Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Frostbite
FROSTBITE
Cellular injury due to cold exposure. Characterized by pallor and numbness of the affected area.
I. Etiology
A. Exposure to cold temperatures, usually for a prolonged period of time
B. The severity of frostbite is influenced by the following:
1. Duration of exposure
2. Intensity of cold exposure determined by both temperature and windchill factor
3. Rate and method of rewarming
II. Incidence
A. Seen in winter months, especially in young children who do not have proper supervision while playing in the snow, skiers, and winter sports enthusiasts (e.g., mountain climbers, winter campers)
B. The parts most subject to cold trauma are the hands, feet, and face, particularly the cheeks, nose, and ears.
III. Subjective data
A. Often asymptomatic
B. Numbness
C. Prickling sensation
D. Pruritus
E. Stiffness
F. Skin white and cold
G. Complaints of pain in mild or moderate frostbite
H. Pertinent subjective data needed in assessing the degree of frostbite:
1. Previous history of frostbite in the same area
2. Duration of exposure
3. Cold intensity: Temperature and wind velocity
4. If treated, how was rewarming accomplished?
IV. Objective data
Note that the degree of frostbite cannot be accurately assessed prior to thawing.
A. Mild
1. Skin pale and cold
2. Edema
3. Area feels frozen on the surface, but gentle pressure reveals soft tissue underneath.
B. Moderate to severe
1. Skin pale, blotchy and/or blue
2. Edema
3. Area feels solidly frozen on deep palpation.
4. Blister and bulla formation 24 to 48 hours after thawing
5. Necrosis of subcutaneous tissues 24 to 48 hours later
V. Assessment
A. Diagnosis of frostbite is made by history of exposure and appearance of white, cold skin in the affected area.
1. Mild: Erythema and edema of part after thawing; sometimes becomes purple; no significant tissue damage
2. Moderate to severe: After thawing, area becomes hyperemic, then blue, purple, or black and edematous. Blister and bulla formation occurs in 24 to 48 hours. With severe frostbite, lack of formation of blebs is indicative of inadequate circulation and necrosis of underlying tissue.
B. Investigate possible parental neglect in young children with moderate to severe frostbite.
VI. Plan
A. Do not attempt rewarming if there is danger of refreezing.
B. Check body temperature to rule out hypothermia.
C. Loosen all constricting garments.
D. Remove all wet clothing in contact with skin.
E. Do not rub or massage affected area.
F. Rewarming: Warm gradually. Rapid rewarming increases cell metabolism and without adequate blood supply (due to vasoconstriction), can damage cells.
1. Immerse part in whirlpool or agitated water at 100F to 105F; monitor water temperature with a thermometer.
2. For face or ears, use warm, moist soaks, changing frequently to maintain temperature at 100F to 105F; monitor water temperature.
3. Continue rewarming for about 20 minutes (until area is unfrozen).
4. Use analgesics as necessary: Aspirin, acetaminophen, or codeine. Rewarming is a painful process.
5. Elevate affected part.
G. General measures
1. Provide dry clothing.
2. Adjust environmental temperature.
3. Encourage warm liquid intake.
H. Assess degree of involvement
1. Mild or first-degree of small area: May be followed at home with a careful follow-up plan.
2. Mild with extensive involvement or moderate to severe: Consult with physician for treatment and admission to hospital.
I. Sterile, loose dressing to necrotic areas
J. Assess status of tetanus booster. Administer if necessary, with tissue injury.
VII. Education
A. Never rewarm with dry heat (e.g., oven or fireplace).
B. Do not rub frostbitten area; it will cause further tissue damage.
C. Protect area from trauma; use padding when indicated.
D. Avoid smoking, which causes peripheral vasoconstriction, decreasing blood flow to skin.
E. Keep affected part elevated.
F. Watch carefully for blistering or tissue damage.
G. Do not puncture blisters.
H. Do not expose part to extremes in temperature.
I. Paresthesia of injured area is common. Expect some burning, prickling, or tingling sensations.
J. Expect future hypersensitivity to cold and increased susceptibility to repeated frostbite in affected area.
K. Use face mask, earmuffs, mittens, or heavy boots as applicable for protection.
L. Prevention
1. Avoid alcohol and cigarettes during cold exposure.
a. Nicotine causes vasoconstriction, inhibiting flow of blood to periphery.
b. Alcohol causes peripheral vasodilation, which increases rate of heat loss from the skin.
2. If suspicious of potential frostbite, warm by natural body heat (e.g., place hands in groin or axilla). Do not use snow, ice, or dry heat.
3. If frostbite has occurred, do not thaw until possibility of refreezing is eliminated.
4. Wear several layers of loose, warm clothing. This protects better than one heavy, well-fitting garment.
5. Do not scrub face, shave, or use aftershave lotion prior to anticipated exposure.
6. Mittens generally offer more protection than gloves.
7. Wet skin increases the cooling and freezing rate. Wet clothing causes conductive heat loss from the part covered.
8. Use “buddy” system when out in severe cold: Check each other’s noses, faces, and ears for evidence of frostbite.
9. If exposure planned, take extra socks and mittens.
VIII. Follow-up
A. Recheck by telephone in 24 hours.
B. Return to office if any blisters appear.
C. Return to office if any signs of infection appear.
IX. Complications
A. Necrosis of affected area with subsequent infection
B. Area has increased susceptibility to frostbite.
X. Consultation/referral
A. Moderate to severe degrees of frostbite; appearance of blisters or bulla
B. Any question of parental neglect