katie dolbec, md. the case a 48-year-old gentleman is brought to the ed by ems. his roommate found...

Katie Dolbec, MD

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.

Frostbite Definition Freezing injury of tissue Ice crystal formation in superficial or deep structures

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

Epidemiology Incidence unknown Common anatomic locations Feet Hands Ears Nose Cheeks Penis

Hershkowitz M. Penile Frostbite, an Unforseen Hazard of Jogging. New England Journal of Medicine. Jan 20, 1977.

Travis S, Roberts D. Arctic Willy. BMJ, Vol. 299, 23-30 December 1989.

Epidemiology Population at risk for co-existing conditions Consider & manage: Hypothermia Trauma

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

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.

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.

Management In the field: If re-freezing is likely If thaw is maintainable Hospital setting: Early treatment Long-term treatment options

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

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

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

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)

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.

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

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

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

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

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

Imaging options Technetium 99 (Tc-99) triple phase scanning Magnetic resonance angiography Angiography These help determine extent of tissue ischemia Hospital Management of Frostbite

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

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.

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.

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.

Vasodilator therapy Prostaglandin E1 Iloprost Nitroglycerin Pentoxifylline Phenoxybenzamine Nifedipine Reserpine Buflomedil Vasodilate and prevent platelet aggregation and microvascular occlusion Hospital Management of Frostbite

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

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

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

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.

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

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%)

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

tPA 1mg/hr Heparin 500u/hr 24 Hrs L Hand R Hand 48 Hrs

Treatment Protocol Initial Therapy Immediate rewarming Fluid resuscitation Tdap Ibuprofen 600mg Pain Control (Debridement of blisters)

Treatment Protocol Consider tPA if: Clinically significant frostbite Severe frostbite or 4 th degree frostbite Physical exam Full-thickness tissue involvement Hemorrhagic blisters Vascular exam = circulatory compromise Absence of pulses/doppler Black/deep purple discoloration

Treatment Protocol Exclusion Criteria Recent trauma Neurologic impairment Recent surgery or hemorrhage Bleeding disorder Recent stroke Intoxication Uncontrolled hypertension Pregnancy Multiple freeze/thaw cycles Prolonged cold exposure (>48 hours) Post-warming time >24 hours

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

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

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

Treatment Protocol Healing wounds Debridement Burn dressing (aloe vera) Skin-grafting Non-healing wounds (Obvious necrosis) (Mummification) Amputation

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

Mimickers of Frostbite Chilblains/Pernio Trench Foot Raynauds Phenomenon/Syndrome

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

Chilblains/Pernio Presentation Violaceous color to skin with plaques or nodules Pain and pruritis with cold exposure Treatment Avoidance of cold Proper clothing Nifedipine

Trench Foot Epidemiology Associated with immobility and dependency Military Pathophysiology Wet cold injury Temperatures above freezing Long duration of exposure (1 day several days)

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

Raynauds Phenomenon Epidemiology 2% of the population Pathophysiology Episodic reduction in peripheral blood flow Cold exposure Stress

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

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References Grace TG. Cold Exposure Injuries and the Winter Athlete. Clinical Orthopedics and Related Research, No. 216, March 1987. Grieve AW, Davis P, Dhillon S, Richards P, Hillebrandt D, Imray CHE. A Clinical Review of the Management of Frostbite. J R Army Med Corps 2011 Mar;157(1):73-8. Gulati SM, Kapur BML, Talwar JR. Sympathectomy in the Management of Frostbite: An Experimental Study. Indian Journal of Medical Resuscitation, 58, 3, March 1970. Hallam MJ, Cubison T, Dheansa B, Imray C. Managing Frostbite. BMJ. 341: 1151-1156, 2010 November. Hamlet MP. Prevention and Treatment of Cold Injury. International Journal of Circumpolar Health 2000; 59: 108-113. Hardenbergh E, Ramsbottom R. Experimental Frostbite: The Effect of Double Freeze on Tissue Survival in the Mouse Foot. Cryobiology, Vol. 5, No. 5, 1969. Hayes DW, Mandracchia VJ, Considine C, Webb GE. Pentoxifylline Adjunctive Therapy in the Treatment of Pedal Frostbite. Clinics in Podiatric Medicine and Surgery, Volume 17, Number 4, October 2000. Heggers JP, Robson MC, Manavalen K, Weingarten MD, Carethers JM, Boertman JA, Smith DJ, Sachs RJ. Experimental and Clinical Observations on Frostbite. Annals of Emergency Medicine, 16:9, September 1987. Hershkowitz M. Penile Frostbite, an Unforseen Hazard of Jogging. New England Journal of Medicine. Jan 20, 1977. 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.

References Kahn JE, Lidove O, Laredo JD, Bletry O. Frostbite arthritis. Ann rheum Dis 2005; 64: 966-967. Kaplan R, Thomas P, Tepper H, Strauch B. Treatment of Frostbite with Guanethidine. The Lancet, October 24, 1981. Kapur BML, Gulati SM, Talwar JR. Low Molecular Dextran in the Management of Frostbite in Monkeys. Ind. Jour. Med. Res. 56, 11, November, 1968. 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. Leung AKC, Lai PCW. Digital Deformities from Frostbite. Canadian Medical Association Journal, Vol. 132, January 1, 1985. Lutz V, Cribier B, Lipsker D. Chilblains and antiphospholipid antibodies: report of four cases and review of the literature. British Journal of Dermatology 2010; 163: 641-666. MacNamarra, BS. Ultrasonic Therapy Severe Frostbite Case. The Physical Therapy Review. Vol. 39, No. 3; pp. 160-161. Malhotra MS, Mathew L. Effect of Rewarming at Various Water Bath Temperatures in Experimental Frostbite. Aviation, Space, and Environmental Medicine, July 1978. Mazur P. Causes of Injury in Frozen and Thawed Cells. Federation Proceedings. 1965 Mar- Apr;24:S175-82.

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References Webster DR, Bonn G. Low-Molecular-Weight Dextran in the Treatment of Experimental Frostbite. Canadian Journal of Surgery; 1965 (Oct): vol. 8, 423-427. Wilson O, Goldman RF. Role of air temperature and wind in the time necessary for a finger to freeze. Journal of Applied Physiology. 29(5): 658-664, 1970 November. Yang X, Perez OA, English JC. Adult perniosis and cryoglobulinemia: A retrospective study and review of the literature. Journal of the American Academy of Dermatology 2010 (June). Yeager RA, Campion TW, Kerr JC, Hobson RW, Lynch TG. Treatment of Frostbite with Intra-arterial Prostaglandin E1. The American Surgeon, Vol. 49, No. 12, December 1983. Zafren K. Prognostic Indicators in Frostbite. Wilderness and Environmental Medicine, 10, 115-116 (1999). Zook N, Hussmann J, Brown R, Russell R, Kucan J, Roth A, Suchy H. Microcirculatory Studies of Frostbite Injury. Annals of Plastic Surgery, Volume 40, Number 3, March 1998.

katie dolbec, md. the case a 48-year-old gentleman is brought to the ed by ems. his roommate found...

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