A middle aged woman with schizophrenia presents to your ED on a cold night in February after being found stranded on a mountain where she became separated from her group of hikers during a snowstorm 2 days ago. You realize that this patient has been outside for days, during a week which has been among the coldest of the season. She reports severe throbbing hand pain. The patients vitals are 33C, BP 130/90, HR 110, RR 16. Your examination of her very cold extremities reveals the following:

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What is the most likely etiology of the patient’s dermatologic findings? What management steps should you take?

 

 

This is a case of frostbite. This is a freezing injury that occurs when skin temperatures fall below 32F. This occurs as the body fights to maintain core temperature within normal limits. Ice crystals eventually form in the extracellular space, and ischemia from progressive vasoconstriction leads to tissue loss -> Edema -> Blusters -> Eschars -> Gangrene. This is most commonly noted on extremities and the face. Patients generally complain of throbbing, shooting pain that eventually progresses to tingling and numbness. Blisters can be clear (superficial) or hemorrhagic (deep). After days of continuous exposure, eschars form.

 

Treatment includes active rewarming in warm water (104 – 107 F). Patients should be treated with analgesia and tetanus should be up to date. Topical aloe vera should be applied and antiinflammatory medications should be administered. Any clear blisters should be aspirated, and further treatment for concurrent hypothermia should be carried out.

 

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