Case Study 30

The Answer

Assessment

  • Possible frostbite to the distal fingers of the right hand.

The Plan

  • Set up camp.
  • Make a decision whether to try to thaw the fingers.
  • Evacuate tomorrow.

Anticipated Problems

  • If we thaw the fingers, we will need to keep them warm and protected from injury during the evacuation. Tomorrow’s temperature prediction is for highs not reaching zero F (-17C).

Comments

In the urban first-aid scenario frostbite is thawed in the emergency room. In the wilderness a critical decision is whether to thaw in the field. Things to consider in making this decision:

  • The ideal treatment for frostbite is rapid thawing by immersion in a warm water bath.
  • Tissue damage seems to be related to the length of time the tissue stays frozen. How long tissue can be kept frozen without increasing damage is unknown.
  • Refreezing thawed tissue causes significantly worse injury.
  • Thawing will be painful.
  • The thawed tissue will be unusable and must be protected from injury, as well as kept warm. Thawed toes may make it impossible to walk or ski. Thawed fingers may not be usable to climb or hold a pole.
  • Most frostbite will thaw spontaneously, and slowly, especially if the patient is taken to shelter and treated for hypothermia.

The Tale Continues

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.

End of the Tale

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 Refreshers

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.

Appearance

  • While frozen, the tissue appears cold, white, and pale.
  • After thawing tissue may appear mottled, blue or waxy, or swollen and red.
  • Cold tissue may feel cold or be numb and wooden. After thawing it may be painful, numb, or tingling.
  • Blisters forming after thawing suggest partial thickness injury. Fluid in blisters may be clear to purple to red.
  • Tissue remaining numb, cold, and bloodless after thawing suggests full thickness injury.

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).

  • However, in the backcountry, skin-to-skin contact might be most practical.
  • If this is not possible, spontaneous or slow thawing may be unavoidable and should be allowed. Don't purposely keep tissue frozen for extended periods of time.

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.