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In the clinical course of frostbite, two periods are clearly distinguished: before warming up - pre-reactive (or latent) and after warming - reactive. Direct cell damage occurs during the reactive period. Consequently, only after an increase in the interstitial temperature and the completion of pathophysiological changes can one judge the degree of frostbite. The process of tissue death sometimes takes up to 5-7 days, after which it is possible to finally judge the frostbite depth.

The clinical picture of the pre-reactive period is quite poor in symptomatology. The earliest symptoms of developing frostbite are numbness, pinsy crawling, then pain and a feeling of stiffness in the affected limb. On examination, paleness of the skin, sometimes cyanosis, is noted; cold extremity to the touch; tactile and pain sensitivity is reduced; swelling, as a rule, no; sometimes there is no pulsation of the arteries on the feet.

The first sign of a reactive period is the appearance of tissue edema, followed by pain and changes in the skin corresponding to the depth of the lesion.

The classification of frostbite adopted in our country is based on the four-degree division proposed in 1940 by T.Ya.Ariev. It is based on the division of lesions into superficial (first and second degrees) and deep (third and fourth degrees).

FROZEN THE FIRST DEGREE develops with a brief exposure to cold. Pallor of the skin during warming is replaced by hyperemia. Tactile and pain sensitivity, as with burns, is preserved and even increased. Movement in the fingers of the hand and foot active. There is moderate edema within the boundaries of hyperemia. Sometimes there is cyanosis or marble coloration of the skin, which are more often with deeper lesions.

FROZEN SECOND DEGREE. The formation of bubbles filled with a clear liquid is most characteristic, as is the case with burns. Before the same skin is hyperemic, with a bluish tinge. Edema, as well as frostbite of the first degree, is insignificant. Bubbles usually form on the first day after injury; less likely to observe the appearance of bubbles during the second day. If the bubbles appear at a later date, and their contents have a dark color, this, as a rule, indicates a deeper lesion.
The healing of such frostbite occurs without the development of granulations and scar formation. Nails fall off, but then grow back.

THIRD DEATH THROTTLE Early blistering bubbles are filled with bloody contents, the bottom of bubbles is of a dark cherry or bluish color. Before their formation, the skin has a purple-bluish color and is cold to the touch, unlike damage of 1-2 degrees. Damaged areas are not sensitive to chemical (ethyl alcohol) and pain stimuli; tactile sensitivity can be maintained, but significantly reduced. With such a lesion, necrosis captures the entire dermis to the subcutaneous fat, as a result of which their healing occurs with the formation of coarse scars. Nails, as a rule, are not restored. The absence of bubbles in the presence of sharp edema and loss of all types of sensitivity within 48 hours or more is an unfavorable prognostic sign and indicates a fourth degree of frostbite.

FROZEN FOURTH DEGREE. The boundary of the lesion is at the level of bones and joints. In the first hours of the reactive period, the skin of the damaged area is sharply cyanotic, sometimes with a marble tinge. The temperature of the skin is significantly reduced. The development of edema begins 1-2 hours after the increase in interstitial temperature. Edema increases within 1-2 days and increases towards the proximal limb. Subsequently, mummification or wet gangrene of the fingers or limbs develops.

In the affected area with deep frostbite, four zones are distinguished from the periphery to the center:

1) total necrosis - all the tissues of this zone by the time of normalization of interstitial temperature are already necrotic;

2) irreversible degenerative processes - the tissues are in a necrobiotic state, and as a result of severe vascular disorders and toxemia, they are necrotic in the coming days after injury;

3) reversible degenerative processes - with timely and correct treatment, necrosis of the tissues of this zone can be prevented;

4) ascending pathological processes - in this zone, osteoporosis, neuritis, and endarteritis develop.
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    On the issue of tactics of first aid and treatment of frostbite in the pre-reactive period, there are two points of view. The first, older, theory of "forced warming up" is based on the fact that the sooner it is possible to stop the effect of the damaging factor (cold) on the fabric, the better the results of treatment will be. The second, more modern, concept of "warming from the inside" comes from
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