FROSTBITE INJURY CLINICAL PEARLS AND PITFALLS Care should be taken not to rub or apply pressure to the affected areas Rewarming is painful and analgesics should be provided Clinical Recognition Frostbite is injury or destruction of the skin and its underlying tissue that can occur in temperatures below the freezing point of water Damage is caused by tissue freezing, hypoxia, and inflammatory response with microvascular thrombus formation mediated by the release of bradykinin, prostaglandin F2α, thromboxane β2, and histamine Children are at greater risk for frostbite injuries due to their high body surface area-to-mass ratios and less subcutaneous fat The most typical body parts affected include the fingers, toes, ears, and nose Emergency physicians should be suspicious when adolescents present with geometrical burn injuries and unexplained circumstances and be aware of the “salt and ice challenge,” which involves putting salt on the skin and then applying ice cubes on top of the salt with the goal to resist the pain from the resultant frostbite for as long as possible The clinical presentation of frostbite can range from superficial areas of pallor and edema to more severe hemorrhagic blisters and necrosis Severe injury can lead to amputations, chronic pain, and premature fusion of the epiphyseal cartilage that can affect growth The treatment goals are to minimize dermal ischemia and promote timely healing Treatment can be described in three phases The initial prethaw period, usually performed by prehospital personnel, involves getting the patient out of the cold environment and then removing wet clothing Soft padding should be applied to protect the affected area; care must be taken not to rub any of these tissues as this may cause further damage The second phase, the actual rewarming process, will take place over the next 15 to 30 minutes with the affected area being immersed in water that is preheated to 40° to 42°C Because rewarming is quite painful, IV analgesics will likely be required The third phase, the postthaw period, involves careful wound management and application of loose, sterile dressings Digits are typically separated with cotton, and extremities are splinted A follow-up with a wound care specialist is highly recommended Tetanus prophylaxis is warranted Prophylactic antibiotic use is controversial; however, coverage for staphylococci, streptococci, and pseudomonas should be