Frostbite

Question 1

What is the pathophysiology of frostbite?

Answer 1

Another significant cold-related injury that may or may not be associated with hypothermia is frostbite. The main risk factor is inadequate insulation against cold weather (i.e., the skin is exposed to the cold, or the person’s clothing offers insufficient protection, which leads to injury). Wet clothing is a poor insulator and facilitates the development of frostbite. Fatigue, dehydration, and poor nutrition are other contributing factors. People who smoke, consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite. Any previous history of frostbite further increases a person’s susceptibility.

Question 2

What are some findings the nurse would expect to see?

Answer 2

Frostbite occurs when body tissue freezes and causes damage to tissue integrity . Like burns, frostbite injuries can be superficial, partial, or full thickness. By contrast, frostnip is a type of superficial cold injury that may produce pain, numbness, and pallor or a waxy appearance of the affected area but is easily relieved by applying warmth. It does not cause impaired tissue integrity . Frostnip typically develops on areas such as the face, nose, finger, or toes. Untreated, it is a precursor to more severe forms of frostbite.

Question 3

What is Grade 1 frostbite?

Answer 3

Grade I frostbite, the least severe type of frostbite, involves hyperemia (increased blood flow) of the involved area and edema formation.

Question 4

What is Grade 2 frostbite?

Answer 4

In Grade 2 frostbite, large, clear-to-milky, fluid-filled blisters develop with partial-thickness skin necrosis

Question 5

What is Grade 3 frostbite?

Answer 5

Grade 3 frostbite appears as small blisters that contain dark fluid and an affected body part that is cool, numb, blue, or red and does not blanch. Full-thickness and subcutaneous tissue necrosis occurs and requires débridement.

Question 6

What is Grade 4 frostbite?

Answer 6

In Grade 4 frostbite, the most severe form, there are blisters over the carpal or tarsal (instead of just the digit); the part is numb, cold, and bloodless. The full-thickness necrosis extends into the muscle and bone. At this stage, gangrene develops, which may require amputation of the affected part. Of note, except for frostnip, other degrees of frostbite may all have the same general appearance while the body part is frozen; the differentiating features of each degree of frostbite only become apparent after the part is thawed. Gangrene may evolve over days to weeks after injury.

Question 7

What interventions are included in the prehospital care?

Answer 7

Recognition of frostbite is essential to early, effective intervention and prevention of further damage to tissue integrity . Asking a significant other to frequently observe for early signs of frostbite such as a white, waxy appearance to exposed skin, especially on the nose, cheeks, and ears, is an effective strategy to identify the problem before it worsens. In people with dark skin, skin becomes paler, waxy, and somewhat gray. In this case the best remedy is to have the person seek shelter from the wind and cold and attend to the affected body part. Superficial frostbite is easily managed using body heat to warm the affected area. Teach patients to place their warm hands over the affected areas on their face or to place cold hands under the arms.

Question 8

What interventions are included in the hospital care?

Answer 8

• Patients with more severe and deeper forms of frostbite need aggressive management. For all degrees of partial-thickness–to–full-thickness frostbite, rapid rewarming in a water bath at a temperature range of 99° to 102°F (37° to 39°C) is indicated to thaw the frozen part. The part should be swirled in the water and not allowed to touch the sides of the container to prevent tissue damage. Because patients experience severe pain during the rewarming process, this intervention is best accomplished in a health care facility; however, it may be done in another setting if no other options exist for prompt transport or rescue. Administer analgesics, IV opiates, and IV rehydration as prescribed. Ibuprofen should also be administered as prescribed, as it decreases thromboxane production in the inflammatory cascade and may reduce secondary tissue injury in frostbite.
• When the rewarming process is complete, handle the injured areas gently and elevate them above heart level if possible to decrease tissue edema. Sometimes splints are used to immobilize extremities during the healing process. Assess the person at least hourly for the development of compartment syndrome—a limb-threatening complication caused by severe neurovascular impairment. Observe for early signs and symptoms, which include increasing pain (even after analgesics are given) and paresthesias (painful tingling and numbness). Compare the affected extremity with the unaffected one to assess for pallor. Assess for pulses and muscle weakness.
• Frostbite destroys tissue and produces a deep tetanus-prone wound; so the patient should be immunized to prevent tetanus. Apply only loose, nonadherent sterile dressings to the damaged areas. Avoid compression of the injured tissues. Both topical and systemic antibiotics may be used. Once a patient’s frozen part has thawed, do not allow it to refreeze, which worsens the injury. Anticipate diagnostic studies such as arteriography to evaluate perfusion to the injured part.
• In cases of severe, deep frostbite, débridement of necrotic tissue may be needed to evaluate tissue viability and provide wound management. Amputation may be indicated for patients with severe injuries or those who develop gangrene or severe compartment syndrome.