• Pre-Hospital Care

Authors: Alex Poole, Nethmi Rajapakse, Yousuf Ahmed, Caitlin Champion

Recognition of injury and initial management

The primary objective of pre-hospital care for frostbite is to prevent further damage to the affected areas. This includes deciding whether to rewarm and provide basic care or urgently transfer advanced injuries where advanced therapeutics such as iloprost and thrombolysis may be given. Given data suggesting that minimizing warm ischemia time is crucial, rapid diagnosis and management decisions need to be taken in the prehospital setting. In the field, clinical assessment using symptoms, such as numbness or pain, and exam findings, such as paleness or cyanosis, to assess the severity of injury is necessary.

During clinical assessment, the basics of hypothermia management and frostbite wound care apply. Immediate and well-executed actions are crucial as they significantly influence the prognosis and extent of the injury. Initially, it is essential to remove the victim from the cold environment to halt further exposure. All wet clothing should be replaced with dry, warm coverings to mitigate heat loss and jewelry or other non-essential materials should be removed from the affected body part. In handling the affected areas, care must be taken to avoid rubbing or applying pressure, which can worsen tissue damage. If ambulation or mobilization of the limb is required for evacuation purposes, care should be taken to protect the affected area with additional supports (i.e. - splinting and/or padding) to prevent further traumatic injury (4) (WMS guidelines).

Rewarming

Prolonged freezing injury or refreezing injury can worsen the degree of frostbite injury. If there is a high risk of refreezing, the limb should be protected along with initiation of evacuation to definitive hospital care for rewarming and treatment. Rewarming should be undertaken as soon as possible once an injury has been recognized, provided the tissue can remain warm and protected afterward. Active or passive rewarming can and should be undertaken in the field, provided refreezing is avoidable. Active rewarming is optimal and involves rewarming in clean water kept at a consistent 37-39°C (feels warm to the touch of an unaffected individual for 30 seconds) until rewarming is achieved, until the tissue feels warm and pliable; antiseptic (i.e. - iodine, chlorhexidine) may be added if available, and is not required. Passive rewarming in a warm environment or through body heat (i.e. - hand on the trunk) is an acceptable alternative if active rewarming with a water bath is not possible (4). (WMS guidelines)

Rewarming via direct heat sources like fires, radiators, heating pads, or water directly sitting on a stove or other heating element should be avoided as they can cause burns (4). (WMS guidelines)

Pain management

Pain management in the field is vital. Ibuprofen/ASA can provide pain relief and may also be beneficial in the overall treatment of frostbite. Opioid analgesics may also be used as additional pain control adjuncts in the acute setting. From a wound care perspective, topical aloe vera can be applied in the field if available. Blisters may be aspirated only if they are at high risk of rupture during transport and loose dry gauze dressings can be applied (4). (WMS guidelines)

Evaluation, transport and initiation of treatment in the pre-hospital setting

In the pre-hospital care of frostbite, Emergency Medical Technicians (EMTs) and Paramedics play the primary roles in an urban area. These professionals are equipped to assess the patient’s condition, provide immediate care, and prepare for transportation to a healthcare facility. First Responders and specialized rescue teams, such as mountain rescue or ski patrol, are often involved in remote or severe conditions, where their training in emergency care under cold environments is crucial. Additionally, in scenarios requiring air transport, Flight Nurses and Flight Paramedics provide essential medical support, ensuring the patient remains stable until arrival at the hospital.

Protocols exist for administration of advanced therapeutics in a prehospital setting (See Guidelines and Protocols). Where personnel are available to monitor, consideration may be given to using iloprost or thrombolytics in the field.