Frostbite

History 1.1 History of Present Illness Get general history of present illness (inside cover).

Also ask the following specific questions: 1. What was patient exposed to? What was the temperature outside? How fast was the wind blowing? How long was he exposed? 2. What was the patient like when he was exposed? How was he dressed? Was he wet? Was he drinking alcohol or taking illegal ("street") drugs? 3. What has the patient done to treat the problem? Has he rewarmed the area? 4. Does patient have any other complaints? 1.2 Past Health History 1. Illnesses? 2. What medicines is patient taking now? 3. Allergies? 4. When was last TETANUS shot? 2. Exam 2.1 general appearance. 2.2 Vital signs: T, P, R, BP. fit here is a chance that patient may also have hypothermia (low body temperature): get a rectal temperature. Use a special low-reading thermometer. If temperature is 95 or less, treat first for hypothermia (p335). 2.3 If needed, do a body survey (p9). 2.4 check face, hands, and feet for frostbite. Compare one side of body to the other: appearance. Feel the skin. check patient's feeling (sensation) with light touch. Check blood supply: press on the skin. When you let go, skin color will look white. Does color return normally, within 2 seconds (good capillary refill)? check pulses on wrists and feet. 3. Assessment 3.1 Your assessment should be: Frostbite. 3.2 Make a more specific assessment. Frostbite: assessment and typical findings Superficial frostbite (on surface) exposed areas of skin have: white or gray colored patches. Doughy feel (firm but not hard). Deep frostbite any of the following: Hard, cold, icy feel to exposed areas or to a whole finger, hand, toe, or foot. Pulse not felt. Large blisters on the area (means that deep frostbite has partly thawed.) 3.3 Include in your assessment that the frostbite is one of the following: Superficial frostbite. Deep frostbite. 3.4 If you are not sure of the assessment, treat patient for possible deep frostbite. 4. Plan 4.1 Report to your referral doctor. report NOW if patient has deep frostbite. While you are waiting to report, follow this plan. 4.2 Decide if you should thaw or transport as follows: If superficial frostbite, thaw. If deep frostbite, it is best to thaw in the hospital. If you can NOT reach a doctor: have someone arrange for transport. Only thaw deep frostbite when patient can not leave the village in the next 2 hours. If you are not sure of the assessment (possible deep frostbite) and you can NOT reach a doctor, thaw and be ready to transport. do NOT thaw a frozen part if there is any danger it will be frozen again. A refrozen part has little chance of living. 4.3 Thawing. Correct treatment of frostbite can prevent the need for amputations, even in severe cases. Follow this plan carefully: If deep frostbite and you can NOT reach a doctor, as you begin to thaw, give patient an I.M. shot of MEPERIDINE (Demerol) or MORPHINE (p417). thawing is very painful. Handle the frozen part very gently. when it is frozen or thawing, it is easily damaged. Thaw in warm water between 100-106F. check the temperature with a thermometer. if you do not have a thermometer, the water should feel warm, NOT hot, to your wrist. support the frozen part so that it does not bump the sides or bottom of the water bath. Stir the water or have patient move his hand or foot around. Add more warm water to keep the temperature between 100-106F. do NOT add very hot water (may burn). do NOT let temperature get over 110F. Do NOT do the following things: do NOT rub the frozen part. do NOT allow patient to have alcohol or tobacco. do NOT apply ice or snow or try to thaw in cold water. do NOT thaw the frozen part near a hot stove, fire, or any other hot place (may burn). do NOT break any blisters that form. Thawing may take 20-30 minutes or longer. Continue warming in 100-106F water until: all areas are slightly red (flushed). the skin stays pink and warm when out of the water. feeling has returned. When you remove the part from the water, let it air dry. do NOT rub or pat dry. 4.4 Just after thawing, bandage only if needed: Superficial frostbite will look swollen, red, possibly scaly. it does NOT need to be bandaged. Deep frostbite may have large blisters or look dark in color (blue, cyanotic). place dry, loose, sterile gauze between frostbitten fingers and toes to protect them, as in the next drawing. * Visual augmentation: Pad between toes. leave other areas uncovered after thawing, unless you plan to transport patient. if transporting, bandage gently with a soft, loose, sterile dressing. 4.5 Other plan should include the following: If patient has NOT had a TETANUS booster shot in the past 10 years: Give I.M. booster shot of TETANUS TOXOID and DIPHTHERIA (Td.) Dose: 0.5 cc I.M. Patient education. tell patient: stay warm. Do NOT refreeze the part. Do NOT break blisters. if frostbite is on an arm or leg, elevate it above the level of the heart. keep covers off the frostbite, and protect it from other injury. avoid alcohol. DO NOT SMOKE or chew tobacco (it decreases blood flow to the injured part). If needed for pain, give ASPIRIN or ACETAMINOPHEN (Tylenol) (p416) If deep frostbite: transport patient to hospital when possible. your referral doctor may suggest that you give an antibiotic to a patient with deep frostbite, to prevent infection: I.M. shot of PROCAINE PENICILLIN (Wycillin) plan to give shot every 24 hours: weight approximate age dose less than 15 lb. less than 4 months 150,000 units 15-24 lb. 4-17 months. 300,000 units 25-34 lb. 18 months-3 years 450,000 units 35 lb. or more 4 years or more 600,000 units OR, if allergic to PENICILLIN: ERYTHROMYCIN (200 mg/5 ml suspension or 250 mg tablets) 4 times a day: weight approximate age dose less than 15 lb. less than 4 months 60 mg (1.5 cc) 15-24 lb. 4-17 months. 80 mg (2 cc) 25-34 lb. 18 months-3 years 140 mg (3.5 cc) 35-49 lb. 4-6 years 200 mg. (5 cc) 50-89 lb. 7-11 years. 250 mg (1 tablet) 90 lb. or more 12 years or more 500 mg (2 tablets) 4.6 Recheck as follows: for superficial frostbite, recheck only as needed. tell patient to return to clinic of getting worse instead of better. for deep frostbite, recheck at least once a day. Examine: temperature frostbitten area. If the area is getting infected (getting more tender, warm, red, swollen, or pus seen), treat as on p321, "Infected wound". When the time is right, talk about frostbite prevention. If frostbite is related to alcohol or other drug abuse: remind patient kindly of this. talk with patient about the alcohol or drug problem. Follow the plan on p204. Frostbite: General Information Frostbite is the freezing of tissues. Skin, muscle, fat, and even bone may freeze. Frostbite usually involves hands, feet, or exposed skin areas such as the ears, cheeks, and nose. As skin starts to freeze, small patches of white appear. the skin then gets slightly stiff. Only if the skin freezes quickly will frostbite cause pain. Once the skin is frozen, there is no feeling.