Frostbite ConcernAPPROACH

ENVIRONMENTAL AND EXPOSURE · 19 SECTIONS

⚲

460 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

Heat Illness Hypothermia And Cold Exposure Frostbite Concern Drowning And Submersion Injury

01History/hx43

HPI

›Frostbite focused history

›OPQRST

›Onset

›First noted numbness or pain

›Time from cold exposure to rewarming

›Provocation and palliation

›Wet exposure

›Wind exposure

›Quality

›Numbness

›Burning pain after rewarming

›Region and radiation

›Digits

›Ears

›Severity

›Functional loss

›Pain score

›Timing

›Continuous symptoms after rewarming

›Refreezing episodes

›Exposure context

›Ambient temperature estimate

›Duration of exposure

›Rewarming details

›Rewarming already attempted

›Refreezing risk after rewarming

Associated symptoms

›Coexisting cold injury symptoms

›Hypothermia symptoms

›Confusion

›Ataxia

›Trauma symptoms

›Falls

›Immobilization time

›Infection symptoms

›Fever

›Purulent drainage

Baseline and prior episodes

›Baseline limb status

›Baseline neuropathy

›Diabetes related

›Alcohol related

›Prior frostbite

›Prior amputations

›Prior cold sensitivity

02Alarm Features/alarm27

Immediate threats

›Time critical triggers

›Systemic hypothermia suspected

›Altered mental status

›Core temperature low

›Compartment syndrome concern

›Pain out of proportion after rewarming

›Tense swelling

›Limb ischemia beyond frostbite

›Absent Doppler signals proximal to injury

›Rapidly progressive mottling

High risk frostbite features

›Severe frostbite indicators

›Hemorrhagic blisters

›After rewarming

›Proximal extent

›Hard wooden tissue after rewarming

›Proximal joint involvement

›Circumferential involvement

›Cyanosis not improving after rewarming

›Persistent pallor

›Non blanching skin

Vital sign danger thresholds

›Physiologic instability

›Hypotension

›Shock physiology

›Concern for sepsis or trauma

›Bradycardia with hypothermia

›Ventricular dysrhythmia risk

›Rough handling risk

03Medications/meds17

Current and recent meds

›Medication exposure relevant to frostbite

›Vasoconstrictive agents

›Stimulants

›Decongestants

›Anticoagulants and antiplatelets

›DOACs

›Warfarin

›Beta blockers

›Blunted tachycardia response

›Peripheral perfusion effects

Medication contraindications to therapies

›Contraindication screen for thrombolysis and vasodilators

›Thrombolysis contraindications

›Recent intracranial hemorrhage history

›Active bleeding

›Vasodilator cautions

›Hypotension

›Severe aortic stenosis history

04Diet/diet10

Recent intake and hydration

›Nutrition and fluid status

›Dehydration risk

›Poor oral intake

›Vomiting

›Alcohol exposure

›Intoxication during exposure

›Withdrawal risk

›Caffeine and energy drinks

›High dose caffeine

›Sympathomimetic additives

05Review of Systems/ros14

General and infectious

›System review targeted to complications

›Constitutional

›Fever

›Chills

›Skin

›Spreading erythema

›Foul odor

Cardiopulmonary and neurologic

›Cold exposure complications

›Cardiopulmonary

›Chest pain

›Dyspnea

›Neurologic

›Confusion

›Syncope

06Collateral History and Family History/chafh14

Collateral source

›Reliability and timeline support

›Collateral informant

›Companion on scene

›EMS report

›Exposure reconstruction

›Last known well time

›Duration outdoors estimate

Family history

›Inherited and early vascular disease

›Early cardiovascular disease

›MI under age 55

›Stroke under age 55

›Thrombophilia history

›VTE history in first degree relative

›Known inherited thrombophilia

07Risk Factors/rf30

Environmental and occupational

›Exposure risk profile

›High altitude exposure

›Low ambient temperatures

›Limited rescue access

›Prolonged immobility

›Intoxication

›Entrapment

›Inadequate insulation

›Wet gloves or socks

›Tight footwear

Patient factors

›Host factors increasing risk and severity

›Peripheral arterial disease (I73.9)

›Claudication history

›Prior revascularization

›Diabetes mellitus (E11.9)

›Neuropathy

›Microvascular disease

›Tobacco use

›Current smoking

›Recent nicotine use

›Raynaud phenomenon (I73.00)

›Cold induced color changes

›Prior ischemic ulcers

Bleeding and thrombosis risk

›Reperfusion and lysis decision context

›Bleeding risk factors

›Recent surgery

›Known intracranial lesion

›Thrombosis risk factors

›Prior VTE

›Estrogen therapy

08Differential Diagnosis/ddx33

Life threatening

›Cannot miss diagnoses

›Moderate to severe hypothermia (T68)

›Bradycardia

›Altered mental status

›Sepsis from infected tissue (A41.9)

›Fever

›Hypotension

›Compartment syndrome

›Pain with passive stretch

›Tense compartments

›Acute arterial occlusion (I74.9)

›Sudden pallor

›Proximal pulse deficit

Common

›Likely diagnoses

›Frostnip

›Reversible numbness

›No blisters after rewarming

›Superficial frostbite

›Clear blisters

›Erythema and edema after rewarming

›Deep frostbite

›Hemorrhagic blisters

›Hard insensate tissue

Less common

›Mimics and related cold injury

›Pernio chilblains

›Itchy erythematous papules

›Subacute onset after cold damp exposure

›Trench foot immersion foot

›Prolonged wet exposure above freezing

›Maceration and swelling

›Cold contact injury

›Localized area matching contact

›Often sharply demarcated

09Past Medical History/pmh17

Conditions and prior care

›Relevant comorbidities

›Vascular disease history

›Peripheral arterial disease

›Prior amputations

›Metabolic disease

›Diabetes

›Hypothyroidism (E03.9)

›Psychiatric and substance use

›Alcohol use disorder (F10.20)

›Stimulant use

Surgeries and devices

›Prior procedures affecting perfusion

›Vascular interventions

›Bypass grafts

›Stents

›Implanted devices

›Pacemaker

›ICD

10Physical Exam/exam37

General and vitals

›Initial assessment

›General appearance

›Toxic appearance

›Shivering status

›Vital signs

›Temp

›HR

›Perfusion

›Capillary refill proximal to injury

›Skin temperature gradient

Extremity and skin exam

›Frostbite staging bedside features

›Pre rewarming findings

›Pallor

›Waxy skin

›Post rewarming findings

›Edema extent

›Blister type

›Demarcation

›Circumferential involvement

›Joint crossing

Neurovascular exam

›Limb viability assessment

›Pulses

›Palpable pulses

›Doppler signals

›Sensation

›Light touch

›Two point discrimination

›Motor

›Active range of motion

›Intrinsic hand or foot strength

Complication screen

›High risk findings

›Compartment syndrome

›Pain with passive stretch

›Tense compartments

›Infection

›Spreading erythema

›Crepitus

11Lab Studies/labs34

Core labs

›Baseline and complication labs

›CBC

›Leukocytosis for infection

›Thrombocytopenia for coagulopathy

›Electrolytes

›Potassium abnormalities

›Renal function

›Glucose

›Hypoglycemia in exposure

›Hyperglycemia and poor healing risk

Rhabdomyolysis and perfusion

›Tissue injury evaluation

›CK

›Rhabdomyolysis screen

›Trend with hydration response

›Lactate

›Shock marker

›Severe hypoperfusion marker

Coagulation and thrombolysis readiness

›Lysis and bleeding risk labs

›INR

›Warfarin effect

›Baseline bleeding risk

›aPTT

›Heparin effect

›Baseline bleeding risk

›Fibrinogen

›Baseline before thrombolysis

›Trend during thrombolysis

Point of care testing

›Bedside tests

›Core temperature method

›Esophageal probe if intubated

›Rectal probe if not intubated

›Blood gas if unstable

›Acidemia severity

›Ventilation status

12Imaging/img31

Scoring Systems

›Frostbite severity grading for reperfusion therapy decisions

›Cauchy classification

›Grade 1

›Grade 2

›Cauchy classification

›Grade 3

›Grade 4

›Application

›Use after rewarming for blister and perfusion pattern

›Higher grade supports iloprost or thrombolysis consideration

MRI

›Limited role in acute frostbite

›Indications

›Suspected osteomyelitis later course

›Deep space infection concern

›Limitations

›Early findings may not predict final tissue loss

›Not first line for reperfusion decisions

›Complication focused CT

›Indications

›Trauma evaluation if fall or altered mental status

›Gas in soft tissue concern

›Contrast considerations

›AKI risk with dehydration

›Allergy history

Ultrasound

›POCUS and vascular assessment

›Doppler evaluation

›Arterial signals

›Venous thrombosis screen if swollen limb

›Limitations

›Distal digital flow may be difficult to assess

›Does not replace angiography if lysis planned

13Special Tests/spec14

Bedside rewarming response

›Functional and perfusion response after rewarming

›Return of sensation

›Frostnip likelihood higher

›Persistent anesthesia suggests deeper injury

›Capillary refill

›Improvement supports perfusion

›Persistent no refill suggests severe injury

Advanced perfusion assessment

›Specialist guided tests

›Angiography

›Candidate selection for intra arterial thrombolysis

›Thrombosis visualization

›Nuclear medicine bone scan

›Tissue viability mapping around day 2 to 4

›Surgical planning aid

14ECG/ecg14

Indications and key findings

›Hypothermia and exposure ECG

›Indications

›Suspected hypothermia

›Syncope during exposure

›High risk findings

›Osborn waves

›Ventricular arrhythmias

Serial ECG and monitoring

›Ongoing monitoring logic

›Continuous telemetry

›Moderate to severe hypothermia

›Electrolyte abnormalities

›Repeat ECG triggers

›Temperature increases

›Rhythm change

15Assessment/ax20

Working diagnosis and severity

›Frostbite classification summary

›Frostnip versus frostbite

›Reversible numbness without blistering

›Persistent sensory loss with blistering

›Superficial versus deep frostbite

›Clear blisters

›Hemorrhagic blisters

›Severe frostbite suspicion

›Perfusion deficit after rewarming

›Proximal joint involvement

Complications to rule out

›Associated problems and alternate diagnoses

›Hypothermia severity

›Core temperature category

›Mental status category

›Rhabdomyolysis

›CK elevation

›AKI risk

›Infection

›Cellulitis features

›Necrotizing infection features

16Plan/plan64

First 5 minutes

›Immediate workflow

›Monitoring

›Continuous pulse oximetry if systemic exposure

›Cardiac monitor if hypothermia suspected

›IV access criteria

›Moderate to severe hypothermia

›Severe frostbite grade concern

›Temperature management

›Remove wet clothing

›Warm environment and active external warming if hypothermic

Local frostbite care

›Tissue protection and rewarming

›Refreezing prevention

›Do not rewarm if refreezing likely

›Protect and insulate until definitive warming

›Rapid rewarming when appropriate

›Water bath 37 to 39 C

›Rewarming until tissue pliable and erythematous

›Mechanical precautions

›No rubbing or massage

›Avoid weight bearing on frostbitten foot if possible

Analgesia and anti inflammatory

›Pain control and antithromboxane support

›Opioid analgesia

›Severe pain during rewarming

›Titrate to effect with respiratory monitoring

›Ibuprofen

›Adult 400 to 600 mg PO every 6 to 8 hours

›Max 2400 mg per day

›Topical aloe vera

›Apply to thawed tissue

›Cover with sterile dressing

Blister and wound management

›Local wound care strategy

›Dressings

›Loose bulky sterile dressings

›Elevation to reduce edema

›Blister management local protocol dependent

›Clear blisters consider selective debridement in specialty care

›Hemorrhagic blisters typically leave intact

›Tetanus prophylaxis

›Update per immunization status

›Treat as wound

Reperfusion therapy and consultation

›Severe frostbite limb salvage pathway

›Early consult activation

›Burn center or plastic surgery

›Interventional radiology if thrombolysis pathway

›Thrombolysis consideration

›Perfusion deficit after rewarming

›Presentation within 24 hours of rewarming

›Iloprost consideration

›Severe frostbite when thrombolysis contraindicated

›Presentation within 48 to 72 hours of rewarming

Antibiotics and infection

›Antimicrobial approach

›Prophylactic antibiotics

›Not routine for uncomplicated frostbite

›Consider only with clear infection risk factors

›Treatment antibiotics if infection

›Cellulitis coverage per local protocol

›Necrotizing infection requires broad spectrum and surgery

Reassessment loop

›Time based reassessment

›Recheck interval

›Pain and perfusion reassess every 30 to 60 minutes early course

›Neurovascular exam after rewarming completion

›Escalation triggers

›Worsening pain with tense swelling

›Progressive perfusion loss

17Disposition/dispo20

Level of care and transfer

›Admission and transfer criteria

›ICU criteria

›Moderate to severe hypothermia with instability

›Ventricular dysrhythmia risk

›Inpatient admission criteria

›Deep frostbite with extensive tissue injury

›Need for reperfusion therapy monitoring

›Transfer to burn center criteria

›Suspected deep frostbite grade 2 to 4

›Perfusion deficit after rewarming

Discharge criteria

›Safe discharge requirements

›Low severity injury

›Frostnip

›Superficial injury without perfusion deficit

›Pain controlled

›Oral regimen effective

›No uncontrolled rewarming pain

›Reliable follow up

›Wound check within 24 to 72 hours

›Return precautions understood

18Discharge Instructions/di15

Copy discharge instructions

›Frostbite discharge text

›You had a cold injury that can worsen over the next several days even after rewarming

›Keep the area clean, dry, elevated, and protected from cold

›Do not rub the area and do not apply direct heat such as a heating pad

›Use ibuprofen as directed unless you were told not to

›Change dressings as instructed and keep blisters intact unless told otherwise

›Return to the ED now for worsening pain, spreading redness, fever, pus, new numbness, black skin, or fingers or toes that become cold and pale again

›Follow up in 1 to 3 days with the recommended clinic or burn service

Activity and prevention

›Prevention focused guidance

›Avoid refreezing

›Do not go back into cold without adequate insulation

›Keep gloves and socks dry

›Activity limits

›Limit walking on affected feet

›Protect digits from trauma

19References/r6

Guidelines and key sources

›Evidence based references

›Wilderness Medical Society clinical practice guidelines for the prevention and treatment of frostbite 2019 update

›Wilderness Medical Society clinical practice guidelines for the prevention and treatment of frostbite 2024

›American Burn Association clinical practice guideline on severe frostbite treatment 2024

›CMAJ Open management of severe frostbite with iloprost and alteplase 2021

›AAFP frostbite recommendations for prevention and treatment summary of WMS guideline 2020

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Frostbite ConcernAPPROACH

ENVIRONMENTAL AND EXPOSURE · 19 SECTIONS

⚲

460 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

Heat Illness Hypothermia And Cold Exposure Frostbite Concern Drowning And Submersion Injury

01History/hx43

HPI

›Frostbite focused history

›OPQRST

›Onset

›First noted numbness or pain

›Time from cold exposure to rewarming

›Provocation and palliation

›Wet exposure

›Wind exposure

›Quality

›Numbness

›Burning pain after rewarming

›Region and radiation

›Digits

›Ears

›Severity

›Functional loss

›Pain score

›Timing

›Continuous symptoms after rewarming

›Refreezing episodes

›Exposure context

›Ambient temperature estimate

›Duration of exposure

›Rewarming details

›Rewarming already attempted

›Refreezing risk after rewarming

Associated symptoms

›Coexisting cold injury symptoms

›Hypothermia symptoms

›Confusion

›Ataxia

›Trauma symptoms

›Falls

›Immobilization time

›Infection symptoms

›Fever

›Purulent drainage

Baseline and prior episodes

›Baseline limb status

›Baseline neuropathy

›Diabetes related

›Alcohol related

›Prior frostbite

›Prior amputations

›Prior cold sensitivity

02Alarm Features/alarm27

Immediate threats

›Time critical triggers

›Systemic hypothermia suspected

›Altered mental status

›Core temperature low

›Compartment syndrome concern

›Pain out of proportion after rewarming

›Tense swelling

›Limb ischemia beyond frostbite

›Absent Doppler signals proximal to injury

›Rapidly progressive mottling

High risk frostbite features

›Severe frostbite indicators

›Hemorrhagic blisters

›After rewarming

›Proximal extent

›Hard wooden tissue after rewarming

›Proximal joint involvement

›Circumferential involvement

›Cyanosis not improving after rewarming

›Persistent pallor

›Non blanching skin

Vital sign danger thresholds

›Physiologic instability

›Hypotension

›Shock physiology

›Concern for sepsis or trauma

›Bradycardia with hypothermia

›Ventricular dysrhythmia risk

›Rough handling risk

03Medications/meds17

Current and recent meds

›Medication exposure relevant to frostbite

›Vasoconstrictive agents

›Stimulants

›Decongestants

›Anticoagulants and antiplatelets

›DOACs

›Warfarin

›Beta blockers

›Blunted tachycardia response

›Peripheral perfusion effects

Medication contraindications to therapies

›Contraindication screen for thrombolysis and vasodilators

›Thrombolysis contraindications

›Recent intracranial hemorrhage history

›Active bleeding

›Vasodilator cautions

›Hypotension

›Severe aortic stenosis history

04Diet/diet10

Recent intake and hydration

›Nutrition and fluid status

›Dehydration risk

›Poor oral intake

›Vomiting

›Alcohol exposure

›Intoxication during exposure

›Withdrawal risk

›Caffeine and energy drinks

›High dose caffeine

›Sympathomimetic additives

05Review of Systems/ros14

General and infectious

›System review targeted to complications

›Constitutional

›Fever

›Chills

›Skin

›Spreading erythema

›Foul odor

Cardiopulmonary and neurologic

›Cold exposure complications

›Cardiopulmonary

›Chest pain

›Dyspnea

›Neurologic

›Confusion

›Syncope

06Collateral History and Family History/chafh14

Collateral source

›Reliability and timeline support

›Collateral informant

›Companion on scene

›EMS report

›Exposure reconstruction

›Last known well time

›Duration outdoors estimate

Family history

›Inherited and early vascular disease

›Early cardiovascular disease

›MI under age 55

›Stroke under age 55

›Thrombophilia history

›VTE history in first degree relative

›Known inherited thrombophilia

07Risk Factors/rf30

Environmental and occupational

›Exposure risk profile

›High altitude exposure

›Low ambient temperatures

›Limited rescue access

›Prolonged immobility

›Intoxication

›Entrapment

›Inadequate insulation

›Wet gloves or socks

›Tight footwear

Patient factors

›Host factors increasing risk and severity

›Peripheral arterial disease (I73.9)

›Claudication history

›Prior revascularization

›Diabetes mellitus (E11.9)

›Neuropathy

›Microvascular disease

›Tobacco use

›Current smoking

›Recent nicotine use

›Raynaud phenomenon (I73.00)

›Cold induced color changes

›Prior ischemic ulcers

Bleeding and thrombosis risk

›Reperfusion and lysis decision context

›Bleeding risk factors

›Recent surgery

›Known intracranial lesion

›Thrombosis risk factors

›Prior VTE

›Estrogen therapy

08Differential Diagnosis/ddx33

Life threatening

›Cannot miss diagnoses

›Moderate to severe hypothermia (T68)

›Bradycardia

›Altered mental status

›Sepsis from infected tissue (A41.9)

›Fever

›Hypotension

›Compartment syndrome

›Pain with passive stretch

›Tense compartments

›Acute arterial occlusion (I74.9)

›Sudden pallor

›Proximal pulse deficit

Common

›Likely diagnoses

›Frostnip

›Reversible numbness

›No blisters after rewarming

›Superficial frostbite

›Clear blisters

›Erythema and edema after rewarming

›Deep frostbite

›Hemorrhagic blisters

›Hard insensate tissue

Less common

›Mimics and related cold injury

›Pernio chilblains

›Itchy erythematous papules

›Subacute onset after cold damp exposure

›Trench foot immersion foot

›Prolonged wet exposure above freezing

›Maceration and swelling

›Cold contact injury

›Localized area matching contact

›Often sharply demarcated

09Past Medical History/pmh17

Conditions and prior care

›Relevant comorbidities

›Vascular disease history

›Peripheral arterial disease

›Prior amputations

›Metabolic disease

›Diabetes

›Hypothyroidism (E03.9)

›Psychiatric and substance use

›Alcohol use disorder (F10.20)

›Stimulant use

Surgeries and devices

›Prior procedures affecting perfusion

›Vascular interventions

›Bypass grafts

›Stents

›Implanted devices

›Pacemaker

›ICD

10Physical Exam/exam37

General and vitals

›Initial assessment

›General appearance

›Toxic appearance

›Shivering status

›Vital signs

›Temp

›HR

›Perfusion

›Capillary refill proximal to injury

›Skin temperature gradient

Extremity and skin exam

›Frostbite staging bedside features

›Pre rewarming findings

›Pallor

›Waxy skin

›Post rewarming findings

›Edema extent

›Blister type

›Demarcation

›Circumferential involvement

›Joint crossing

Neurovascular exam

›Limb viability assessment

›Pulses

›Palpable pulses

›Doppler signals

›Sensation

›Light touch

›Two point discrimination

›Motor

›Active range of motion

›Intrinsic hand or foot strength

Complication screen

›High risk findings

›Compartment syndrome

›Pain with passive stretch

›Tense compartments

›Infection

›Spreading erythema

›Crepitus

11Lab Studies/labs34

Core labs

›Baseline and complication labs

›CBC

›Leukocytosis for infection

›Thrombocytopenia for coagulopathy

›Electrolytes

›Potassium abnormalities

›Renal function

›Glucose

›Hypoglycemia in exposure

›Hyperglycemia and poor healing risk

Rhabdomyolysis and perfusion

›Tissue injury evaluation

›CK

›Rhabdomyolysis screen

›Trend with hydration response

›Lactate

›Shock marker

›Severe hypoperfusion marker

Coagulation and thrombolysis readiness

›Lysis and bleeding risk labs

›INR

›Warfarin effect

›Baseline bleeding risk

›aPTT

›Heparin effect

›Baseline bleeding risk

›Fibrinogen

›Baseline before thrombolysis

›Trend during thrombolysis

Point of care testing

›Bedside tests

›Core temperature method

›Esophageal probe if intubated

›Rectal probe if not intubated

›Blood gas if unstable

›Acidemia severity

›Ventilation status

12Imaging/img31

Scoring Systems

›Frostbite severity grading for reperfusion therapy decisions

›Cauchy classification

›Grade 1

›Grade 2

›Cauchy classification

›Grade 3

›Grade 4

›Application

›Use after rewarming for blister and perfusion pattern

›Higher grade supports iloprost or thrombolysis consideration

MRI

›Limited role in acute frostbite

›Indications

›Suspected osteomyelitis later course

›Deep space infection concern

›Limitations

›Early findings may not predict final tissue loss

›Not first line for reperfusion decisions

›Complication focused CT

›Indications

›Trauma evaluation if fall or altered mental status

›Gas in soft tissue concern

›Contrast considerations

›AKI risk with dehydration

›Allergy history

Ultrasound

›POCUS and vascular assessment

›Doppler evaluation

›Arterial signals

›Venous thrombosis screen if swollen limb

›Limitations

›Distal digital flow may be difficult to assess

›Does not replace angiography if lysis planned

13Special Tests/spec14

Bedside rewarming response

›Functional and perfusion response after rewarming

›Return of sensation

›Frostnip likelihood higher

›Persistent anesthesia suggests deeper injury

›Capillary refill

›Improvement supports perfusion

›Persistent no refill suggests severe injury

Advanced perfusion assessment

›Specialist guided tests

›Angiography

›Candidate selection for intra arterial thrombolysis

›Thrombosis visualization

›Nuclear medicine bone scan

›Tissue viability mapping around day 2 to 4

›Surgical planning aid

14ECG/ecg14

Indications and key findings

›Hypothermia and exposure ECG

›Indications

›Suspected hypothermia

›Syncope during exposure

›High risk findings

›Osborn waves

›Ventricular arrhythmias

Serial ECG and monitoring

›Ongoing monitoring logic

›Continuous telemetry

›Moderate to severe hypothermia

›Electrolyte abnormalities

›Repeat ECG triggers

›Temperature increases

›Rhythm change

15Assessment/ax20

Working diagnosis and severity

›Frostbite classification summary

›Frostnip versus frostbite

›Reversible numbness without blistering

›Persistent sensory loss with blistering

›Superficial versus deep frostbite

›Clear blisters

›Hemorrhagic blisters

›Severe frostbite suspicion

›Perfusion deficit after rewarming

›Proximal joint involvement

Complications to rule out

›Associated problems and alternate diagnoses

›Hypothermia severity

›Core temperature category

›Mental status category

›Rhabdomyolysis

›CK elevation

›AKI risk

›Infection

›Cellulitis features

›Necrotizing infection features

16Plan/plan64

First 5 minutes

›Immediate workflow

›Monitoring

›Continuous pulse oximetry if systemic exposure

›Cardiac monitor if hypothermia suspected

›IV access criteria

›Moderate to severe hypothermia

›Severe frostbite grade concern

›Temperature management

›Remove wet clothing

›Warm environment and active external warming if hypothermic

Local frostbite care

›Tissue protection and rewarming

›Refreezing prevention

›Do not rewarm if refreezing likely

›Protect and insulate until definitive warming

›Rapid rewarming when appropriate

›Water bath 37 to 39 C

›Rewarming until tissue pliable and erythematous

›Mechanical precautions

›No rubbing or massage

›Avoid weight bearing on frostbitten foot if possible

Analgesia and anti inflammatory

›Pain control and antithromboxane support

›Opioid analgesia

›Severe pain during rewarming

›Titrate to effect with respiratory monitoring

›Ibuprofen

›Adult 400 to 600 mg PO every 6 to 8 hours

›Max 2400 mg per day

›Topical aloe vera

›Apply to thawed tissue

›Cover with sterile dressing

Blister and wound management

›Local wound care strategy

›Dressings

›Loose bulky sterile dressings

›Elevation to reduce edema

›Blister management local protocol dependent

›Clear blisters consider selective debridement in specialty care

›Hemorrhagic blisters typically leave intact

›Tetanus prophylaxis

›Update per immunization status

›Treat as wound

Reperfusion therapy and consultation

›Severe frostbite limb salvage pathway

›Early consult activation

›Burn center or plastic surgery

›Interventional radiology if thrombolysis pathway

›Thrombolysis consideration

›Perfusion deficit after rewarming

›Presentation within 24 hours of rewarming

›Iloprost consideration

›Severe frostbite when thrombolysis contraindicated

›Presentation within 48 to 72 hours of rewarming

Antibiotics and infection

›Antimicrobial approach

›Prophylactic antibiotics

›Not routine for uncomplicated frostbite

›Consider only with clear infection risk factors

›Treatment antibiotics if infection

›Cellulitis coverage per local protocol

›Necrotizing infection requires broad spectrum and surgery

Reassessment loop

›Time based reassessment

›Recheck interval

›Pain and perfusion reassess every 30 to 60 minutes early course

›Neurovascular exam after rewarming completion

›Escalation triggers

›Worsening pain with tense swelling

›Progressive perfusion loss

17Disposition/dispo20

Level of care and transfer

›Admission and transfer criteria

›ICU criteria

›Moderate to severe hypothermia with instability

›Ventricular dysrhythmia risk

›Inpatient admission criteria

›Deep frostbite with extensive tissue injury

›Need for reperfusion therapy monitoring

›Transfer to burn center criteria

›Suspected deep frostbite grade 2 to 4

›Perfusion deficit after rewarming

Discharge criteria

›Safe discharge requirements

›Low severity injury

›Frostnip

›Superficial injury without perfusion deficit

›Pain controlled

›Oral regimen effective

›No uncontrolled rewarming pain

›Reliable follow up

›Wound check within 24 to 72 hours

›Return precautions understood

18Discharge Instructions/di15

Copy discharge instructions

›Frostbite discharge text

›You had a cold injury that can worsen over the next several days even after rewarming

›Keep the area clean, dry, elevated, and protected from cold

›Do not rub the area and do not apply direct heat such as a heating pad

›Use ibuprofen as directed unless you were told not to

›Change dressings as instructed and keep blisters intact unless told otherwise

›Return to the ED now for worsening pain, spreading redness, fever, pus, new numbness, black skin, or fingers or toes that become cold and pale again

›Follow up in 1 to 3 days with the recommended clinic or burn service

Activity and prevention

›Prevention focused guidance

›Avoid refreezing

›Do not go back into cold without adequate insulation

›Keep gloves and socks dry

›Activity limits

›Limit walking on affected feet

›Protect digits from trauma

19References/r6

Guidelines and key sources

›Evidence based references

›Wilderness Medical Society clinical practice guidelines for the prevention and treatment of frostbite 2019 update

›Wilderness Medical Society clinical practice guidelines for the prevention and treatment of frostbite 2024

›American Burn Association clinical practice guideline on severe frostbite treatment 2024

›CMAJ Open management of severe frostbite with iloprost and alteplase 2021

›AAFP frostbite recommendations for prevention and treatment summary of WMS guideline 2020

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.