Date:
Patient:
MRN:
Clincian: (Emergency Physician, Urgent Care Physician, Surgeon)
Reason for Visit:
Evaluation of frostbite injury
Assessment of tissue involvement and potential for rewarming
Pain management
Tetanus prophylaxis (if not up to date)
History of Present Illness:
Onset and duration of cold exposure
Specific body parts affected (fingers, toes, ears, nose, cheeks)
Initial symptoms (tingling, numbness, burning pain)
Progression of symptoms (skin color changes, blistering)
Efforts made to rewarm the affected area(s)
Past Medical History:
Underlying conditions that may increase susceptibility to frostbite (peripheral vascular disease, diabetes)
History of previous frostbite injuries
Social History:
Occupation or hobbies that involve exposure to cold environments
Physical Exam:
Vital Signs: Monitor for signs of hypothermia (low body temperature).
Affected body part(s):
Skin color changes (pallor, cyanosis – bluish discoloration)
Blistering (clear or bloody)
Leathery induration (hardening) – may indicate deeper tissue freezing
Sensation (numbness, anesthesia)
Peripheral pulses: Assess for diminished or absent pulses in the affected extremity, suggesting possible vascular compromise.
Imaging (may not be routinely used initially):
X-rays: May be used later to assess for underlying bone injury in severe cases.
Assessment:
Stage the frostbite injury based on clinical presentation (frostbite stages typically range from superficial to deep frozen).
Evaluate the potential for rewarming based on the depth of tissue involvement and return of sensation.
Assess for risk of infection in areas with blisters or skin breakdown.
Plan:
Outline the treatment plan based on the assessment:
Gradual rewarming: Immerse the affected area(s) in warm (not hot) water (38-42°C or 100-108°F) for 15-30 minutes. Monitor for reperfusion (return of pink color) and return of sensation.
Pain management: Medications like ibuprofen or acetaminophen for pain relief.
Blister care: Leave intact blisters alone. Aseptic dressing may be applied to open blisters to prevent infection.
Tetanus prophylaxis: Administer tetanus vaccine if the patient’s immunization status is not up to date.
Antibiotics: May be considered for established infection.
Elevation: Elevate the affected extremity to reduce swelling.
Consult with a specialist: Consider referral to a plastic surgeon for complex cases or deep frostbite injuries.
Prognosis:
Briefly discuss the prognosis. Superficial frostbite injuries typically heal without complications with prompt rewarming and proper care.
Deep frostbite injuries may result in permanent tissue damage, scarring, and potential need for amputation in severe cases.
Advise on the importance of avoiding refreezing of the injured area.
Education:
Document any education provided to the patient regarding:
The signs and symptoms of frostbite and the importance of seeking immediate medical attention.
Safe cold exposure practices and proper clothing for cold weather conditions.
Proper care for frostbite injuries at home, including pain management, wound care, and elevation.
The potential for long-term complications and the importance of follow-up care.
Notes:
Include any additional relevant information not covered above, such as the patient’s pain level and any concerns they may have about the injury.
Consider mentioning the importance of monitoring for signs of infection and the potential need for additional wound care or surgical debridement.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis, treatment recommendations, and prognosis.