You explained the situation and the decision parameters to the patient and your companions. The patient agreed that his fingers would likely thaw slowly now that he was warm and in shelter. He anticipated he could ski to the road tomorrow with one pole and without a pack. He agreed to the warm water bath. You removed a ring from his index finger and a bracelet from his wrist. He immersed the fingers on his right hand into the pot of warm water. The pain was intense. The patient was only able to tolerate the procedure for 15 minutes. Assessment at that point showed the fingers were pink and warm to the end of the digits. The fingers were kept warm through the night. At dawn the fingertips were painful and pink. Clear fluid blisters had formed overnight on all four fingers extending from the last joint about two-thirds of the way to the fingertip. The patient took 600 mg ibuprofen every six hours through the night. The pain was rated 7 on a 1-10 scale.
The fingers were dressed lightly with gauze and protected from the cold with two spare socks and one large expedition over-mitten. The patient began the ski with the hand in a sling and swathe, but this made him unbalanced. He completed the ski without falling with his arm free to move, but not using a ski pole. The fingers remained warm throughout. The blisters did not grow larger or rupture.
The patient healed well. He eventually lost his fingernails, but no other tissue. He returned to winter camping with a heightened resolve not to tolerate cold fingers or toes.
Frostbite is a local freezing cold injury. It is most likely to occur on fingers, toes, ears, and nose. It creates a spectrum of injury ranging from minor irritation to extensive tissue loss.
Treatment Principles for Frostbite
1. Ideally thaw superficial frostbite promptly. Skin-to-skin warming is acceptable.
2. Partial or full-thickness injury is ideally thawed in a warm water bath at 99-102°F (37-39°C).
3. Protect from re-freezing.
4. Never massage or use radiant heat.
5. Consider ibuprofen for pain. Non-steroidal anti-inflammatory medications (NSAIDs) block chemicals that can lead to vasoconstriction and further tissue damage. Although no studies have directly demonstrated that any particular anti-inflammatory agent or dosing is clearly beneficial to outcome, ibuprofen is often recommended.
6. Avoid constriction. Protect blisters or damaged tissue.
7. Extent of injury is often only apparent over time.