Case Study of the Week: Frostbite

My husband and I made the trek (OK, we didn't actually "trek" but it was a really long flight) to Alaska this summer with his family.  During our time in the remote Glacier Bay, I couldn't help thinking about about all of the medical conditions such an environment can propagate.  Then, when my husband decided to jump into the freezing Alaskan waters littered with icebergs I realized I am definitely not up to date on the latest treatment guidelines for frostbite (luckily, he grew out his beard for the occasion which I think kept him warm enough to avoid this complication). Although it is August, winter is coming.  What do you do when a patient presents with symptoms of frostbite?

Introduction

Frostbite is a condition of tissue freezing long recognized among military members.  Among civilians, homeless individuals, persons working outdoors and individuals with exposure to extreme environments such as mountaineers are susceptible to the condition.  Smoking and alcohol consumption increases risk of this disease.  Prolonged exposure to extreme cold results in vasoconstriction and resulting cellular death.  Frostbite can result in scarring and loss of digits or limbs.  Prompt intervention is important to reduce complications. 

 

Case Presentation 

A homeless 58 year old male presents to your ER with complaints of pain and swelling in his feet bilaterally.  He states he has been sleeping on the streets during the recent snowstorm because nearby shelters are full.  Vital signs are stable with a temperature of 97.4.  This patient has a history of poorly controlled hypertension and alcohol abuse. 

On exam, you find the patient's toes are erythematous with blistering and a slight dusky color to the plantar surface.  A clear, milky fluid is present in the blisters. 

Based on this patients exam, you suspect he has second degree frostbite.  Differential diagnoses include trench foot (peripheral neurovascular damage resulting from prolonged exposure to a wet, cold, non-freezing environment), cellulitis and perino (painful inflammatory skin lesions caused by chronic, repeated exposure to damp, nonfreezing temperatures). 

Management and Outcome

The goal of frostbite treatment is to reperfuse to the affected area.  Frostbite is best treated in a burn unit by rewarming of the affected area with circulating water at 104F to 107F as quickly as possible.  Rewarming can be extremely painful and narcotic pain medications may be required.  Consider giving IV fluids as dehydration is common in association with frostbite.  After rewarming, clear blisters should be debrided.  If the provider suspects amputation of the suspected area may be necessary, tPA can be injected at the site to reduce the incidence of blood clots.  Amputation of digits affected by frostbite should be avoided early in the disease process as it is important to wait until dead and viable tissues are clearly demarcated, often months after injury.  Patients with frostbite are usually admitted to the burn unit for 1 to 2 days to determine extent of injury.  65% of patients will continue to suffer long-term complications of frostbite including pain or abnormal sensation in the extremity, heat or cold sensitivity and arthritis. 

Discussion

Although rare, frostbite warrants emergent treatment in order to prevent complication and further tissue damage.  Burn centers are best prepared to treat frostbite so patients presenting with the condition should be transferred to a facility with a burn center. 

References

Mechem, C. Crawford, Frostbite, http://emedicine.medscape.com/article/926249-overview

McIntosh, Scott, Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Frostbite, http://www.wemjournal.org/article/S1080-6032(11)00077-9/abstract