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Guideline: Prevention and treatment of frostbite

A very cold guideline to keep you warm this holiday season: The WMS has published an update for the guideline “prevention and treatment of frostbite”. We present you a useful summary and some recommendations.

A simplified classification system for diagnosing frostbite is often used in the field. After rewarming, frostbite can be classified as superficial (numbness, erythema, mild edema, clear blistering) or deep (hemorrhagic blisters, tissue necrosis).

Figure 1. Gradation of frostbite; superficial on the left two pictures, severe on pictures on the right.

Prevention of frostbite is focused on maintaining adequate tissue perfusion and minimizing heat loss. To ensure perfusion it is important to maintain core temperature and body hydration. Avoid blood flow restriction (e.g. cover all skin, wear comfortable clothing, keep moving) and take into account that some diseases and medication decrease perfusion. Further, it is advised to use supplemental oxygen above an altitude of 7500 meters. Shortening the duration of cold exposure and use of proper clothing can minimize heat loss. Perform cold checks when exposed to conditions where there is a risk of developing frostbite (specifically below -15°C).

Treatment of frostbite in the field can be challenging. Frozen tissue should only be thawed when there is no substantial risk of refreezing since this  leads to severe damage.

‘Avoiding refreezing is the cornerstone of prehospital treatment of frostbite’

When definite care is over 2 hours away, the following treatment is advised:

  1. Treat hypothermia, serious trauma and ensure hydration
  2. If there is no substantial risk of refreezing: Rapidly rewarm in water heated and maintained between 37°C and 39°C until area becomes soft and pliable to the touch.
  3. Ibuprofen (12 mg/kg per day divided twice daily).
  4. Pain medication (e.g. opiate) as needed.
  5. Air dry (i.e. do not rub at any point).
  6. Protect from refreezing and direct trauma, dry, bulky dressings
  7. Apply topical aloe vera cream or gel if available.
  8. Elevate the affected body part if possible.
  9. Is referral for possible thrombolysis possible?
  10. Make sure to avoid early surgery!!

‘Remember: Freeze in winter, amputate in summer’

For more detailed information and recommendations for in hospital and long-term management, read the full guideline here.

Other useful guidelines can be found on the following webpages:

Wilderness Medical Society

UIAA medical committee


McIntosh SE, Opacic M, Freer L, Grissom CK, Auerbach PS, Rodway GW, Cochran A, Giesbrecht GG, McDevitt M, Imray CH, Johnson EL, Dow J, Hackett PH. Wilderness medical society practice guidelines for the prevention and treatment of frostbite: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S43-54.