensory loss, and hyperhidrosis.
The initial appearance of frostbite does not accurately predict the eventual extent and depth of tissue damage. Signs and symptoms vary according to severity of the frostbite injury. The hands, feet, ears, and nose are the most commonly affected (see images below).
Frostbite of the foot. Photo courtesy of Kevin P. Kilgore, MD, Department of Emergency Medicine, Regions Hospital.
Frostbite of the ear. Photo courtesy of Kevin P. Kilgore, MD, Department of Emergency Medicine, Regions Hospital.Physical examination in patients with superficial frostbite reveals the presence of soft, palpable skin. If a thumbprint can be left in the skin, the patient usually has more viable underlying tissue. Individuals with deeper frostbite effects present with skin that is hard to the touch.
Other signs may include the following:
Excessive sweating
Joint pain
Pallor or blue discoloration
Hyperemia
Skin necrosis
Gangrene
Four classic stages of frostbite injury have been defined: first degree, second degree, third degree, and fourth degree. This staging system has limited clinical usefulness, however, because it has not been shown to have a direct correlation with survival or tissue loss.
First-degree frostbite has the following characteristics:
Nonsensate, central, white plaque surrounded by a ring of hyperemia
Epidermal involvement
Mild edema
Sequelae over the next few weeks include desquamation, transient swelling and erythema, and cold sensitivity.
Second-degree frostbite has the following characteristics:
Full-thickness skin freezing
Clear blister formation with surrounding erythema
Hard outer skin but resilient tissue underneath
Substantial edema
Blisters contain high amounts of thromboxane and prostaglandins. They contract and dry within 2-3 weeks, forming a dark eschar that sloughs off in 4 weeks, leaving poorly keratinized skin that is easily traumatized. Sequelae include paresthesias, hyperhidrosis, and persistent or transient cold sensitivity.
Third-degree frostbite has the following characteristics:
Subdermal plexus freezing
Hemorrhagic blister formation
Blue-gray discoloration of the skin
Deep burning pain on rewarming, lasting 5 weeks
Thick gangrenous eschar formation within 2 weeks
Sequelae include tropic ulceration, severe cold sensitivity, and growth plate injury.
Fourth-degree frostbite has the following characteristics:
Involvement of muscle, bone, and tendons
Frozen, hard, and avascular skin and tissue underneath
Mottled tissue, with nonblanching cyanotic skin that eventually becomes dry, black, and mummified
Relatively little pain experienced on rewarming
Minimal-to-mild postthaw edema
Demarcation between living and nonviable tissue takes 1 month. Spontaneous amputation takes another month after demarcation.
Some experts have moved to a simpler classification of the severity of frostbite injury, in which frostbite is described as either superficial (ie, first- and second-degree injury) or deep (ie, third- and fourth-degree injury). This approach yields a better correlation between severity of injury and final outcome.
Superficial injury is characterized as follows:
Only skin and subcutaneous tissues are involved
Subcutaneous tissue is pliable
Superficial injury precedes deep injury
The lesion has a white mottled appearance with minimal capillary refill, becoming hyperemic and edematous with rewarming
Initial numbness gives way to burning and stinging with rewarming
Blisters, if present, are usually clear
Neurovascular dysfunction is usually reversible
Tissue loss is minimal to nonexistent
Deep injury is characterized as follows:
Skin, subcutaneous levels, muscles, tendons, and bone are all involved
The dermis does not roll over bony prominences
Tissue remains mottled and pulseless after rewarming
Loss of sensation persists after rewarming
Increased loss of flexibility occurs with deeper tissue injury
Blister formation is infrequent; when present, blisters tend to be hemorrhagic
Tissue loss is common
A high risk of infection is present because of devitalized tissue and loss of skin barrier
Rewarming edema appears within 3 hours and lasts 1 week. Large clear blebs appear within 6-24 hours with superficial injuries. Small hemorrhagic blebs appear after 24 hours with deep injuries.
Eschar forms in 9-15 days and is described as a shrunken black carapace shell covering the wound. If the frostbite is superficial, new skin appears beneath the carapace. With deep injury, the area self-amputates. Mummification results in an apparent line of demarcation in 3-6 weeks.
The degree of long-term disability is related to the severity of frostbite injury. An increased risk of frostbite with lesser exposures and poor cold tolerance in the previously injured extremity are commonplace. Permanent sensory loss is also common.
Wound infection, which is observed in 30% of patients, may be caused byStaphylococcus aureus, beta-hemolytic streptococci, gram-negative bacilli, or anaerobes and may present with the following:
Increased pain, swelling, redness, and fever
Red streaks extending from area
Pus discharge
Other complications may include the following:
Tetanus
Tissue loss and gangrene
Bacteremia
Lymphedema
Fascial compartment syndrome [36]
Irreversible growth plate injury (ie, destruction, fragmentation, or fusion of epiphyses) leading to growth deformities and postinjury arthritis [37]
Premature closure of growth plates, the extent of which is related to the severity of the frostbite
Premature closure in the digits, more frequently occurring in a distal-to-proximal direction
Complex regional pain syndrome
Altered thermal perception at the injury site, especially cold sensitivity
Hyperesthesia
Hyperhidrosis
Squamous cell carcinoma development at the frostbitten area
Hyperglycemia
Acidosis
Refractory dysrhythmias
Death, in very rare cases
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Bobak Zonnoor , MD, MMM Assistant Professor of Emergency Medicine, SUNY Downstate School of Medicine; Director, ED Observation Unit, Department of Emergency Medicine, Kings County Hospital; Volunteer Assistant Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Clinical Faculty, University of California, Riverside, School of Medicine
Bobak Zonnoor , MD, MMM is a member of the following medical societies:American College of Emergency Physicians,Emergency Medicine Residents' Association
Disclosure: Nothing to disclose.
Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine
Dirk M Elston, MD is a member of the following medical societies:American Academy of Dermatology
Disclosure: Nothing to disclose.
David Cheng, MD Associate Professor of Emergency Medicine, Education Director, Associate Emergency Medicine Residency Director, Case Medical Center
David Cheng, MD is a member of the following medical societies:American College of Emergency Physicians,International Society for Mountain Medicine,Council of Residency Directors in Emergency Medicine,American Heart Association,National Association of EMS Physicians,Society for Academic Emergency Medicine,Society of Critical Care Medicine,Wilderness Medical Society
Disclosure: Nothing to disclose.
C Crawford Mechem, MD, MS, FACEP Professor, Department of Emergency Medicine, University of Pennsylvania School of Medicine; Emergency Medical Services Medical Director, Philadelphia Fire Department
C Crawford Mechem, MD, MS, FACEP is a member of the following medical societies:American College of Emergency Physicians,National Association of EMS Physicians,Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Ramy Yakobi, MD, MBA Medical Director, Department of Emergency Medicine, Beth Israel Medical Center
Ramy Yakobi, MD, MBA is a member of the following medical societies:American Academy of Emergency Medicine,American College of Emergency Physicians
Disclosure: Nothing to disclose.
Tonya M Thompson, MD, MA Assistant Professor, Departments of Pediatrics and Emergency Medicine, Associate Fellowship Director, Pediatric Emergency Medicine Fellowship, Associate Medical Director, The PULSE Simulation Center, Arkansas Children's Hospital, University of Arkansas for Medical Sciences College of Medicine
Tonya M Thompson, MD, MA is a member of the following medical societies:Academic Pediatric Association,American Academy of Pediatrics,American College of Emergency Physicians,American Medical Women's Association,Phi Beta Kappa,Southern Society for Pediatric Research
Disclosure: Nothing to disclose.
H Scott Bjerke, MD, FACS Clinical Associate Professor, Department of Surgery, University of Missouri-Kansas City School of Medicine; Medical Director of Trauma Services, Research Medical Center; Clinical Associate Professor, Department of Surgery, Indiana University School of Medicine
H Scott Bjerke, MD, FACS is a member of the following medical societies:American Association for the History of Medicine,American Association for the Surgery of Trauma,American College of Surgeons,Association for Academic Surgery,Eastern Association for the Surgery of Trauma,Midwest Surgical Association,National Association of EMS Physicians,Pan-Pacific Surgical Association,Royal Society of Medicine,Southwestern Surgical Congress, andWilderness Medical Society
Disclosure: Nothing to disclose.
Burt Cagir, MD, FACS Assistant Professor of Surgery, State University of New York, Upstate Medical Center; Consulting Staff, Director of Surgical Research, Robert Packer Hospital; Associate Program Director, Department of Surgery, Guthrie Clinic
Burt Cagir, MD, FACS is a member of the following medical societies:American College of Surgeons,American Medical Association, andSociety for Surgery of the Alimentary Tract
Disclosure: Nothing to disclose.
John Geibel, MD, DSc, MA Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies:American Gastroenterological Association,American Physiological Society,American Society of Nephrology,Association for Academic Surgery,International Society of Nephrology,New York Academy of Sciences, andSociety for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other
Dawn Hackshaw, MD Consulting Staff, Northwest Pediatrics, Inc
Disclosure: Nothing to disclose.
David L Morris, MD, PhD Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
Disclosure: RFA Medical None Director; MRC Biotec None Director
Harold K Simon, MD, MBA Professor of Pediatrics and Emergency Medicine, Associate Division Director of Pediatric Emergency Medicine, Director of Research, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston
Harold K Simon, MD, MBA is a member of the following medical societies:Ambulatory Pediatric Association,American Academy of Pediatrics,American Pediatric Society, andSigma Xi
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment
Amit Tevar, MD Staff Physician, Department of Surgery, Methodist Hospital of Indianapolis and University of Indiana
Amit Tevar, MD is a member of the following medical societies:Indiana State Medical Association
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Wayne Wolfram, MD, MPH Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center
Wayne Wolfram, MD, MPH is a member of the following medical societies:American Academy of Emergency Medicine,American Academy of Pediatrics, andSociety for Academic Emergency Medicine
Disclosure: Nothing to disclose
