Assessing And Treating Cold-Related Injuries Among Athletes

Start Page: 111
Here we see frostbite on both feet of a 49-year -old patient.  Note the marked purple, cyanotic appearing discoloring of the digits.
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Author(s): 
By Mark Caselli, DPM

How To Identify The Varying Degrees Of Frostbite
Frostbite represents the worst of the local cold-related injuries and usually involves the hands and feet. It is caused by the actual freezing of the soft tissue. The danger of frostbite must be considered very strongly whenever there is exposure to extreme cold. Frostbite can be classified into four stages based on the degree of injury.
First-degree frostbite produces white patches on the skin surface. It is often painless and there is numbness of the affected area. There is no tissue loss, but sometimes edema occurs if it is not treated immediately.
Second-degree frostbite occurs when the white patch is not caught in time. Persistent cold, pale skin that does not blanch with pressure is a common sign. You may see vesiculation or blistering with surrounding edema and erythema. The blisters are usually clear. If the patient has minor tissue loss, then recovery from these blisters is the same (over the next few weeks with reepithelialization) as if they occurred from friction or burning. Caution the patient that these same tissues may be more vulnerable to re-frosting for the next few months. If any numbness occurs that does not clear in a few hours, then deeper tissue damage may have resulted, and these tissues might be more vulnerable to cold injury for the next several years.
In cases of third-degree frostbite, the blisters are larger, deeper and purplish with blood. The swelling and redness of the surrounding tissues can be quite dramatic. There is a high probability of deep tissue injury and some permanent loss. If there is little tissue loss, there will still be prolonged numbness of the area and vulnerability to cold injury for years to life. In some cases, the swelling and blistering can appear severe, yet there is no tissue loss and full recovery. Early appearances can sometimes be deceiving. Fourth-degree frostbite involves the deep soft tissues including bone and can result in mummification of the tissues and the need for amputation.

Clarifying Appropriate Treatment For Frostbite
The treatment of frostbite is divided into pre-hospital care, immediate care (thawing) and post-thaw care. You should direct your treatment toward preventing further injury to the tissue and deterring the necrosis of any damaged tissue. The rubbing or massaging of frostbitten tissues is strongly contraindicated because it may lead to further damage.
(It is strongly recommended not to thaw the frostbitten parts while still in the field unless there is a mechanism available to keep them thawed. If the frostbitten part is thawed and then allowed to refreeze, there is a greater risk of more extensive damage.)
The accepted therapy for frostbite is rapid re-warming. In this situation, a whirlpool is ideal. The temperature of the water should be between 104 to 108ºF (40 to 42ºC) with thermometer control, making sure it does not become too hot. The temperature must be checked continually since immersing the cold extremity causes loss of heat. The container should be large enough so that neither the extremity nor the athlete touches the sides. Continue to emphasize re-warming until the frozen area is deep red or bluish in color. The athlete’s body temperature can be maintained with warm drinks. Depending on the extent of the frostbite and the penetration into deeper tissues, thawing can take from 30 to 45 minutes. Upon re-warming of the frostbitten body part, the athlete will experience pain proportional to the degree of frostbite injury. An analgesic may be required to help deal with the pain.
Once the body part has been re-warmed and blood flow returns, the injured tissue may appear mottled, blue or purple. There may also be swelling, resulting in large blisters or gangrenous areas several days after treatment. These blisters eventually form blackened, necrotic areas of tissue that are easily separated from the normal skin. The new skin is usually of poorer quality than the original and is very sensitive to cold.

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