After a four hour football game in Denver in the sleet, -21 degrees with windchill, a player took off his cleats in the locker room and reported that his feet felt numb. The trainer noted bilateral white extremities with an area of ecchymosis and blistering, along with decreased sensation bilaterally and was concerned for frostbite.

How is this managed prior to arrival in the ED? What is the ED managment?

More than 75% of patients with frostbite present complaining of numbness and some initial sensory deficit. Initial presenting signs of frostbite include a hard, cold, white, and anesthetic body part.

The severity of the frostbite determines the extent of the injury; in more severe cases, victims have an early black, dry eschar prior to mummification. In the most severe cases (fourth degree), victims have tissue necrosis and gangrene.

Prehospital care is an important component of treatment and should include removal of wet or constrictive clothing. Friction massage should be avoided to prevent further damange, and rewarming should never be initiated if there is any risk for interrupted or incomplete thawing.

In the ED, generous analgesia is important during rewarming, as reperfusion can be intensely painful. A common pitfall in the treatment of frostbite is the premature termination of rewarming secondary to return of sensation (in the setting of intense pain), resulting in a partially thawed part. Rewarming is complete when the part feels pliable and appears erythematous, typically requiring 10 – 30 minutes of submersion in 40C-42C water.

Post-thaw injuries can include severe edema caused by vascular permeability resulting in compartment syndrome, gangrene, and superinfection with tetanus, Staph or Strep.

Current research suggests that the use of digital angiography and thrombolytic drugs might have a place as part of the immediate post-thaw management of frostbite.

[Answer courtesy of PEER VIII, while the scenario is all mine]