Assessing And Treating Cold-Related Injuries Among Athletes

By Mark Caselli, DPM
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. What About Post-Thaw Therapy? Management of frostbite injuries after thawing should be of a protective nature. Protect the skin with soft, sterile bandages and emphasize judicious use of topical or systemic antibiotics. Blisters should be left intact when possible, but be aware that debridement may be required after the patient has arrived at your facility. The inflammatory cascade can be inhibited by ibuprofen and aloe vera cream. You should administer tetanus toxoid to all frostbite patients. Emphasize to patients that they should protect the involved skin from prolonged contact by either elevating the limb or employing a protective cradle around the limb to prevent any pressure. Implore them to perform range of motion exercises in order to prevent stiffness of the involved joints and loss of function. For More Severe Cases Of Frostbite … Patients who have frostbite injuries that are greater than first degree should be observed in a hospital. It is difficult to assess viability accurately from the initial gross appearance of the damaged part. You should observe such injuries over time, especially when you’re considering the possibility of amputation. You should delay amputation as long as possible — sometimes weeks to months — in order to determine which tissues are truly necrotic and which are salvageable.

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