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Evaluation of a patient with an apparent freezing cold injury

Authoring team

Evaluation of a patient with an apparent freezing cold injury (1)

History

  • obtain information on how and when the cold injury occurred
  • focus on factors which affects the severity e.g. - likely temperature, wind chill, and duration of exposure
  • additional information should focus on finding predisposing factors e.g. - patient’s premorbid state, particularly history of peripheral vascular disease and smoking status

Examination

  • early features
    • affected parts feel cold and possibly painful
    • continued freezing produce a paraesthesia or numbness (or both)
    • areas of blanching blending into areas of apparently uninjured skin

  • late features
    • white and waxy skin with distinct demarcation from uninjured tissues
    • woody, insensate tissue
    • progression to bruising and blister formation (usually on thawing)

Note

  • full extent of the injury may not be visible initially for few days. Therefore close observation is required

In true freezing cold injury, clinical appearance of the tissue can be used to identify the degree of injury:


clinical appearance

mild frostbite injury

severe frostbite injury

first degree

second degree

third degree

fourth degree

depth of tissue freezing

partial thickness skin freezing

full thickness skin freezing

freezing of the skin and subcutaneous tissue

freezing of the skin, subcutaneous tissue, muscle, tendon, and bone

colour of tissues

erythematous or hyperaemic

erythematous

blue or black

initially deep red and mottled; eventually black and mummified

blistering or necrosis

none

blisters containing clear fluid

haemorrhagic blisters and some tissue necrosis

profound necrosis

oedema

minor

substantial

substantial

little or none

Note - frostbite is a clinical diagnosis. Using additional laboratory testing may be helpful in determining the extent to which comorbid conditions may be contributing to tissue ischemia. 

Technetium-99 (Tc-99) triple phase scanning and magnetic resonance angiography (MRA) may help to determine extent of amputation in the first few days after injury (2,3)

 

Reference:

  1. McIntosh SE, Freer L, Grissom CK, 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.
  2. Cauchy E, Marsigny B, Allamel G, Verhellen R, Chetaille E. The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities: A retrospective study of 92 severe frostbite injuries. J Hand Surg Am. 2000 Sep;25(5):969-78.
  3. Barker JR, Haws MJ, Brown RE, Kucan JO, Moore WD. Magnetic resonance imaging of severe frostbite injuries. Ann Plast Surg. 1997 Mar;38(3):275-9.

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The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.

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