A 21-year-old man slept in a car in upstate New York for three winter nights. Discomfort and swelling of his toes developed, which progressed to marked discoloration of the digits.
A 21-year-old man slept in a car in upstate New York for three winter nights. Discomfort and swelling of his toes developed, which progressed to marked discoloration of the digits. Drs Shyam Varadarajulu, Gayathri Bhagwath, and Michael DiSalle of Rochester took this photo of the man's frostbitten feet.
Frostbite is characterized by hyperemia, edema, and clear blister formation, which may lead to tissue necrosis and amputation. Early signs include localized cold, pain, and numbness; absence of sensation in the affected tissue (usually exposed surfaces, such as the face and hands) signals deep-tissue involvement.1 Cold injury occurs after a local tissue temperature of –6°C (–21°F) is reached and maintained.1
The first step in managing frostbite, write Drs Varadarajulu, Bhagwath, and DiSalle, is to rule out hypothermia and sepsis.2 Rewarming, pain control, tetanus prophylaxis, hydration, local care, and monitoring for necrosis are vital in the initial care of frostbite.1 Aloe vera cream (a thromboxane A2 inhibitor) is an accepted treatment for frostbite, and a recent study shows pentoxifylline to be equally effective.3
Surgical intervention is withheld until demarcation of gangrenous tissue occurs. This waiting period increases the risk of secondary infection. Technetium TC 99m is widely used to assess tissue viability soon after injury. A recently published study indicates that MRI and magnetic resonance angiography demonstrate a clear line of demarcation of ischemic tissue and have the added advantage of assessing the condition of surrounding tissue.4
This patient was given tetanus toxoid, intravenous antibiotics, and ibuprofen. Eventually, all 10 toes became necrotic and were amputated.
REFERENCES:1. Sullivan SA. How severe is this frostbite? Am J Nurs. 1993;93:59-64.
2. Pulla RJ, Pickard LJ, Carnett TS. Frostbite: an overview with case presentations. J Foot Ankle Surg. 1994;33:53-63.
3. Miller MB, Koltai PJ. Treatment of experimental frostbite with pentoxifylline and alone vera cream. Arch Otolaryngol Head Neck Surg. 1995;121:678-680.
4. Barker JR, Haws MJ, Brown RE, et al. Magnetic resonance imaging of severe frostbite injuries. Ann Plast Surg. 1997;38:275-279.