The Case A 48-year-old gentleman is brought to the ED by EMS.
His roommate found him staggering back into his house after being
outside. The patient got into a fight with his roommate and
overdosed on Ambien - possibly up to sixty 5-mg tablets. The
patient went outside for an unclear period of time. He fell while
he was outside, striking his face on a woodpile. He apparently lost
consciousness and then was outside in the bitter cold with
temperatures at 0 degrees. His core temperature on arrival is 32 o
C by Foley catheter. He has evidence of significant frostbite of
both hands with limited range of motion of his fingers and toes;
his hands are frozen, discolored red and white and without
capillary refill. He also has evidence of superficial frostbite of
his knees and his left elbow. His tetanus is up-to-date. He does
not smoke cigarettes.
Slide 3
Slide 4
Frostbite Definition Freezing injury of tissue Ice crystal
formation in superficial or deep structures
Slide 5
Epidemiology Risk Factors Alcohol consumption (46%) Motor
vehicle problems (19%) Psychiatric illness (17%) Vehicular failure
(15%) Drug misuse (4%) Homelessness Military Recreational and
athletic participants Improper clothing History of previous cold
injury Fatigue Dehydration Wound infection Atherosclerosis Diabetes
Smoking High Altitude, Hypoxia African American race Being raised
in the south Excessive sweating (Elderly, Young children) Age 30-49
Male Sex (10:1) Vascular Psych/Behavioral (and car troubles)
Genetic/Inherent
Slide 6
Epidemiology Incidence unknown Common anatomic locations Feet
Hands Ears Nose Cheeks Penis
Slide 7
Hershkowitz M. Penile Frostbite, an Unforseen Hazard of
Jogging. New England Journal of Medicine. Jan 20, 1977.
Slide 8
Travis S, Roberts D. Arctic Willy. BMJ, Vol. 299, 23-30
December 1989.
Slide 9
Epidemiology Population at risk for co-existing conditions
Consider & manage: Hypothermia Trauma
Slide 10
Pathophysiology Frostbite occurs when tissue heat loss exceeds
the ability of local tissue perfusion to prevent freezing of
tissues 4 Overlapping phases of tissue cooling: Prefreeze phase
Freeze-thaw phase Vascular stasis phase Late ischemic phase
Slide 11
Pathophysiology Prefreeze Phase Tissue cooling
Weather Conditions & Frostbite Ambient air temperature
Frost nip doesnt generally happen until skin temperature is below
-6 degrees C Skin rarely freezes above -15 to -10 degrees C (+5 to
+14 F) Skin will readily supercool Cold-induced vasodilation
occurs; skin temperature levels off Rate of air movement (wind
speed) Duration > temperature of exposure Skin surface moisture
Contact with cold objects Wilson O, Goldman RF. Role of air
temperature and wind in the time necessary for a finger to freeze.
Journal of Applied Physiology. Nov 1970.
Slide 36
Emollients Traditionally used by Finnish reindeer herders to
prevent frostbite Large prospective epidemiological study 913
frostbite cases, 2,478 uninjured controls Use of protective
ointments associated with increased risk of frostbite on face (OR
3.3), nose (OR 5.6) and ears (OR 4.5) Prospective experimental
study 24 young, healthy male subjects (med students) Placed in a
climatic chamber 4 emolients tested on the face Thermistor and
infra-red scanner temperatures Emolients do not delay cooling of
facial skin Skin cooler on treated half in the majority of tests
Lehmuskallio E. Rintamaki H. Anttonen H. Thermal Effects of
Emollients on Facial Skin in the Cold. Acta Derm Venereol. 2000.
Lehmuskallio E. Emollients in the Prevention of Frostbite.
International Journal of Circumpolar Health, 2000; 59:
122-130.
Slide 37
Management In the field: If re-freezing is likely If thaw is
maintainable Hospital setting: Early treatment Long-term treatment
options
Slide 38
Field Management of Frostbite General Guidelines: Treat
concomitant hypothermia Before treating frostbite if
moderate-severe Maintain hydration Administer ibuprofen (600mg
BID-QID) Blocks arachidonic pathway decreased PGF2 and TxA2 Protect
the frozen part Do not rub Do not actively thaw if re-freezing is
possible Caveat: consider thawing if hospital is in distant future
Avoid re-freezing a thawed part Do not prevent thawing if it is
going to happen spontaneously
Slide 39
Field Management of Frostbite If re-freezing is possible or
inevitable: Apply clean, bulky dressings to the frozen part and
between toes and fingers Avoid ambulation and pressure on frozen
extremity minimize additional trauma If use is unavoidable: Pad
well Splint Immobilize as much as possible
Slide 40
Field Management of Frostbite If thaw can be maintained:
Rapidly rewarm Warm water immersion bath (37-39 degrees C) Dry by
blotting (avoid rubbing) Antiseptic solution Theoretical benefits,
but no evidence Pain control NSAIDs Opiates
Slide 41
Field Management of Frostbite If thaw can be maintained,
continued: Do not debride blisters Apply topical aloe vera Reduces
prostaglandin and thromboxane formation Only beneficial for
superficial injuries Bulky, clean dressings wrapped loosely
(swelling) Avoid ambulation if possible Elevate the injured
extremity Provide supplemental oxygen if hypoxia is present or at
high altitude (>4000m)
Slide 42
Field Management of Frostbite McIntosh SE. Hamonko M, et al.
Wilderness Medical Society Guidelines for the Prevention and
Treatment of Frostbite. Wilderness and Environmental Medicine,
2011(22):156-166.
Slide 43
Hospital Management of Frostbite Impossible to ascertain
prognosis immediately after thawing Immediate therapeutic options:
Treatment of hypothermia, trauma Rapid rewarming of frozen tissues
Water bath (37-39 o C) Hydration Topical aloe vera
Slide 44
Hospital Management of Frostbite Immediate therapeutic options,
continued: Debridement of blisters Selectively needle aspirate
clear blisters Leave hemorrhagic blisters intact Systemic
antibiotics Cover Staph aureus and Pseudomonas aeruginosa No need
for universal antibiotic coverage Tetanus prophylaxis Low molecular
weight dextran
Slide 45
Low Molecular Weight Dextran Polysaccharide plasma expander
Proposed mechanism of action in frostbite: Decreases blood
viscosity Inhibits intravascular cellular aggregation and improves
small vessel perfusion
Slide 46
Low Molecular Weight Dextran Pro: Mundth ED, et al. 1964.
Improves tissue survival if given PRIOR TO freezing May improve
tissue survival if given one hour after rewarming and BID x5 days
Webster DB, et al. 1965. Animals treated with LMWD before and after
freezing injury had less necrosis than controls Con: Penn I, et al.
1964. LMWD therapy associated with increased edema Increased
compression of blood vessels & interference of blood flow
through injured area No significant reduction in the amount of
tissue loss
Slide 47
Low Molecular Weight Dextran Take-home: LMWD is worth
considering if you can get it into the patient before the injury or
within a couple of hours of presentation but it should not be given
immediately Most recent research is in the 1960s We probably have
better options
Slide 48
Imaging options Technetium 99 (Tc-99) triple phase scanning
Magnetic resonance angiography Angiography These help determine
extent of tissue ischemia Hospital Management of Frostbite
Slide 49
Thrombolytic therapy Angiography, Technetium-99, or MR-A IV or
IA tPA within 24 hours of thawing may salvage some or all tissue at
risk Should only be considered in deep frostbite with potential for
significant morbidity (proximal to interphalangeal joints) Consider
risks and contraindications Heparin therapy as adjuvent to tPA (+/-
warfarin) Hospital Management of Frostbite
Slide 50
Prospective study 19 patients over 14 years 6 intra-arterial
tPA 0.075 mg/kg/hr x6 hrs 13 intra-venous tPA 0.15 mg/kg bolus,
then 0.15 mg/kg/hr x 6 hrs No complications with IV tPA; 2 IA
patients with bleeding 16/19 patients responded to tPA Equal
efficacy with IV and IA IV tPA is safe & reduced predicted
digit amputations Twomey JA, Peltier GL, Zera RT. An Open-Label
Study to Evaluate the Safety and Efficacy of Tissue Plasminogen
Activator in Treatment of Severe Frostbite. The Journal of Trauma
2005 (Dec); Volume 59, Number 6, pp. 1350-1355.
Slide 51
Retrospective study 7 patients in experimental group 25
controls traditional treatment group IA tPA 0.5-1.0 mg/hr t-PA
reduced digital amputation rate from 41% to 10%! Bruen KJ, Ballard
JR, Morris SE, Cochran A, Edelman LS, Saffle JR. Reduction of the
Incidence of Amputation in Frostbite Injury with Thrombolytic
Therapy. Arch Surg 2007; 142:546-553.
Slide 52
Sheridan RL, Goldstein MA, Stoddard FJ, Walker G. Case 41-2009:
A 16-year-old Boy with Hypothermia and Frostbite. The new England
Journal of Medicine 2009 (December 31); 361: 2654-2662.
Slide 53
Vasodilator therapy Prostaglandin E1 Iloprost Nitroglycerin
Pentoxifylline Phenoxybenzamine Nifedipine Reserpine Buflomedil
Vasodilate and prevent platelet aggregation and microvascular
occlusion Hospital Management of Frostbite
Slide 54
Other post-thaw options (medical): Hydrotherapy 37-39 degrees
Celcius 1-2 times per day Theoretically increases circulation,
removes superficial bacteria, debrides devitalized tissue No trials
to support its use Hyperbaric oxygen therapy Unlikely to work in
setting of lost blood supply Limited data Hospital Management of
Frostbite
Slide 55
Other post-thaw options (surgical) Sympathectomy (removal of
sympathetic chain and ganglion) Theoretically alleviates vasospasm
May also help prevent long-term pain, paresthesias, and
hyperhidrosis Should be performed early (first 24 hrs) for tissue
salvage or late for relief of chronic symptoms
Fasciotomy/Escarotomy Should be performed if compartment syndrome
Hospital Management of Frostbite
Slide 56
Other post-thaw options (surgical): Amputation Should occur 1-3
months after injury Need complete demarcation of necrotic tissue
Need protective orthoses and footwear while waiting Involve
multi-disciplinary rehabilitation team Will need to occur sooner if
sepsis develops Hospital Management of Frostbite
Slide 57
McIntosh SE. Hamonko M, et al. Wilderness Medical Society
Guidelines for the Prevention and Treatment of Frostbite.
Wilderness and Environmental Medicine, 2011(22):156-166.
Slide 58
Other Modalities That Have Been Tried Ultrasound therapy
Adrenocorticotrophic Hormone (ACTH) Topical steroid
(Tetran-hydrocortisone ointment) Subatmospheric Pressure (VAC
Dressing) Distal Volar Forearm Nerve Block Causes hyperemia,
warmth, and anesthesia in fingers anesthetized for carpal tunnel
release Aspirin Blocks all prostaglandin synthesis, including
beneficial
Slide 59
Long term sequellae Single episode of frostbite Can result in
cold intolerance (75%) Can increase risk of recurrent frostbite
injury Chronic pain (67%) Amitriptyline Sympathectomy Bony
involvement Localized osteoporosis or subchondral bone loss
Frostbite arthritis ~50% Premature epiphyseal fusion in children
Skin Involvement Hyperhidrosis (75%) Dry, cracking skin Sensory
loss (68%)
Slide 60
The Case - Revisited Admitted to trauma; IR consultation Also
psych, ortho, plastics consults Wound care nursing debrided
blisters Angiography 1/16, 1/17, 1/18 IA tPA (0.5mg/hr) was given
1/16 through 1/17 Angio 1/18 showed good flow in the palmar arches;
no filling of bilateral digital arteries Transferred to P6 for his
Ambien overdose, where he continues to reside
Slide 61
Slide 62
tPA 1mg/hr Heparin 500u/hr 24 Hrs L Hand R Hand 48 Hrs
Slide 63
Treatment Protocol Initial Therapy Immediate rewarming Fluid
resuscitation Tdap Ibuprofen 600mg Pain Control (Debridement of
blisters)
Treatment Protocol Interventional Radiology Consult Perfusion
evaluation on angiography Absent filling of digital arteries tPA
0.5 1 mg/h Femoral or brachial arterial catheter sheath Heparin 500
u/h Femoral or brachial arterial catheter sheath Surgery consult
SCU admission
Slide 67
Treatment Protocol Evaluation while on treatment Dedicated burn
unit / Intensive Care Unit Local wound care Debridement with burn
dressing (aloe vera) Repeat Angiography Q 8-12 hrs tPA discontinued
when perfusion is restored to distal vessels OR at absolute limit
of 48 hrs
Slide 68
Angiograhic Findings that Predict Good Clinical Outcome
Restoration of arterial flow to terminal digital arteries
Visualization of PAIRED digital arteries Persistent arterial flow
on serial angiogram
MMC Treatment Algorithm Rapid Rewarming IV hydration TDap
Ibuprofen 600mg Pain Control (Debride blisters) (Aloe vera)
Assessment of damaged tissue Assessment for contraindications IR
Consult Angiography Trauma surgery consult ICU Admission Treat
hypothermia or trauma
Slide 71
Mimickers of Frostbite Chilblains/Pernio Trench Foot Raynauds
Phenomenon/Syndrome
Slide 72
Chilblains/Pernio Epidemiology ~10% of population in England
Hands, feet, face, lower leg Thighs, buttocks: overweight young
female horseback riders Pathophysiology Unknown Chronic
vasculitis/vascular instability Vasodilation of superficial minute
vessels and vasoconstriction of subcutaneous arteries and
arterioles Repeated exposure to near freezing, humidity No ice
crystal formation
Slide 73
Chilblains/Pernio Presentation Violaceous color to skin with
plaques or nodules Pain and pruritis with cold exposure Treatment
Avoidance of cold Proper clothing Nifedipine
Slide 74
Trench Foot Epidemiology Associated with immobility and
dependency Military Pathophysiology Wet cold injury Temperatures
above freezing Long duration of exposure (1 day several days)
Slide 75
Trench Foot Treatment: Rewarming Causes severe pain Immediate
Sequellae: Anesthesia Edema Parasthesias Anhydrosis Muscluar
atrophy Ulceration Gangrene Long-term Sequellae: Hypersensitivity
to cold and weight bearing
Slide 76
Raynauds Phenomenon Epidemiology 2% of the population
Pathophysiology Episodic reduction in peripheral blood flow Cold
exposure Stress
Slide 77
Raynauds Phenomenon Presentation Skin color changes White
ischemia from vasoconstriction Blue venous stasis Red hyperemia
Sensory changes Pain Parasthesias Treatment Nifedipine IV
Prostacyclin or prostaglandin E1 for severe cases Evening primrose
oil
Slide 78
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