Frostbite: a practical approach to hospital management.

Charles Handford,Luanne Freer,Caitlin Ea Imray,Scott E Mcintosh,Christopher He Imray,Pauline Buxton,Katie Russell,Amalia Cochran

doi:10.1186/2046-7648-3-7

Abstract

Frostbite presentation to hospital is relatively infrequent, and the optimal management of the more severely injured patient requires a multidisciplinary integration of specialist care. Clinicians with an interest in wilderness medicine/freezing cold injury have the awareness of specific potential interventions but may lack the skill or experience to implement the knowledge. The on-call specialist clinician (vascular, general surgery, orthopaedic, plastic surgeon or interventional radiologist), who is likely to receive these patients, may have the skill and knowledge to administer potentially limb-saving intervention but may be unaware of the available treatment options for frostbite. Over the last 10 years, frostbite management has improved with clear guidelines and management protocols available for both the medically trained and winter sports enthusiasts. Many specialist surgeons are unaware that patients with severe frostbite injuries presenting within 24 h of the injury may be good candidates for treatment with either TPA or iloprost. In this review, we aim to give a brief overview of field frostbite care and a practical guide to the hospital management of frostbite with a stepwise approach to thrombolysis and prostacyclin administration for clinicians.

Highlights

Frostbite is a freezing, cold thermal injury, which occurs when tissues are exposed to temperatures below their freezing point for a sustained period of time [1]
Twomey et al published results of an open-label study to evaluate the safety and efficacy of tissue plasminogen activator in the treatment of severe frostbite found that recombinant tissue plasminogen activator (rTPA) and heparin after rapid rewarming is safe and reduced predicted digit amputations
Deep frostbite is a serious condition that is associated with significant morbidity, and it is becoming more frequent in young active individuals who put themselves at risk

Summary

Introduction

Cold thermal injury, which occurs when tissues are exposed to temperatures below their freezing point (typically −0.55°C, but can occur as high as 2°C) for a sustained period of time [1]. Twomey et al published results of an open-label study to evaluate the safety and efficacy of tissue plasminogen activator (rTPA) in the treatment of severe frostbite found that rTPA and heparin after rapid rewarming is safe and reduced predicted digit amputations. Similar efficacy was reported in both the intravenous and intra-arterial delivery arms [25] Those patients with more than 24 h of cold exposure, warm ischaemia times greater than 6 h or evidence of multiple freeze-thaw cycles were least likely to benefit [25]. Normal contraindications to TPA apply including existing trauma, recent surgery, neurological impairment or bleeding diathesis It is not appropriate for superficial frostbite (grade 1), only deep tissue injuries that affect more proximal phalanges and the forefoot or foot should be considered, as treatment is not without risks of haemorrhage [17]. A virtual opinion or more specialized advice can be sought from almost anywhere in the world using a combination of digital images and telephone advice [4,11,42,43]

Conclusions

10. Reamy BV

31. Mills WJ Jr

37. Taylor MS

Findings

43. British Mountaineering Council