Synthesis of Protocols for Frostbite Care from the FROST Study Sites

Frostbite injuries can have lasting sequelae including amputations, intolerance to cold, chronic pain, paresthesia, and inability to return to work. Despite this morbidity, the treatment of frostbite remains understudied. The FRostbite ObServational Trial (FROST) aims to address this gap through a multicenter evaluation of treatment practices and outcomes. As part of FROST, we reviewed institutional frostbite care protocols from 16 participating sites across North America. Practices were categorized as demonstrating uniform agreement $\Big(\ge$90% mentioned the practice), consensus ($\ge$75%), or majority if ($\ge$50%). Uniform agreement was limited to use of rapid rewarming and thrombolytics, the latter being influenced by site selection criteria for FROST participation. Consensus was achieved in multiple areas (such as urgency of treatment, perfusion assessment, the therapeutic windows for pharmaceutical interventions, and the therapeutic dosing of IV thrombolytics). Protocols varied on grades for thrombolytic treatment initiation, prostacyclin analogue use, post-thrombolytic anticoagulation treatment and duration, the role of physical or occupational therapy, splinting, and appropriate wound care. This manuscript provides a synthesis of protocols and expert opinion for the acute management of frostbite injury. This synthesized protocol may serve as a tool for centers to develop their own standard protocol to facilitate care for frostbite patients. Additionally, current opportunities for frostbite research and improving care are detailed in the manuscript. Education regarding prevention of injury and the need for emergent treatment is needed for both the public and the medical community.