Classification — superficial (1st/2nd degree) (**1st degree:** numbness, pale waxy skin, erythema after rewarming, no blisters · **2nd degree:** clear fluid-filled blisters after thaw, edema, erythema — tissue loss uncommon (WMS 2019, AAP, WHO))
Frostbite vs frostnip (**Frostnip:** reversible cold paresthesia, no tissue freezing, no permanent damage · **Frostbite:** ice crystals in tissue — distinguish before management; assess neurovascular status before and after rewarming (WMS, AAP))
First-line therapy
Paracetamol • p.o. • 10–15 mg/kg/dose • 4×/day
Max 1000 mg/dose · Max 4000 mg/day · Duration: PRN · 10–15 mg/kg/dose q4–6 h PRN — start **before** rewarming; max 60 mg/kg/day or 4 g/day (whichever lower); adjunct to ibuprofen for thaw pain (WMS, AAP, WHO)
• **ABCDE first:** assess concurrent **hypothermia** — stabilize core temperature before or during frostbite care; frostbite and hypothermia often coexist (ERC hypothermia guidelines, WMS, AAP).
• **Initial assessment:** affected areas (fingers, toes, ears, nose, cheeks); duration of exposure, wet clothing, wind chill, **refreezing history**; neurovascular status (capillary refill, pulse, sensation) before and after thaw.
• **Field management:** protect from further cold; shelter; remove wet clothing; **avoid walking on frostbitten feet** if possible; handle tissue gently — **no rubbing, massaging, or direct heat** (fire, heating pad, water >40°C) (WMS, AAP, WHO).
• **Rewarming decision:** **do NOT rewarm if refreezing is possible** — refreezing causes worse injury; transport to facility for definitive rewarming instead. If no refreezing risk: rapid immersion rewarming acceptable in field (WMS 2019, AAP).
• **Wound care:** leave blisters **intact** initially; loose sterile dressings; elevate extremity; tetanus prophylaxis per immunization status; **no prophylactic antibiotics** unless infection; topical aloe vera may reduce inflammation (WMS); avoid early debridement — demarcation takes days to weeks.
Enter weight on Kids to calculate doses
Outpatient follow-up + admission if criteria met • procedure
Duration: As indicated · Discharge with wound care instructions if superficial thaw complete, pain controlled orally, reliable follow-up — admit if deep injury suspected, hypothermia, or inadequate analgesia (WMS, AAP, WHO)
• **Tetanus:** assess vaccination history — give Tdap/Td booster if indicated; TIG for tetanus-prone wound with incomplete primary series (AAP Red Book, WHO wound management).
• **Outpatient suitable:** superficial (1st/2nd degree) frostbite after successful rewarming; clear blisters only; pain controlled with PO analgesia; no concurrent significant hypothermia; reliable caregivers and follow-up within 24–48 h.
• **Admission triggers:** deep frostbite suspected (hemorrhagic blisters, hard/cold tissue, cyanosis, mottling); failed outpatient care; concurrent hypothermia requiring active rewarming; signs of infection; pain requiring IV analgesia (WMS, AAP).
• **Follow-up:** serial wound checks; demarcation over **1–3 weeks**; physical therapy and joint protection; educate on cold sensitivity and long-term neuropathy risk; return if infection, black eschar progression, or new numbness (WMS, AAP).
• **Hypothermia link:** if core temperature low, prioritize hypothermia stabilization per ERC/AHA rewarming principles — frostbite management follows once patient is hemodynamically stable; see drowning card hypothermia cross-reference for concurrent cold-water exposure.
Clinical notes
• Assessment: ABCDE; check core temp for hypothermia first; document exposure duration, wet/wind, refreezing risk, and neurovascular status before/after thaw (WMS, ERC, AAP).
• Classification: superficial = pale waxy skin, clear blisters after thaw; distinguish from frostnip (reversible, no tissue loss) — deep injury needs hospital pathway (WMS 2019).
• Rewarming: 37–39°C circulating water 15–30 min until soft and pliable — no rubbing, no direct heat, no rewarming if refreezing possible (WMS, AAP, WHO).
• Analgesia: anticipate severe thaw pain — ibuprofen 12 mg/kg/day BID × 2–3 days + paracetamol PRN; opioids if inadequate (WMS, AAP).
• Wound care: blisters intact; loose dressings; elevate; tetanus update; no prophylactic antibiotics; no early debridement or amputation — await demarcation (WMS, AAP, WHO).
• WMS — Wilderness Medical Society frostbite guidelines (2019)
• AAP — Cold injuries in children (2024)
• ERC — Hypothermia and cold injury principles (2021)
+ 1 more
• WHO — Environmental health: cold exposure and injury prevention (2022)
