Modern management of patients with frostbite

Abstract

Background: Frostbite is a local cold injury that may lead to loss of tissue, and result in disability. It is normally a consequence of prolonged exposure of unprotected regions to subzero ambient temperatures, which causes impairment of the microcirculation. In Slovenia, the main risk group for frostbite injury are mountain climbers. Frostbite is classified as either a superficialreversible injury, or an irreversible deep tissue injury. Superficial frostbite is managed in out-patient clinics, whereas hospital treatment is required for deep frostbite. The success of frostbite management depends a great deal on the field first aid and emergency medical treatment, as well as on the subsequent hospital treatment. The present study reports of the success of a protocol for hospital treatment of frostbite (Planica Protocol), comprising the early diagnosis with three-phase bone scintigraphy (TS), administration of appropriate medications, particularly iloprost, and initiation of hyperbaric oxygen treatment (HBOT). Patients and methods: A total of 27 mountain climbers presented with frostbite injury between 2000 and 2010. Of these, 16 suffered superficial injuries and were treated as outpatients. The remaining 11 mountaineers (2 females, and 9 males) suffered deep frostbite and were hospitalised. Frostbite injury was sustained at different altitudes (range: 2000 to 8848 meters above sea level) in the toes (n = 9; 82 %) and fingers (n = 2; 18 %). Some climbers (n = 9; 82 %) received field first aid, and some (n = 9; 82 %) also emergency medical treatment in the field. On admission to hospital, patients received the following treatpatient clinics, whereas hospital treatment is required for deep frostbite. The success of frostbite management depends a great deal on the field first aid and emergency medical treatment, as well as on the subsequent hospital treatment. The present study reports of the success of a protocol for hospital treatment of frostbite (Planica Protocol), comprising the early diagnosis with three-phase bone scintigraphy (TS), administration of appropriate medications, particularly iloprost, and initiation of hyperbaric oxygen treatment (HBOT). Patients and methods: A total of 27 mountain climbers presented with frostbite injury between 2000 and 2010. Of these, 16 suffered superficial injuries and were treated as outpatients. The remaining 11 mountaineers (2 females, and 9 males) suffered deep frostbite and were hospitalised. Frostbite injury was sustained at different altitudes (range: 2000 to 8848 meters above sea level) in the toes (n = 9; 82 %) and fingers (n = 2; 18 %). Some climbers (n = 9; 82 %) received field first aid, and some (n = 9; 82 %) also emergency medical treatment in the field. On admission to hospital, patients received the following treatment: early diagnosis with TS (n = 7; 64 %); pharmaceutcial interventions, including acetylsalicylic acid, low-molecular weight heparin, pentoxifylline, antibiotics, iloprost (n = 8; 64 %); and HBOT (n = 8; 73 %). Results: Of the 11 climbers with deep frostbite, tissue loss and amputation was avoided in 6 (55 %). Necrectomy (full amputation) was performed in 5 climbers (45 %): full-length digit amputation (n = 2), and part-length (one or two phalanges) amputations (n = 3). Amputation of the toes was required in both female climbers. Conclusions: Timely field first aid and emergency medical treatment is of paramount importance for a good outcome of frostbite injury. Early diagnostics using three-phase bone scintigraphy (TS) can assess the extent of tissue damage before final clinical manifestation of frostbite is fully developed. The Planica Protocol for the treatment of frostbite injury, comprising early diagnostics (TS), proper medication (acetylsalicylic acid, low-molecular weight heparin, pentoxifylline, antibiotics, iloprost), and HBOT appears to provide a beneficial outcome of deep frostbite injury.