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Dr William J. Mills Jr., an Alaskan orthopedic surgeon, helped establish the current protocols for frostbite treatment and changed a dogma used for more than 140 years that was established by Napoleon's surgeon general of the army, Baron Dominique-Jean Larrey. During Napoleon's 1812 siege of Moscow, Larrey noticed the destructive effects of using open fire heat for warming frozen body parts, so he suggested rubbing snow or immersion in cold water. Dr Mills treated many cold injuries during his medical career. After setting up his medical practice in Anchorage, Alaska, he realized the inefficiency of the established protocols and started researching new treatments for frostbite. Dr Mills followed Meryman's method of rapidly thawing frozen red blood cells in warm water. Mills and his colleagues established a treatment protocol for freezing cold injury that included rapid warming in warm water. These studies resulted in the publication of three key papers in 1960 and 1961. These papers were the first clinical studies that described rapid warming as a treatment. Subsequently, rapid warming, with some variation in water temperatures, has been accepted as the standard of treatment. Due to his outstanding contribution to the treatment of frostbite, he has been referred to as "the nation's leading authority on cold injury." Mills and his colleagues created a new classification system that divided frostbite into two levels, superficial and deep, which was more applicable in clinics than the traditional 4-tier classification. The 2-tier classification is still useful outside of the hospital setting., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for the prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the guidelines published in 2019.

A 19-year-old male presented with facial frostbite and severe oropharyngeal edema after prolonged riding of a snowmobile without any facial covering. The diffuse swelling eventually progressed to airway obstruction, requiring a surgical airway. No alternative explanation was found for his presentation, making this the first case found in the literature of airway obstruction secondary to environmental cold exposure.

Flexible epidermal sensors based on conductive hydrogels hold great promise for various applications, such as wearable electronics and personal healthcare monitoring. However, the integration of conductive hydrogel epidermal sensors into multiple applications remains challenging. In this study, a multifunctional PAAm/PEG/hydrolyzed keratin (Hereinafter referred to as HK)/MXene conductive hydrogel (PPHM hydrogel) was designed as a high-performance therapeutic all-in-one epidermal sensor. This sensor not only accelerates wound healing but also provides wearable human-computer interaction. The developed sensor possesses highly sensitive sensing properties (Gauge Factor = 4.82 at high strain), strong mechanical tensile properties (capable of achieving a maximum elongation at break of 600 %), rapid self-healing capability, stable self-adhesive capability, biocompatibility, freeze resistance at -20 °C, and adjustable photo-thermal conversion capability. This therapeutic all-in-one sensor can sensitively monitor human movements, enabling the detection of small electrophysiological signals for diagnosing relevant activities and diseases. Furthermore, using a rat frostbite model, we demonstrated that the composite hydrogel sensor can serve as an effective wound dressing to accelerate the healing process. This study serves as a valuable reference for the development of multifunctional flexible epidermal sensors for personal smart health monitoring. STATEMENT OF SIGNIFICANCE: Accelerated wound healing reduces the risk of wound infection, and conductive hydrogel-based sensors can monitor physiological signals. The multifunctional application of conductive hydrogel sensors combined with wound diagnostic and therapeutic capabilities can meet personalized medical requirements for wound healing and sensor monitoring. The aim of this study is to develop a multifunctional hydrogel patch. The multifunctional hydrogel can be assembled into a flexible wearable high-performance diagnostic and therapeutic integrated sensor that can effectively accelerate the healing of frostbite wounds and satisfy the real-time monitoring of multi-application scenarios. We expect that this study will inform efforts to integrate wound therapy and sensor monitoring., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Nitrous oxide is used as a recreational drug. Contact frostbite injury from compressed gas canisters has previously been described in the literature, but an increased number of such cases has been noted in our busy regional burns center in the UK. A single-center prospective case series of all patients referred and treated for frostbite injury secondary to misuse of nitrous oxide compressed gas canisters between January and December 2022 is presented. Data collection was performed through a referral database and patient case notes. Sixteen patients, of which 7 were male and 9 were female, satisfied the inclusion criteria. Mean patient age was 22.5 years. The median TBSA was 1%. In total, 50% of patients in the cohort had a delayed initial presentation to A&E of greater than 5 days. Eleven patients were reviewed at our burns center for further assessment and management. In total, 11 patients had bilateral inner thigh frostbite injuries, of which 8 had necrotic full-thickness injury, including subcutaneous fat. Seven patients were reviewed at our burns center and offered excision and split-thickness skin graft. Four patients presented with contact frostbite injury to the hand and one patient to the lower lip. This subgroup was managed successfully with conservative management alone. The reproducible pattern of frostbite injury secondary to the abuse of nitrous oxide compressed gas canisters is demonstrated in our case series. The distinct pattern of injury, patient cohort, and anatomical area affected presents an opportunity for targeted public health intervention in this group., Competing Interests: Conflicts of interest None declared., (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Despite current treatment modalities, frostbite remains an injury with a poor prognosis which may cause functional morbidities. Several experimental and clinical studies have demonstrated that stromal vascular fraction is an autologous mixture, which can improve wound healing and vasculogenesis. The aim of this study was to show the beneficial effects of stromal vascular fraction on experimental frostbite healing., Material and Methods: Stromal vascular fraction (SVF) was harvested from 5 rats after excision of the inguinal fat pads. Another 20 rats were separated into 2 groups of 10 as the SVF group and the control group. A frostbite injury was created on each rat using a cryoprobe frozen with liquid nitrogen (-196 °C). SVF was applied to the SVF group and phosphate-buffered saline to the control group. All injections were performed subcutaneously within the frostbite injury area. Biopsies were performed on days 5 and 14 for histopathological and immunochemical evaluations. The tissue perfusion rates of both groups were assessed on day 14 using indocyanine green angiography (SPY system)., Results: The increase in mean tissue perfusion was 373.3% ( ± 32.1) in the SVF group and 123.8% ( ± 16.3) in the control group (p < 0.001). The macroscopic wound reduction rates of the SVF and control groups were 25.5% ( ± 19.1) and 18.0% ( ± 5.9), respectively on day 5%, and 78.2% ( ± 9.2) and 57.3% ( ± 16.7) on day 14 (p = 0.007; p = 0.003). Acute inflammation and the fibrosis gradient were significantly decreased in the SVF group compared to the control group (p = 0.004, p = 0.054 respectively on day 14). Granulation tissue amount, re-epithelialization score and neovascularization were significantly increased in the SVF group (p = 0.006, p = 0.010 and p = 0.021, respectively on day 14)., Conclusions: The study results demonstrated that SVF increases frostbite wound healing by increasing tissue perfusion rate, neovascularization and re-epithelialization, and modulating acute inflammation and fibrosis., (Copyright © 2022 Elsevier Ltd and ISBI. All rights reserved.)

Objectives: Frostbite refers to the freezing of body tissue which is caused by prolonged exposure to cold temperatures and results in tissue destruction. Tissue damage is due to both immediate cold-induced cell death and the more gradual development of localized inflammatory processes and tissue ischemia. A detailed treatment plan based on the current UpToDate literature is needed to decrease morbidity and mortality rates., Methods: The United States National Library of Medicine (PubMed/Medline), EMBASE, Web of Science, and the Cochrane Database of Systematic Reviews were systematically searched to identify publications relevant to this review., Conclusion: In this review, we present the current knowledge on the diagnosis and treatment of frostbite injuries. We then provide an extended and detailed treatment plan, from first aid in the field to treatment of short and long-term complications ., Competing Interests: Declaration of Competing Interest Nothing to declare., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the guidelines published in 2014., (Copyright © 2019. Published by Elsevier Inc.)

Objective: To describe frostbite (freezing cold injured tissue) in children and intrinsic (psychological and behavioral) and extrinsic (meteorological and safety hazard) factors related to the injury., Methods: Retrospective chart review of children <18 years old referred to a regional pediatric hospital for frostbite, to determine the demographics, environment, and risk factors related to injuries., Results: 47 patients met the inclusion criteria. Median age was 15 years (IQR 12-16). All injuries occurred between November and March. 49% were admitted to the hospital and frostbite was associated with use of alcohol (53%), cigarettes (34%), marijuana (23%), and symptoms of depression (with and without suicidal ideation) (32%). Frostbite injury treated with conservative wound management presented at <-6°C and injury that underwent surgical procedures occurred at temperatures ≤-23°C (p=0.001). Longer exposure duration also significantly increased the likelihood of a surgical procedure (p<0.001). Intoxication and lack of supervision were two common factors, with lack of supervision at time of injury most common among patients 0-12 years (64%), and intoxication most common among patients ages 13-17 (61%)., Conclusion: Frostbite injuries in children begins at temperatures <-6°C; with risk of tissue loss increasing at temperatures below -23°C. Lack of supervision and intoxication are major risk factors for frostbite in children. Two-thirds of younger children were unsupervised, whereas intoxication was frequently related to frostbite in adolescents. Both of these factors can be addressed through an education-based prevention program., (Copyright © 2018 Elsevier Ltd and ISBI. All rights reserved.)

Greenland is not only the largest island in the world, it is also the least densely populated country on the globe. The majority of Greenland's landmass lies within the Arctic Circle. Weather conditions in Arctic areas can be extreme, thus exposing locals and visitors to a high risk of acquiring frostbite injuries. More than two thirds of Greenland is covered by a permanent ice sheet, and temperatures can drop to below -70°C. In addition, frequent storms, occupational exposure, and alcohol all contribute to an increased risk for frostbite injury. Frostbite may cause major morbidity, including tissue loss and limb amputation. Hence, proper diagnosis and treatment of frostbite injuries is of utmost importance. We present 6 cases of frostbite injuries in Greenland, ranging from mild to severe frostbite in both locals and foreign visitors. The cases illustrate some of the known risk factors for frostbite injuries. The etiology, pathophysiology, clinical presentation, and recommended management of frostbite are summarized. Novel treatments for frostbite and frostbite sequelae are discussed in the context of the Greenlandic healthcare system. Furthermore, cultural aspects and reasons for a seemingly low incidence of frostbite injuries in Greenland are explored., (Copyright © 2018 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

This essay will review historical and medical aspects of cold exposure, hypothermia, and frostbite during the Napoleonic era. The 19th century writings of Dominique Jean Larrey, Pierre Jean Moricheau-Beaupré, and others are used to provide an evocative supporting narrative to illustrate some of the cold illnesses, physiology, and theory of both an earlier era and the present time. Medical care for over a century followed the how but not the why of treating frostbite and hypothermia slowly with snow or cold water rather than heat. There were 2 main reasons: First was a practical attempt to limit gangrene. Less known, and long forgotten, is a major rationale based on the erroneous theory of heat called "the caloric." Because of these 2 reasons, the slow method of "cold warming" remained standard medical practice well into the 20th century. Although these recommendations are now known to be flawed, some of the reasons behind them will be discussed, along with early but correct observations on afterdrop and circumrescue collapse. There is a long backstory of treatment from 1812 to the present., (Copyright © 2016 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Despite advances in outdoor clothing and medical management of frostbite, individuals still experience catastrophic amputations. This is a particular risk for those in austere environments, due to resource limitations and delayed definitive treatment. The emerging best therapies for severe frostbite are thrombolytics and iloprost. However, they must be started within 24 hours after rewarming for recombinant tissue plasminogen activator (rt-PA) and within 48 hours for iloprost. Evacuation of individuals experiencing frostbite from remote environments within 24 to 48 hours is often impossible. To date, use of these agents has been confined to hospitals, thus depriving most individuals in the austere environment of the best treatment. We propose that thrombolytics and iloprost be considered for field treatment to maximize chances for recovery and reduce amputations. Given the small but potentially serious risk of complications, rt-PA should only be used for grade 4 frostbite where amputation is inevitable, and within 24 hours of rewarming. Prostacyclin has less risk and can be used for grades 2 to 4 frostbite within 48 hours of rewarming. Until more field experience is reported with these agents, their use should probably be restricted to experienced physicians. Other modalities, such as local nerve blocks and improving oxygenation at high altitude may also be considered. We submit that it remains possible to improve frostbite outcomes despite delayed evacuation using resource-limited treatment strategies. We present 2 cases of frostbite treated with rt-PA at K2 basecamp to illustrate feasibility and important considerations., (Copyright © 2016 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for the prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the original guidelines published in Wilderness & Environmental Medicine 2011;22(2):156-166., (Copyright © 2014. Published by Elsevier Inc.)

Frostbite is damage caused by the freezing of tissue owing to exposure to extreme cold. Clinically, it is often difficult to identify the severity of frostbite injury. There may be a wide discrepancy between the extent of damage to the skin versus that to the deeper structures. The initial clinical impression is usually worse than actual tissue damage. In addition to physical examination, diagnostic imaging, especially triple-phase bone scan, has been proposed to help differentiate between superficial and deep damage. Principles of treatment involve rapid rewarming to thaw the tissues and halt direct cellular damage, methods to minimize progressive dermal ischemia, and active wound care to promote timely healing. Pharmacological adjuncts, such as fibrinolytics, have been proposed to minimize tissue damage. Surgical therapy is postponed until there is clear demarcation between healthy and necrotic tissue., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The external ear is composed of the auricle (pinna) and the external auditory canal. Both of these structures contain elastic cartilage (except the earlobe) and a small amount of subcutaneous fat, which are covered by skin. The skin of the cartilaginous canal contains hair cells, sebaceous (lipid-producing) glands, and apocrine (ceruminous) glands; this is in contrast with the osseous canal, which contains neither glands nor hair follicles. The auricle is susceptible to environmental influences and trauma. Due to its exposed locale, the ear is particularly vulnerable to the effects of ultraviolet light and, consequently, to preneoplastic and neoplastic skin lesions. The ear also has a sound-receiving function and a location that is both visible and aesthetically obvious, thereby drawing considerable attention from the patient. Dermatologic diseases on the external ear are seen in a variety of medical disciplines. Dermatologists, otorhinolaryngologists, family practitioners, and general and plastic surgeons are regularly consulted about cutaneous lesions on the ear. These lesions can be grouped into three main categories: (1) infectious; (2) tumoral; and (3) noninfectious inflammatory. The purposes of this contribution are to review various dermatologic diseases of the external ear and to update current diagnosis and treatment information related to these conditions., (© 2013 Elsevier Inc. All rights reserved.)

Background: Frostbite injury occurs when exposure to cold results in frozen tissue. To screen drugs and other field therapies that might improve the outcome for a frostbite victim, it would be helpful to have a reliable and cost-effective preclinical in vivo model., Objective: We sought to create a novel mouse skin model of induced frostbite injury. This model would allow quantification of the surface area of involved skin, histology of the wound, rate of wound healing, and skin loss in a standardized fashion after the frostbite injury., Methods: Thirty-six mice were studied. Standardized 2.9-cm diameter circles were tattooed on the mouse dorsum. Magnets frozen in dry ice (-78.5°C) were used to create a frostbite injury on skin within the circle, either as a continuous 5-minute freeze or as 3 repeated freeze (1-minute) and thaw (3-minute) cycles. Appearance, healing rate, skin surface area loss, and histology were recorded until the wounds were healed., Results: The amount of skin surface area loss was approximately 50% for both freeze methods. Although the time to surface skin healing was similar for both freeze methods, the initial healing rate was significantly (P = .001) slower in mice exposed to the freeze-thaw cycles compared with the continuous freeze model. Histopathology reflected inflammatory changes, cell death, and necrosis., Conclusions: This novel in vivo mouse model for frostbite allows quantification of affected skin surface area, histology, healing rate, and skin loss and has the potential of being utilized to screen future treatment modalities., (Copyright © 2013 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for the prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded based on the quality of supporting evidence and balance between the benefits and risks/burdens for each modality according to methodology stipulated by the American College of Chest Physicians., (Copyright © 2011 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

Frostbite is frequently seen in high altitude climbers. Many Sherpas, members of an ethnic community living high in the Himalayas in Nepal, help the climbers as a guide or an assistant. They often seem to undertake few precautionary measures thus suffer more from frostbite. A young Sherpa, who had reached the top of Mt Kanchenjunga in March 2009, suffered from deep frostbite in his fingers. Fortunately, he recovered well with generous treatment. Though there is no evidence whether Sherpas are more or less prone to frostbite, simple techniques for adequate prevention of hypoxia, hypothermia and dehydration will benefit any climber to the high altitudes., (Copyright (c) 2010 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.)

This article examines environmental illness in athletes. Causes, symptoms, and treatment of heat-related illness, cold-related illness, and altitude-related illness are discussed.

Objective: Previous frostbite classifications were mainly based on retrospective diagnosis and, most of the time, could not be used to predict the final outcome of the lesions and especially the probability of an amputation and its level. The aim of this study was to suggest a new classification at day 0 based mainly on the topography of the lesions and on early bone scan results, which are more convenient and accurate in predicting the final outcome of frostbites., Methods: The retrospective study of the clinical histories of 70 patients hospitalized at Chamonix Hospital (Mont-Blanc Massif) from 1985 to 1999 for severe frostbite injuries of the extremities has allowed us to classify the aspects of the initial lesions on day 0 and to compare them with final outcomes., Results: A strong correlation was found between the extent of the lesion and the outcome of each finger or toe. When the initial lesion was on the distal phalanx, the probability of bone amputation was around 1% for the digit, 31% for the middle phalanx, 67% for the proximal phalanx, 98% for the metacarpal/metatarsal, and 100% for the carpal/tarsal., Conclusions: Based on these clinical results and on the results of bone scans (previously validated), a new classification of frostbite severity at day 0 is proposed. Four degrees of severity are defined: first degree, leading to recovery; second degree, leading to soft tissue amputation; third degree, leading to bone amputation, and fourth degree, leading to large amputation with systemic effects.

Unlabelled: An 11-year-old boy in good general health conditions suffered deep frostbite on six fingers while he was working without gloves as a beater during a hunt in Poland at an outdoor temperature of -32 degrees C over a 4 h-period. Three days later he was first seen by a physician who planned to amputate the affected fingers. The patient was transferred by his family to our University Hospital in Aachen, Germany. We found third degree frostbite on four fingers of the right and on two fingers of the left hand. Because of the late beginning of the therapy, the patient was treated by HBO(2) according to the Marx-schema for problem wounds (2,4 bar, total time at depth: 90 min, alternations of 100% O(2) and air breathing). HBO(2)-treatment was repeated daily for 14 days. No adverse events were recorded during the course of therapy. A total recovery of the severe frostbite was observed after 14 days of HBO(2)-treatment. Twenty-eight months after the injury the patient reports fully regained sensibility and no pain. The plain X-ray after this period showed no premature closure of the epiphyses or sclerosis of the metaphyses., Conclusions: Because of the low risk associated with HBO(2), and its potential therapeutic efficiency, HBO(2) should be recommended as adjunct therapy in the treatment of deep frostbite.

The environment can have a profound impact on human performance. Over the past decade there has been considerable interest in the scientific study of the human ability of to protect oneself against heat and cold. This new knowledge has led to a better understanding of physiology and resulted in better prevention, recognition, and treatment of hyperthermia, hypothermia, and frostbite. This article reviews the pathophysiology of extreme environmental exposure and discusses current strategies for prevention and treatment.

The role of interventional radiology in the management and diagnosis of frostbite injury in 18 patients at the West Side VA Medical Center is presented. Conservative treatment and the use of intra-arterial long acting vasodilators, such as reserpine, are emphasized, even in patients referred 48 to 72 hours after the initial injury. This modality of treatment should be attempted before surgical decision or amputation is necessary. Satisfactory responses were obtained in most of the treated subjects and in some cases, results were dramatic with significant recovery and a minimum of sequelae. Generally clinical principles and physiopathology in frostbite injuries are reviewed.

The winter of 1981-1982 in Oxfordshire was unusually cold. During this winter, 18 patients with frostbite were referred to the Peripheral Vascular Service of the Nuffield Department of Surgery. The age-range was 52-83 years. None was diabetic. Seven were smokers. All had frostbite of either feet or fingers, sometimes of both. Patients could be divided into 2 groups based on the severity of their injury. In the first group 10 patients had mild injuries and were managed as outpatients. One patient had terminal phalanges amputated as a day case. Patients in this group had adequate homes and no associated medical disease. Eight patients in the second group had severe frostbite. All were socially disadvantaged and 4 had significant medical disease (mitral valve disease, lymphoma, alcoholism and depression). Because of social circumstances and because it takes time to establish the line of demarcation between healthy and dead tissue, all patients in this group were in hospital for a minimum of 2 months (range 2-10 months). Four patients required skin grafting and 2 needed special shoes to enable them to walk. There needs to be greater public awareness of the dangers and risks of cold injury.

A variety of cold exposure injuries were discussed, including frostnip, chilblains, trench foot, frostbite, and hypothermia. The usual precipitating factors for each were discussed along with the clinical course, the pathophysiology, and management from the perspective of one being in the field or backcountry. Prevention is the key to all cold-related problems as adequate treatment is often not possible out of the hospital setting. Detailed recommendations were made for all conditions, relative to treatment and prevention, with special emphasis on hypothermia.