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© 2020 Journal of Marine Medical Society | Published by Wolters Kluwer - Medknow
136
Original Article
IntroductIon
Initial reports on frostbite injuries date back up to 5000 years
old are described in pre-Columbian mummies.[1] Frostbite
is not uncommon in military medicine because of soldiers’
deployment in the extremes of weather. During WWII,
frostbite accounted for 2%–4% of the combat surgical trauma
and 1%–2% of the total mortality and morbidity among
the Red Army.[2] Indian troops are posted at the altitudes
of 12,000–22,000 feet above the sea level in the northern
regions to man the international borders. Medical care to
these personnel at peripheral farthest posts is provided by the
echelons of eld hospitals comprising doctors, paramedics,
equipment for rst aid, and essential medicines. Frostbite
remains one of the major health hazards in the troops posted in
that area and mountaineers. Young people who are active are
the most commonly affected. The frequently involved include
armed forces personnel, agricultural workers, mountaineers,
cross-country skiers, expedition members, and climbers. In
most occurrences, the patients are not aware about the onset
and progress of frostbite until it is severe. Vasoconstriction
following blood clotting results from exposure to extreme cold
weather. Ice crystals form in the tissues and the capillaries,
when the atmospheric temperature drops below −4°C,
ultimately leading to cell membrane damage. As the dead cells
are replaced by broblasts, scar tissue forms.[3] Insensitivity and
clumsiness are the common symptoms noted by the affected
individual, at rst. When remedial measures such as rewarming
are instituted, these symptoms tend to disappear rapidly. The
spectrum of illness presented by frostbite patients varies widely
Epidemiology and Treatment Outcome of Frostbite at High
Altitudes in North India – A Cross‑Sectional Study
Dr. Vivek Agrawal, Dr MS Prakash1, Dr Pallab Chatterjee2, Dr Vishnuprasad R3, Dr Abhimannyu Choudhury4, Dr Abhijeet Lal5, Dr Atul Kotwal6
Department of Vascular Surgery, Army Hospital R&R, Delhi Cantt, 1Prof Nephrology, Rajarajeswari Medical College and Hospital, Bangalore, 2Depatment of Plastic
Surgery, Army Hospital R&R, Delhi Cantt, 3Public Health Specialist, Firozepur Cantt, 4Deparmtent of General Surgery, Military Hospital, Namkum, 5Deparmtent of
General Surgery, Air Force Hospital, Jodhpur, 6Public Health Specialist, Jalandhar Cantt, India
Context: Frost bite is an important cause of morbidity among armed forces personnel who are employed in high altitude areas. Aims: The aim of
the present study was to evaluate the epidemiological aspects and treatment outcome of frostbite injuries among healthy adults working in sub-
zero temperatures of the Himalayas. Settings and Design: The study was carried out as a retrospective observational study among all frost bite
patients (n = 72) reporting to two zonal hospitals in Northern sector of India from during January 2014 to November 2016. Methods and Material:
Patients who had no signs of life on arrival, and patients with injuries due to sunburn / UV rays were excluded from the study. Statistical Analysis
Used: Means and proportions were calculated for continuous and nominal variables respectively. Results: All patients were males with mean
age of 27.8±2.5 years. Majority of cases 57 (79.2%) had rst and second degree frost bite while, third and fourth degree frost bites were noted in
10 and ve patients respectively. Maximum cases were reported during the months of December and January. Wound debridement (6.9%), and
hyperbaric oxygen therapy (5.6%) were the most common adjunct procedures. Auto amputation was observed in 8.3%. Full recovery was noted
in most of the patients except four, who had to undergo amputation of the affected part. Conclusion: Frostbite can result in a wide spectrum of
injury, ranging from complete resolution without signicant sequelae to major limb amputation and its functional morbidity. First and second
degree frost bite were the most common, predominantly noticed in young individuals during peak winter months of December and January.
Keywords: Epidemiology, Frost bite, High altitude
Address for correspondence:(Dr) R Vishnuprasad,
NP23 Site 10 Jhoke Road, Firozepur Cantt, Punjab, India.
E‑mail:vishnuprasath2@gmail.com
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DOI:
10.4103/jmms.jmms_60_19
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How to cite this article: Agrawal V, Prakash MS, Chatterjee P, Vishnuprasad R,
Choudhury A, Lal A, et al. Epidemiology and treatment outcome of frostbite
at high altitudes in North India – A cross-sectional study. J Mar Med Soc
2020;22:136-40.
Abstract
Submission: 08-Sep-2019 Accepted: 12-Jan-2020 Published: 14-Aug-2020
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Agrawal, et al.: Epidemiology of frostbite at high altitudes
Journal of Marine Medical Society ¦ Volume 22 ¦ Issue 2 ¦ July-December 2020 137
from minimal tissue loss with mild long-term sequelae to
major necrosis of the distal limbs, even leading to amputations
of the affected part, thus, resulting in signicant morbidity,
loss of extremities, or even mortality in extreme cases.
Some of the common predisposing factors include alcohol
consumption (46%), psychiatric illness (17%), vehicular
failure (19%), and drug misuse (4%).[4] Temperature, wind chill
factor, duration of exposure, wet/dry cold, immersion, clothing,
and patient comorbidities such as smoking, peripheral vascular
disease, neuropathies, and Raynaud’s disease tend to determine
the severity of illness.[5,6] Many soldiers have even lost their
limbs/lives due to adverse climatic conditions while occupying
the strategic heights in the extreme adverse climatic conditions
of North Indian borders. These incidents highlight the extreme
risks that soldiers face in manning the inhospitable terrain at
heights of 21,000 feet under extreme weather conditions on
the world’s highest battleeld (redundant). There is a lack of
comprehensive Indian statistics about the epidemiology of
frostbite injuries occurring in these regions. The purpose of this
study is to evaluate the epidemiological aspects and treatment
outcome of frostbite injuries among healthy adults working in
subzero temperatures of the Himalayas.
MaterIals and Methods
The present study was carried out as a retrospective observational
study of frostbite patients reporting to two zonal hospitals in the
northern sector of India during the study period starting from
January 2014 to November 2016. The hospital catered to the
population of the defence services in the northern sector. All
serving personnel who are deployed in such areas are screened for
any comorbidities and those who are found t were only engaged.
All patients reporting to the hospital with frostbite were included in
the study. Patients who had no signs of life on arrival and patients
with injuries due to sunburn/ultraviolet rays were excluded from
the study. On arrival, patients were evaluated and managed as per
the hospital management protocols, which are predesigned based
on the existing updated medical knowledge.[7,8] Predisposing or
precipitating factors were assessed, including the duration of
exposure, time interval of onset of disease, and initiation of First
Aid were documented by the authors. The lesions were divided
into four degrees and treated accordingly. The affected parts were
cleaned and kept in lukewarm water (37°C–39°C) for 15 min to
1 h. Thereafter, dressing was done with frostbite cream which
was made by mixing soframycin cream, lignocaine ointment,
and silver sulfadiazine ointment and subsequently covered with
framycetin sulfate (Sofra Tulle ®) dressing and highly absorbent
padding.[7,8] Bullas were punctured to remove the uid collection;
however, the overlying skin was left intact. Patients were kept in
ambient environment at 26°C–30°C temperature. A predesigned
pro forma was used for data collection by the investigators,
which included detailed description demographic factors, various
possible risk factors, symptoms/signs of various degrees of
frostbite, severity of the disease, and management. The patients
were asked to dene the body parts affected (by choosing from a
list of locations, namely the hands, feet, nose, and ears), height of
post, duration of exposure, the season in which the injury occurred,
the appropriateness of the equipment being used (checked against
a list of indispensables consisting of proper boots, socks, gloves
with cover, and windbreaker), whether they were properly trained
or educated by a designated trainer and patients’ perception on the
cause of frostbite. An inquiry was also made regarding alcohol
and tobacco consumption and/or the use of other drugs. The dead
tissues were excised only after a clear line of demarcation. In
the absence of infection, amputations were usually delayed up
to 3 months to give all possible chances to the deeper tissues to
recover spontaneously.[7,8] The Institutional Ethical Committee
Clearance was sought and obtained before the study was begun.
Informed written consent was obtained from all the patients
before including them in the study. Statistical analysis: data entry
was carried out using MS Excel 2013, and data analysis was
carried out using IBM SPSS (Statistical Package for the Social
Sciences) software version 21.0, New York, United States. Means
and proportions were calculated for the continuous and nominal
variables, respectively.
results
The present study included 72 patients who reported with
frostbite during the study period. All patients were males,
with a mean age of 27.8 ± 2.5 years. Only four patients were
under the age of 20 years, 48 (66.7%) were between 20 and
30 years, 18 (25%) were between 30–40 years, and 2 (2.8%)
were over 40 years. None of the patients were suffering from
any chronic disease such as coronary heart disease, diabetes
mellitus, and hypertension. Majority of the patients (57; 79.2%)
reported with frostbite who were exposed to freezing cold of
up to 3–6 h. Of these, 22 of them were caught in blizzards with
freezing cold and developed frostbite in <3 h of exposure. After
6–12 h of cold exposure, 10 patients (13.9%) developed frostbite,
whereas ve cases (6.9%) had exposure of more than 12 h. Only
27 (37.5%) patients could be evacuated to the nearest hospital
within 6 h from the site of occurrence, and 39 patients (54.7%)
were evacuated in 6–12 h time. The rest six patients (8.3%)
could reach the hospital only after 12 h of incident. A history of
smoking of 6–10 cigarettes/day was given by the six patients.
These patients also had delayed recovery and poor prognosis
than nonsmokers. On evaluation, two patients were found to have
evidence of peripheral vascular disease. They developed frostbite
only in 3–4 h of cold exposure. The majority of the cases (42,
58.3%) developed frostbite at an altitude between 12,000 and
17,000 feet above the sea level, followed by 27 (37.5%) patients
who developed frostbite between 17,000 and 21,000 feet. Only
3 cases (4.2%) had frostbite above 21,000 feet. The maximum
cases affected were during the month of January (n = 13) followed
by December (n = 11), November (n = 9), and October (n = 8).
From October to January, there are more blizzards and “wind-chill
effect” due sudden fall in atmospheric temperature (up
to − 35°C). Only 13 cases (18%) had frostbite during the summer
months (April to September) [Table 1]. Feet were the most
frequently affected part (44, [61.1%]). In 23 cases (31.9%), hands
were affected. Head-and-neck exposure usually involved nose
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Agrawal, et al.: Epidemiology of frostbite at high altitudes
Journal of Marine Medical Society ¦ Volume 22 ¦ Issue 2 ¦ July-December 2020
138
and ears and was observed in ve cases (6.9%). At least, two
body parts were involved in 45 cases (62.5%), and 21 (29.2%)
had one body part affected. Six patients were noted having the
involvement of three body parts. Majority of cases (57, [79.2%])
had the rst- and second-degree frostbite, whereas third- and
fourth-degree frostbites were noted in 10 and ve patients,
respectively [Figures 1 and 2]. Majority of the patients required
only a conservative dressing (65%), whereas nearly one third
of the patients required adjunctive procedures in the course of
management. Wound debridement (6.9%) and hyperbaric oxygen
therapy (5.6%) were the most common adjunct procedures.
Amputation was done in 6.9% cases, whereas autoamputation
was observed in 8.3% of the study participants [Table 2].
Complete healing and full recovery were noted in the rest of the
patients. Causalgia (8.3%) and infection (6.9%) were the most
common sequelae following frostbite [Table 3].
dIscussIon
In the past years, frostbite was chiey encountered in the
military populations; however, the demographic trends have
now loosened to include homeless individuals, outdoor workers,
mountaineers, and winter sports enthusiasts.[9,10] In patients with
frostbite, early recognition and timely evacuation to the nearest
hospital are directly proportional to the degree of frostbite
and the better outcome. Prevention is through wearing proper
clothing, maintaining hydration and nutrition, avoiding low
temperatures, and staying active without becoming exhausted.
The present study results revealed a higher incidence of cases
among the younger age group (<30 years) and this is similar
to the observations of the other studies carried out among
military personnel. In a study among military personnel, it was
noted that the majority of the affected were females <20 years
old.[11] This could be because of the fact that individuals in
the armed forces who are deployed for tasks in such high
altitude areas are usually moung and healthy. However, it
is also noted that the higher prevalence among the general
public and mountaineers was found to be in the age group of
30–49 years.[12] A study among 637 mountaineers reported that
the mean age of their study population was 28.8 ± 1.1 years,
Figure 1: Distribution of the study participants based severity of frostbite
Table 1: Distribution of the study participants based on
the baseline characteristics (n=72)
Parameter Frequency (%)
Age (years)
18-20 4 (5.6)
21-30 48 (66.7)
31-40 18 (25)
41-50 2 (2.8)
Duration of exposure (h)
<6 57 (79.2)
6-12 10 (13.9)
>12 5 (6.9)
Evacuation time (h)
<6 27 (37.5)
6-12 39 (54.7)
>12 6 (8.3)
Height of place where deployed (feet)
12,000-17,000 42 (58.3)
17,000-21,000 27 (37.5)
>21,000 3 (4.2)
Incidence month
January 11 (15.28)
February 12 (16.67)
March 08 (11.11)
April 03 (4.17)
May 04 (5.56)
June 0 (0.00)
July 02 (2.78)
August 03 (4.17)
September 02 (2.78)
October 05 (6.94)
November 09 (12.50)
December 13 (18.06)
Total 72 (100.0)
Table 2: Distribution of the study patients based on the
type of management (n=72)
Type of management Frequency (%)
Conservative dressing 47 (65.3)
Wound debridement 5 (6.9)
Split skin grafting 3 (4.2)
Amputation
Amputation
All ngers at interphalangeal joints 1 (1.4)
Great toe 2 (2.8)
Middle nger at proximal interphalangeal joint 1 (1.4)
Index nger at distal proximal interphalangeal
joint
1 (1.4)
Autoamputation
Fore feet including toes 1 (1.4)
Middle nger right 2 (2.8)
Tip of little toe 1 (1.4)
Great toe 2 (2.8)
Four-quadrant fasciotomy 2 (2.8)
Hyperbaric oxygen 4 (5.6)
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Agrawal, et al.: Epidemiology of frostbite at high altitudes
Journal of Marine Medical Society ¦ Volume 22 ¦ Issue 2 ¦ July-December 2020 139
and the youngest among them was 16 years and the oldest
was 65 years.[13] Strohle et al. reported in their research work
that the mean patient’s age was 41.6 ± 17.5 years, ranging
from 20 to 90 years.[14] These demographic observations of
frostbite cases were concordant with that of the present study
ndings. After detailed epidemiological investigation, it was
noted that the most common risk factors were tight boots,
nonadherence to the instructions regarding self-examination,
not doing regular foot parade, use of wet socks, and exhaustion.
The foot parade consists of self-examination of feet, washing
them with lukewarm water, and jumping on feet which helps in
rewarming. In our study, among 23 cases (31.9%), hands were
affected which was also due to the use of single or wet glove.
All the study patients recovered without amputation except
four. Two cases required proximal phalanx amputation of one
nger, one required proximal phalanx amputation of left great
toe, and one required amputation of all ngers at the junction of
metacarpophalangeal joints. In a large review among the British
military personnel, it was reported that extremities (hands and
feet) accounted for the majority of cases (60.8%), only hands
in 28.9%, only feet in 23.7%, and 7% had both hands and
feet involvement. Face and neck involvement was recorded
in 1% of the study sample.[15] However, another study stated
that feet and the hands accounted for 90% of injuries while it
also affects the buttocks (sitting) and penis (joggers).[12] In a
study among Norwegian armed forces personnel, 96% suffered
frostbite on ngers/hands or toes/feet.[16] These results were
comparable to that of the present study ndings, in terms of
body part involved. The correlation of the independent effect of
height on the degree of frostbite showed that height adversely
affected the lesions beyond 17,000 feet. The decline beyond
21,000 feet was because of the fact that persons who went
and stayed at those heights were conned to their shelters
with very little movement. However, the study reported the
majority of the affected patients at altitude levels starting from
12,000 to 17,000 feet as compared to the higher altitude. This
could be explained by the fact that a relatively higher number
of personnel are deployed at this altitude range as compared
to the higher altitude, thereby increasing the number of
incident case, however not the incidence rate. Incidence rates
could not be estimated in our study because of constantly
mobile military population in the study area. Furthermore,
complacency in the prevention measures among these
personnel could be a potential explanation, which may not
be expected among individuals at greater altitude levels. An
Australian Alps study also reported that most of the frostbite
injuries occurred over 5000 feet (67.8%).[14] A prospective
study was conducted in four different geographical regions
of the Himalayas and reported that the rst-, second-, and
third-degree frostbite comprised 62.2%, 34.3%, and 3.49%
of patients, respectively.[17] These ndings were similar to
that of the present study reports. In the study on frostbite
cases in the Australian Alps, rescue of affected was mostly
terrestrial (32.3%), followed by helicopter (38.7%), and the
rest (22.6%) cases involved both.[14] The present study setting
involved a similar hilly terrain with restricted access by land;
however, most patients were evacuated by road when possible
while air evacuation to the hospital was also used based on
the prevailing weather conditions. The seasonal distribution
of frostbite shows the highest occurrence in January and
Table 3: Distribution of the study participants based on
sequelae after frostbite (n=25)
Sequelae Frequency (%)
Disgurement 4 (5.6)
Causalgia/chronic regional pain 6 (8.3)
Cold hypersensitivity 3 (4.2)
Numbness of the digits 4 (5.6)
Reduced sensitivity 3 (4.2)
Infection 5 (6.9)
None 47 (65.3)
Total 25 (100.0)
Figure 2: (a) Third degree frostbite in the healing phase.(b) Fourth degree frostbite with dry gangrene of the fingers.(c) Four th degree frostbite
with dry gangrene of toes.(d) Fourth degree frostbite with dry gangrene of great toe.(e) Second degree frostbite having bullae filled with clear fluid.
(f) Third degree frostbite of the hand
d
c
b
f
a
e
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Agrawal, et al.: Epidemiology of frostbite at high altitudes
Journal of Marine Medical Society ¦ Volume 22 ¦ Issue 2 ¦ July-December 2020
140
February (with at least three times as many injuries as in other
months), with another less striking rise in the incidence during
summer months when large-scale expeditions to high peaks
are scheduled. Inappropriate clothing was believed by the
mountaineers to be the main cause of the injury followed by
the lack or incorrect use of equipment and lack of knowledge
about dealing with cold and severe cold weather.[13]
The principles of treatment in frostbite include prevention
of refreezing, aspirin and ibuprofen can be given to prevent
clotting and inammation, managing coexisting hypothermia,
antibiotics are added if there is trauma, skin infection (cellulitis),
or severe injury, and debridement or amputation of necrotic
tissue should be delayed. Early hyperbaric oxygen therapy
is also documented to curb amputations.[18] Tissue loss and
autoamputation are the potential consequences of frostbite. In
a retrospective study of 265 frostbite injuries in Canada, it was
noted that 35% of patients with deep frostbite had operative
interventions and autoamputations occurred in 28% of them.[19]
Although the present study did not evaluate the proportion
of adjunctive procedures among the subclasses of frostbite,
because of relatively smaller sample size, these proportions
observed in the above study are comparable to that of the
present study. Treatment is usually conservative. If the part
becomes gangrenous, it should be left to autoamputate. Surgical
amputation should be done if the patient has intolerable pain or
wound gets infected. The use of hyperbaric oxygen, medical
sympathectomy using intraarterial reserpine, and recombinant
tissue plasminogen activator have also been attempted with
limited success.[7,8,20-22] More randomized control studies
are required to establish their role in the management. The
limitations of the study include that the study involved only
personnel of the armed forces who are in most occasions young
and healthy, which makes the study population not easily
comparable with that of the general population.
Timely prehospital and denitive hospital management are
important to minimize the nal tissue loss and maximize the
functionality of the affected limb. Frostbite can result in a wide
spectrum of injury, ranging from complete resolution without
signicant sequelae to major limb amputation and its functional
consequences. The rst- and second-degree frostbite was the
most common, predominantly noticed in young individuals
during peaks winter months of December and January. The
higher proportion of adjunct operative procedures is required
as the severity of frostbite increases. Once in the hospital
setting, the best outcomes will be achieved for the patient
when a multidisciplinary approach is utilized.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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