On-site Management of Frostbite in the Himalayas

Document Type : Original Article


Clinical Microbiology, Army College of Medical Sciences and Base Hospital, Delhi Cantt 110010 India


Introduction: Frostbite is a common debilitating condition seen in travelers and residents at high altitudes. Emergent on-site management is warranted in the absence of institutionalized care and compromised evacuation facilities. This prospective, observational study assessed the outcome of on-site emergent management in low-resource, high altitude healthcare setups in the field, applicable in situations of delayed evacuation.
Methods: This is a prospective cohort study. All frostbite patients presenting at 4 Himalayan regions were included. Patients were diagnosed, assessed clinically, and evaluated for causation. On-site emergent management was given in situations of delayed evacuation, and responses were monitored. Further prevention was advised for all patients.
Results: Frostbite presented in 172 healthy, acclimatized patients having knowledge of frostbite. A total of 158 (91.86%) males and 14 (8.14%) females with a mean age of 27.8 ± 7 years sustained frostbite at altitudes between 9000-24000 feet with a mean of 14575 ± 3848 feet. First-, second-, and third-degree frostbite comprised 62.2%, 34.3%, and 3.49% of cases, respectively. Fingertips were most frequently affected, followed by toe tips. Of the frostbite cases treated on-site, 57.94% were first-degree and 34.29% were second-degree.
Conclusion: Frostbite can occur in people who are cold-experienced and knowledgeable. Therapeutic and preventive rewarming can be attempted in limited-resource setups outside the hospital. Frostbite up to second-degree can be treated under high altitude field conditions; however, this is advisable only in situations of delayed evacuation.


  1. Cauchy E, Davis CB, Pasquier M, Meyer EF, Hackett PH. A new proposal for management of severe frostbite in the austere environment. Wilderness Environ Med. 2016;27(1):92-99. doi:10.1016/j.wem.2015.11.014.
  2. DeGroot DW, Castellani JW, Williams JO, Amoroso PJ. Epidemiology of U.S. Army cold weather injuries, 1980-1999. Aviat Space Environ Med. 2003:74(5):564-570.
  3. Heil KM, Oakley EH, Wood AM. British Military freezing cold injuries: a 13-year review. J R Army Med Corps. 2016;162(6):413-418. doi:10.1136/jramc-2015-000445.
  4. O’Donnell FL, Taubman SB. Update: Cold weather injuries, active and reserve components, U.S. Armed Forces, July 2011-June 2016. MSMR. 2016;23(10):12-20.
  5. Zafren K. Frostbite: prevention and initial management. High Alt Med Biol. 2013;14(1):9-12. doi:10.1089/ham.2012.1114.
  6. Jayaswal R, Sivadas P, Mishra SS. Health and performance of military personnel in cold climate environment of the Western Himalayas. Medical Journal Armed Forces India. 2001;57:322-325.
  7. Ervasti O, Hassi J, Rintamaki H, et al. Sequelae of moderate finger frostbite as assessed by subjective sensations, clinical signs, and thermophysiological responses. Int J Circumpolar Health. 2000;59(2):137-45.
  8. Hashmi MA, Rashid M, Haleem A, et al. Frostbite: epidemiology at high altitude in the Karakoram mountains. Ann R Coll Surg Engl. 1998;80(2):91-95.
  9. Khan ID. Extreme Altitude Pulmonary Oedema in Acclimatized Soldiers. Medical Journal Armed Forces India. 2012;68:339-345.
  10. Berendsen RR, Kolfschoten NE, de Jong VM, Frima H, Daanen HA, Anema HA. Treating frostbite injuries. Ned Tijdschr Geneeskd. 2012;156(25):A4702.
  11. Dwivedi DA, Alasinga S, Singhal S, Malhotra VK, Kotwal A. Successful treatment of frostbite with hyperbaric oxygen treatment. Indian J Occup Environ Med. 2015;19(2):121-122. doi:10.4103/0019-5278.165336.
  12. McIntosh SE, Hamonko M, Freer L, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite. Wilderness Environ Med. 2011;22(2):156-166. doi:10.1016/j.wem.2011.03.003.
  13. Imray C, Grieve A, Dhillon S. The Caudwell Xtreme Everest Research Group. Cold damage to the extremities: frostbite and non-freezing cold injuries. Postgrad Med J. 2009;85:481-488.
  14. Fudge J. Preventing and managing hypothermia and frostbite injury. Sports Health. 2016;8(2):133-139. doi:10.1177/1941738116630542.
  15. McLeron, K. State of Alaska Cold Injury Guidelines. 7th ed. Department of Health and Social Services Division of Public Health Section of Community Health and EMS, Juneau, AK; 2003
  16. Khan ID. Comorbid Cerebral and Pulmonary Edema at 7010 M/23000 Ft: An Extreme Altitude Perspective. J Med. 2013;14(2):153-155.
  17. Headquarters, Department of the Army. April 2005 TBMED 508. Prevention and Management of Cold Weather Injuries. US Army Research Institute of Environmental Medicine (USARIEM). http://usariem.army.mil/download/tbmed508.pdf.
  18. Danzl DF. Hypothermia and frostbite. In: Fauci AS, Harrison TR, eds. Harrison’s Principles of Internal Medicine. 19th ed. New York, NY: McGraw Hill; 2015.
  19. Daanen HA, van Ruiten HJ. Cold-induced peripheral vasodilation at high altitudes - a field study. High Alt Med Biol. 2000;1(4):323-329.
  20. Heil K, Thomas R, Robertson G, Porter A, Milner R, Wood A. Freezing and non-freezing cold weather injuries: a systematic review. Br Med Bull. 2016;117(1):79-93. doi:10.1093/bmb/ldw001.
  21. Su H, Li Z, Li Y, et al. Treatment of 568 patients with frostbite in northeastern China with an analysis of rate of amputation. Zhonghua Shao Shang Za Zhi. 2015;31(6):410-415.
  22. Khan ID. Cerebral Venous Sinus Thrombosis (CVST) Masquerading as High Altitude Cerebral Edema (HACE) at Extreme Altitude (6700 m/22000 ft). Int J Travel Med Glob Health. 2016;4(3):96-98.
  23. Khan ID. Extreme Altitude Chronic Mountain Sickness Misdiagnosed as High Altitude Cerebral Edema. Int J Travel Med Glob Health. 2016;4(4):132-134.
  24. Nygaard RM, Whitley AB, Fey RM, Wagner AL. The Hennepin Score: Quantification of Frostbite Management Efficacy. J Burn Care Res. 2016;37(4):e317-e322.
  25. Khan ID, Sahni AK. Possession Syndrome at High Altitude (4575m/15000ft). Kathmandu Univ Med J. 2013;43(3):247-249.
  26. Nagarajan S. Update: Cold weather injuries, active and reserve components, U.S. Armed Forces, July 2010-June 2015. MSMR. 2015;22(10):7-12.