New Hampshire American College of Surgeons Prevent Further Tissue Loss: (Treat the hypothermia if present.) 1) Preserve blisters....do not open them...avoid infection, use "silvadene". 2) Rapid rewarming at 40 degrees Centigrade.... use a pan and keep replacing cooled water over 1-2 hours. 3) Hydration orally to ensure light coloured urine, may use IV fluids, warmed. 4) Pain control.... Toradol may be effective, can use narcotics as well. 5) Vasodilators may have effect (alpha blockers can be given IV, and then orally over several days)*CHECK with NEW PROTOCOLS 6) Anticoagulant agents may be effective ( Toradol +/- heparin or substitute, or Lovenox)* 7) Low molecular weight dextran IV may be effective* 8) Elevate parts frostbitten, to reduce oedema, and reduce subsequent poor venous return. 9) Wrap parts for protection, when skin has returned to normal temperature. 10) Avoid pressure or chafing of part. 11) May need bedrest in hospital, until area afflicted is stable. Grade I can be discharged, Grade II must stay until after 2nd day bone scan; Grade III may be discharged after 8th day bone scan; Grade IV may need ICU. 12) Tetanus immunisation must be updated. 13) Antibiotics not necessary, unless area is infected. CHAMONIX GRADES of FROSTBITE*** Grade I Skin discolouration Grade II Clear blisters Grade III Haemorrhagic blisters Grade IV Line of demarcation proximal to MTP/MCP joint COMMENT: Consider technetium 99 scan in first 48 hours, to determine depth of injury. The haemorrhage over the frozen tissue from prehospital chafing may make the area look worse than it is. Refreezing will cause increased damage. The process is about 6 weeks, before clinical determination of final results can occur. * Past and present research on the optimisation of tissue preservation is ongoing, and trials are underway. These pharmaceuticals are given by some Cold Weather Injury experts, and not by others. **Determination of the extent of tissue loss is being schematised in ongoing research**. **REFERENCES: Wilderness Environ Med 2001 Winter;12(4):248-55 Retrospective study of 70 cases of severe frostbite lesions: a proposed new classification scheme.*** Cauchy E, Chetaille E, Marchand V, Marsigny B. Department of Mountain Medicine and Trauma, Chamonix Hospital, France.*** Advanced Trauma Life Support for Doctors, Instructor Course Manual 1997 American College of Surgeons Committee on Trauma