Frostbite and Frostnip: This time, don't ice it

Frostbite and Frostnip: This time, don't ice it
Posted on 01/13/2021
Frostbite and Frostnip: This time, don’t ice it

Seth Beal MAT, LAT, ATC, NASM-CES
Associate Athletic Trainer, Highlands Ranch High School


Frostbite is an environmental illness that has not often received as much attention from the public as other medical pathologies. This may be due to its low mortality rate or because people feel familiar with general prevention practices, the most important of which is decreasing your time of exposure to the cold. However, with the occurrence of COVID-19 and our attempts to limit its spread, many people may be forced to increase their exposure to the cold as social and athletic events are required to move outdoors during the winter and spring seasons.

Athletic seasons have been organized in order to best accommodate each sports team with the facilities necessary for competition. In Colorado, sports like football, baseball and soccer typically are not held in the winter months due to snow. However, with the arrival of the COVID-19 virus, many team’s seasons have been moved from when they would originally compete. This requires entirely new forms of preparation to prevent student athletes (and spectators) from developing cold related injuries, such as frostbite and frostnip. But before describing preventative measures, it is imperative to understand what these injuries are.

Frostnip
Frostnip is a freezing of the superficial bodily layers that typically leaves no long term or permanent damage. Crystals form on the surface of the patient’s skin, but never reach the underlying tissue. Interestingly, frostnip is not actually classified as a form of frostbite due to the depth that the crystals reach. However, it is a serious precursor to frostbite and if symptoms are noticed, the skin should be rapidly rewarmed so as to avoid deeper penetration of the ice crystals and severe damage to the extremities.

Frostbite
When diagnosing cases of frostbite there are four degrees of severity. The first two are classified as “superficial frostbite” and the second two are classified as “deep frostbite.” First-degree frostbite is characterized by partial freezing of the skin with white or yellowish discoloration, numbness, erythema (superficial red patches on the skin) and mild edema (swelling trapped within bodily tissue). With Second-degree frostbite blisters begin to appear around the damaged tissue and fill with a milky fluid. Also there is erythema and edema on the border of each blister and the skin’s color darkens.

Once a patient reaches third-degree frostbite the exposed blisters become hemorrhagic and extend beneath the blood supply to the dermal layer. In addition, the subcutaneous layer (tissue below the superficial layer of fat) has begun to freeze and the skin turns a more blue-ish gray color. With the final stage of frostbite the subcutaneous tissues, muscles, tendons and even bones have begun to freeze. Initially there is little edema and there may be slight reddish discoloration on the skin. However, this quickly changes. The skin becomes dry, turns black and will often peel away at the surface due to cell and tissue death.

Treatment and Prevention
In the past, medical practitioners were taught to warm the afflicted tissues gradually so as not to shock or damage the nervous system during treatment. In the last twenty years, however, there has been a drastic shift in approach. Medical practitioners are now taught to rewarm the area rapidly, which has been shown to save more of the body’s tissue. Rewarming should be performed by submerging the afflicted area in water that has been heated to between 40-42 degrees Celsius using a tub or whirlpool. Do not use dry heat or steam. This is the primary initial step for treating frostbite and could be required for days to weeks depending on severity. Other steps include cleaning any open wounds and applying certain intravenous medications to expedite the body’s natural healing process, all of which must be performed by a trained medical professional. However, while these treatments are generally very effective, there is no substitute for prevention.

The first measure in preventing cold related injuries is to be aware of changes in the weather prior to attending an outdoor event. Extra care should be taken if the weather is expected to be wet, windy, and/or dry as these conditions significantly increase one’s risk for developing cold related injuries. In these cases, it is imperative to layer clothing and cover the extremities with gloves and boots. When layering, the base layer of clothing should allow for the evaporation of sweat. Clothing that absorbs water may decrease the body’s core temperature and lead to decreased blood flow to the extremities. The middle layer of clothing should act to insulate the body and the external layer should provide wind resistance.

For athletes in outdoor sports, it is typically required to wear athletic footwear for optimal performance and not insulated boots or shoes. This means that wearing wool socks or layering athletic socks should be a common practice for athletes this spring. In fact, bringing extra shoes, socks and gloves would be ideal in case one pair gets wet, which again increases an individual’s risk for freezing bodily tissue. Finally, another method to prevent cold related injuries is proper hydration and balanced diet. When exposed to the cold for extended periods of time (typically two hours or more), an individual’s thirst response is often blunted and they may experience cold induced diuresis. Cold induced diuresis causes dehydration through increased urination. With this in mind, athletes and spectators should be diligent about consuming water or sports drinks leading up to and during prolonged exposure to the cold.

To recap, prevention of the development of cold related injuries is dependent on reducing prolonged exposure to the cold, applying layers of clothing, and maintaining proper hydration. However, if an individual’s tissue becomes discolored or blisters after being exposed to the cold, rapid rewarming of the afflicted area should be performed by submerging the damaged tissue in water that has been heated to between 40-42 degrees Celsius. If the discoloration and pain do not subside, an evaluation from a medical professional should be performed.


References
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  2. Handford, C, Buxton, P, Russell, K, Imray, CE, McIntosh, SE, Freer, ., Imray, CH. Frostbite: a practical approach to hospital management. 2014; Extreme Physiology & Medicine. 3(1): 7.

  3. Imray C, Grieve A, Dhillon S. Cold damage to the extremities: frostbite and non-freezing cold injuries. Postgr Med J. 2009;85(1007):481-488.

  4. Cappaert TA, Stone JA, Castellani JW, Krause BA, Smith D, Stephens BA. National athletic trainers’ association position statement: Environmental cold injuries. J Athl Train. 2008;43(6):640-658.

  5. McIntosh SE, Hamonko M, Freer L, et al. Wilderness medical society practice guidelines for the prevention and treatment of frostbite. Wilderness Environ Med. 2011;22(2):156-166.

  6. Daniell H. NIH Public Access. 2012;76(October 2009):211-220.

  7. Poole A, Gauthier J. Treatment of severe frostbite with Iloprost in Northern Canada. Cmaj. 2016;188(17-18):1255-1258.
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