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Use of frostbite care protocols may support the initiation and consistent application of evidence-based practice guidelines and encourage timely access to frostbite care. Frostbite care protocols currently exist and are under development in many centres across Canada and around the world. While some centres and regions in Canada have established frostbite treatment protocols based on their local resources, many do not and frostbite care is quite variable across the country. Current evidence demonstrates potential benefit in the early use of systemic treatment with tPA and iloprost, with further studies required. There exists a debate within the frostbite community if using iloprost precludes the need for thrombolytics and vice versa. Some protocols use both for the most severe cases (grade 4) and that too is debated. With this in mind, most centres have access or one or both treatment options and have the capability to provide early systemic therapy in advanced frostbite. While the use of nuclear imaging (i.e. - bone scan, SPECT-CT) and Hyperbaric Oxygen Therapy (HBOT) occurs routinely in some centres, we do not currently recommend their routine use due to variable access across Canada, though they can be considered where available and may have benefit. We recommend connecting with your local burn centre or tertiary regional centre where possible regarding local and regional practices including the use of iloprost, nuclear imaging and HBOT.
Overviews of evidence-based frostbite care principles and practices can be found in the following Clinical Practice Guidelines:
American Burn Association Guidelines on the Treatment of Severe Frostbite (2023)
Below are examples of pre-hospital, hospital-based and post-injury frostbite care protocols currently in use in Canada.
Pre-hospital frostbite protocols that include initiation of systemic therapy are in use in some jurisdictions. Below is a sample protocol from the Yukon that includes field initiation of iloprost.
Below are two sample treatment protocols for centres with access to tPA only, and those with access to both tPA and iloprost. These treatment protocols are based on the authors’ experience with the Yukon frostbite care protocol (see below for detailed protocol), which includes access to iloprost. Both protocols initiate rapid rewarming, pain management (i.e. - ibuprofen/ASA) and wound care (i.e. -aloe vera) followed by post-rewarming injury grading using the Cauchy clinical grading scale (Grade 1-4). tPA may be administered within 24h of rewarming in Grade 3-4 injuries, and iloprost may be administered up to 72h from rewarming in Grade 2-4 injuries. If the injury is Grade 1, there is no further treatment required and the patient may be discharged with advice to avoid refreezing. If the injury is Grade 2 or higher, we recommend Ibuprofen or ASA as well as topical aloe vera as an antithromboxane treatment. If the injury is within 72 hours of rewarming and iloprost is available, it can be given as an intravenous infusion to all Grade 2-4 injuries (see iloprost Treatment Algorithm below). If a Grade 4 injury is within 24 hours of rewarming, thrombolysis (tPa) may be added.
If there is access to only thrombolysis and not iloprost we suggest using thrombolysis in grade 3 and 4 frostbite (see Thrombolysis Only Treatment Algorithm below). Unlike iloprost, it is the authors’ opinion that the complication risks of thrombolysis outweigh its use in Grade 2 injuries. The main decision points are classifying the injury as a Grade 2, 3, or 4 frostbite. If one has access to iloprost we suggest treating Grades 2-4 with iloprost and only add thrombolysis in Grade 4.
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A comprehensive reference for acute frostbite specific wound care is available from the British Columbia Provincial Nursing Skin and Wound Committee.
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Commissioner O of the. FDA. FDA; 2024 [cited 2024 Jun 27]. FDA Approves First Medication to Treat Severe Frostbite. Available from: https://www.fda.gov/news-events/press-announcements/fda-approves-first-medication-treat-severe-frostbite.
Lorentzen AK, Penninga L. Frostbite-A Case Series From Arctic Greenland. Wilderness Environ Med. 2018 Sep;29(3):392–400.
Zhang Y, Song J, Huang G. Comprehensive Treatment of Single Finger Frostbite: A Case Study. J Burn Care Res Off Publ Am Burn Assoc. 2021 May 7;42(3):555–9.
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Lorentzen AK, Penninga L. Frostbite-A Case Series From Arctic Greenland. Wilderness Environ Med. 2018 Sep;29(3):392–400.
Zhang Y, Song J, Huang G. Comprehensive Treatment of Single Finger Frostbite: A Case Study. J Burn Care Res Off Publ Am Burn Assoc. 2021 May 7;42(3):555–9.
McIntosh SE, Freer L, Grissom CK, Auerbach PS, Rodway GW, Cochran A, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2019 Update. Wilderness Environ Med. 2019 Dec 1;30(4):S19–32.
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Mohr WJ, Jenabzadeh K, Ahrenholz DH. Cold injury. Hand Clin. 2009 Nov;25(4):481–96.
Weatherley-White RCA, Sjostrom B, Paton BC. Experimental studies in cold injury: II. The pathogenesis of frostbite. J Surg Res. 1964 Jan 1;4(1):17–22.
Quintanilla R, Krusen FH, Essex HE. Studies on frost-bite with special reference to treatment and the effect on minute blood vessels. Am J Physiol. 1947 Apr;149(1):149–61.
Manson PN, Jesudass R, Marzella L, Bulkley GB, Im MJ, Narayan KK. Evidence for an early free radical-mediated reperfusion injury in frostbite. Free Radic Biol Med. 1991;10(1):7–11.
Robson MC, Heggers JP. Evaluation of hand frostbite blister fluid as a clue to pathogenesis. J Hand Surg. 1981 Jan;6(1):43–7.
McIntosh SE, Freer L, Grissom CK, Rodway GW, Giesbrecht GG, McDevitt M, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2024 Update. Wilderness Environ Med. 2024 Jun;35(2):183–97.
Wibbenmeyer L, Lacey AM, Endorf FW, Logsetty S, Wagner ALL, Gibson ALF, et al. American Burn Association Clinical Practice Guidelines on the Treatment of Severe Frostbite. J Burn Care Res Off Publ Am Burn Assoc. 2023 Apr 13;irad022.
Higdon B, Youngman L, Regehr M, Chiou A. Deep Frostbite Treated With Hyperbaric Oxygen and Thrombolytic Therapies. Wounds Compend Clin Res Pract. 2015 Aug;27(8):215–23.
Davis A, Sinopoli B, Mann N, Stenbit AE. A Photographic Case of Frostbite Treated with Delayed Hyperbaric Oxygen Therapy. High Alt Med Biol. 2022 Jun;23(2):194–7.
Coward A, Endorf FW, Nygaard RM. Revision Surgery Following Severe Frostbite Injury Compared to Similar Hand and Foot Burns. J Burn Care Res Off Publ Am Burn Assoc. 2022 Sep 1;43(5):1015–8.
Endorf FW, Nygaard RM. Social Determinants of Poor Outcomes Following Frostbite Injury: A Study of the National Inpatient Sample. J Burn Care Res Off Publ Am Burn Assoc. 2021 Nov 24;42(6):1261–5.
Rossis CG, Yiacoumettis AM, Elemenoglou J. Squamous cell carcinoma of the heel developing at site of previous frostbite. J R Soc Med. 1982 Sep;75(9):715–8.
Mohr WJ, Jenabzadeh K, Ahrenholz DH. Cold injury. Hand Clin. 2009 Nov;25(4):481–96.
Weatherley-White RCA, Sjostrom B, Paton BC. Experimental studies in cold injury: II. The pathogenesis of frostbite. J Surg Res. 1964 Jan 1;4(1):17–22.
Quintanilla R, Krusen FH, Essex HE. Studies on frost-bite with special reference to treatment and the effect on minute blood vessels. Am J Physiol. 1947 Apr;149(1):149–61.
Zhang Y, Song J, Huang G. Comprehensive Treatment of Single Finger Frostbite: A Case Study. J Burn Care Res Off Publ Am Burn Assoc. 2021 May 7;42(3):555–9.
Quintanilla R, Krusen FH, Essex HE. Studies on frost-bite with special reference to treatment and the effect on minute blood vessels. Am J Physiol. 1947 Apr;149(1):149–61.
Gauthier J, Morris-Janzen D, Poole A. Iloprost for the treatment of frostbite: a scoping review. Int J Circumpolar Health. 2023 Dec;82(1):2189552.
Quintanilla R, Krusen FH, Essex HE. Studies on frost-bite with special reference to treatment and the effect on minute blood vessels. Am J Physiol. 1947 Apr;149(1):149–61.
McCauley RL, Heggers JP, Robson MC. Frostbite. Methods to minimize tissue loss. Postgrad Med. 1990 Dec;88(8):67–8, 73–7.
McCauley RL, Hing DN, Robson MC, Heggers JP. Frostbite injuries: a rational approach based on the pathophysiology. J Trauma. 1983 Feb;23(2):143–7.
Heggers JP, Robson MC, Manavalen K, Weingarten MD, Carethers JM, Boertman JA, et al. Experimental and clinical observations on frostbite. Ann Emerg Med. 1987 Sep;16(9):1056–62.
McIntosh SE, Freer L, Grissom CK, Rodway GW, Giesbrecht GG, McDevitt M, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2024 Update. Wilderness Environ Med. 2024 Jun;35(2):183–97.
Heggers JP, Robson MC, Manavalen K, Weingarten MD, Carethers JM, Boertman JA, et al. Experimental and clinical observations on frostbite. Ann Emerg Med. 1987 Sep;16(9):1056–62.
Manson PN, Jesudass R, Marzella L, Bulkley GB, Im MJ, Narayan KK. Evidence for an early free radical-mediated reperfusion injury in frostbite. Free Radic Biol Med. 1991;10(1):7–11.
McCauley RL, Heggers JP, Robson MC. Frostbite. Methods to minimize tissue loss. Postgrad Med. 1990 Dec;88(8):67–8, 73–7.
McCauley RL, Hing DN, Robson MC, Heggers JP. Frostbite injuries: a rational approach based on the pathophysiology. J Trauma. 1983 Feb;23(2):143–7.
Heggers JP, Robson MC, Manavalen K, Weingarten MD, Carethers JM, Boertman JA, et al. Experimental and clinical observations on frostbite. Ann Emerg Med. 1987 Sep;16(9):1056–62.
McCauley RL, Hing DN, Robson MC, Heggers JP. Frostbite injuries: a rational approach based on the pathophysiology. J Trauma. 1983 Feb;23(2):143–7.
Heggers JP, Robson MC, Manavalen K, Weingarten MD, Carethers JM, Boertman JA, et al. Experimental and clinical observations on frostbite. Ann Emerg Med. 1987 Sep;16(9):1056–62.
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Ghumman A, St Denis-Katz H, Ashton R, Wherrett C, Malic C. Treatment of Frostbite With Hyperbaric Oxygen Therapy: A Single Center’s Experience of 22 Cases. Wounds Compend Clin Res Pract. 2019 Dec;31(12):322–5.
Magnan MA, Gayet-Ageron A, Louge P, Champly F, Joffre T, Lovis C, et al. Hyperbaric Oxygen Therapy with Iloprost Improves Digit Salvage in Severe Frostbite Compared to Iloprost Alone. Med Kaunas Lith. 2021 Nov 22;57(11):1284.
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Lacey AM, Fey RM, Gayken JR, Endorf FW, Schmitz KR, Punjabi GV, et al. Microangiography: An Alternative Tool for Assessing Severe Frostbite Injury. J Burn Care Res Off Publ Am Burn Assoc. 2019 Aug 14;40(5):566–9.
Raleigh SM, Samson M, Nygaard R, Endorf F, Walter J, Masters T. Bedside Fluorescence Microangiography for Frostbite Diagnosis in the Emergency Department. West J Emerg Med. 2022 Oct 23;23(6):872–7.
Poole A, Gauthier J, MacLennan M. Management of severe frostbite with iloprost, alteplase and heparin: a Yukon case series. CMAJ Open. 2021 Jun;9(2):E585–91.
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Ilomedin Package Insert. Bayer HealthCare
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