Transcript Frostbite and Cold Injury

FROSTBITE AND DERMAL COLD
INJURY
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
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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 32oC 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
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Alcohol consumption (46%)
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Motor vehicle problems (19%)
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Psychiatric illness (17%)
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Vehicular failure (15%)
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Drug misuse (4%)
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Homelessness
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Military
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Recreational and athletic participants
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Improper clothing
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History of previous cold injury
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Fatigue
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Dehydration
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Wound infection
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Atherosclerosis
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Diabetes
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Smoking
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High Altitude, Hypoxia
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African American race
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Being raised in the south
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Excessive sweating
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(Elderly, Young children)
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Age 30-49
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Male Sex (10:1)
Psych/Behavioral
(and car troubles)
Vascular
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 <10oC
 Sensation is lost at 10oC
 Vasoconstriction
 Hunting reflex (cold-induced vasodilation)
 Episodes of transient vasodilation every 7-10 min
 Disappears with prolonged exposure to cold
 Ischemia
 No ice crystal formation
Pathophysiology –
Freeze-Thaw Phase
 Temperatures between -6oC and -15oC
 Ice crystals form intracellularly (rapid freeze)
and/or extracellularly (slow freeze)
 Cellular damage
 Thawing initiates reperfusion injury and
inflammatory response
Pathophysiology –
Vascular Stasis Phase
 Vessels alternate between constriction and
dilation
 Blood leaks from vessels or coagulates within
them
Pathophysiology –
Late Ischemic Phase
 Ongoing reperfusion injury
 Inflammatory cascade
 Intermittent vasoconstriction
 Microvascular emboli/macrovascular thrombi
 Progressive tissue ischemia and infarction
Pathophysiology
 Mechanisms of Tissue Damage:
 Cellular injury
 Tissue ischemia
 Inflammatory mediator release
Pathophysiology –
Cellular Injury
 Extracellular and intracellular ice crystal formation
 1) Extracellular ice increases extracellular oncotic pressure
 Water moves out of cells
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Cellular electrolyte, pH shifts
Cellular dehydration
Protein and lipid derangement
Cell membrane lysis
 2) Intracellular ice causes disruption of cell membranes
 With thawing, tissue edema ensues
***Cellular necrosis***
Pathophysiology –
Tissue Ischemia
 Local vasoconstriction
 Increased blood viscosity
 Microvascular damage
 Endothelial disruption
 Transcapillary plasma loss
 Edema
 Further limitation of blood flow
 Endothelial damage  microthrombi formation
 Freeze-thaw-refreeze increases severity of
thrombosis and ischemia
 Immediately after thawing  blood flows freely
 Five-ten minutes post-thaw  blood begins to
sludge
 Clot
 Ischemia
 Necrosis
 Frostbitten skin from rabbit ear transplanted
autogenously to normal ear
 Normal skin transplanted to frozen area
 Frostbitten skin survived on normal tissue bed
 Normal skin necrosed on frostbitten bed
Weatherly-White RCA, Sjostrom B, Paton BC. Experimental Studies in Cold Injury. Journal of Surgical Research;
1964 (Jan): Vol. IV, No. 1.
Pathophysiology - Inflammatory
Mediator Release
 Secondary effect of pro-inflammatory cytokine
release
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Thromboxane A2
Prostaglandin F2-alpha
Bradykinin
Histamine
Found in frostbite blister fluid
 Exacerbates cellular damage
 Causes further ischemia
 Vasoconstriction
 Platelet aggregation
 Blood vessel thrombosis
 Tissue frozen and thawed twice sustained greater
injury
 Double 3-min freezes caused more damage than a
continuous 6-minute freeze
Hardenbergh E, Ramsbottom R. Experimental Frostbite: The Effect of “Double Freeze” on
Tissue Survival in the Mouse Foot. Cryobiology, Vol. 5, No. 5, 1969
Reamy BV.Frostbite: Review and Current Concepts. Journal of American Board of
Family Practice, Jan. – Feb. 1998, Vol. 11, No. 1
Classifying Frostbite
Frostnip
 Superficial non-freezing cold injury
 Tends to occur on exposed skin
 Ears, cheeks, nose
 Intense vasoconstriction
 Ice crystals (frost) form on skin surface
 Indicates favorable conditions for frost bite
***DOES NOT EQUAL FROSTBITE***
***RESULTS IN NO TISSUE LOSS***
***NO LONG-TERM SEQUELAE***
First-degree Frostbite
 White or yellow firm, slightly raised plaque
 Numbness
 No gross tissue infarction
 Slight epidermal sloughing
 Mild edema
Second-degree Frostbite
 Superficial skin vesiculation
 Clear or milky fluid in blisters
 Surrounding erythema and edema
Third-degree Frostbite
 Deeper, hemorrhagic blisters
 Injury has extended into reticular dermis and
dermal vascular plexus
Fourth-degree Frostbite
 Extends through the dermis
 Involves subcutaneous tissues
 Necrosis extending into muscle and to bone
Two-Tiered Classification System
 Better in the field
 More of a clinical diagnosis
 Superficial frostbite
 Deep frostbite
Superficial Frostbite
 No or minimal anticipated tissue loss
 Corresponds with 1st- and 2nd-degree injury
 Treat conservatively
 Favorable prognostic factors:
 Retained sensation
 Normal skin color
 Clear blisters
 Blisters only in distal phalanges
Deep Frostbite
 Deeper injury and anticipated tissue loss
 Corresponds with 3rd- and 4th-degree injury
 Requires aggressive management
 Poor prognostic features:
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Nonblanching cyanosis
Absent Doppler pulses
Firm skin
Dark, fluid-filled (hemorrhagic) blisters
 OR
 Little or no blister formation (even worse)
Prevention
 Pathophysiology told us that tissue perfusion
has to exceed heat loss…
 Maintain peripheral perfusion
 Blood flow = heat
 Allow heat to get to tissues
 Protection from the cold
 Prevent heat loss
Maintaining Peripheral Perfusion
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Maintain core temperature
Hydration
Adequate nutrition
Minimize effects of known diseases or perfusionlimiting drugs (including smoking)
Cover skin – prevent vasoconstriction
Prevents restriction to blood flow
Prevent hypoxemia with supplemental O2 if needed
Exercise*
 Raises core temperature and causes vasodilation
 *Leads to exhaustion
Protection from the Cold
 Protect skin
 Emollients DO NOT protect skin & actually increase risk
 Avoid perspiration or wet extremities
 Increase insulation & skin protection – layers
 Avoid alcohol/drugs/hypoxemia
 Allows you to respond behaviorally to changing conditions
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Use chemical hand and foot warmers, electric foot warmers
Perform “cold checks”
Recognize frostnip & superficial frostbite early
Minimize duration of cold exposure
Avoid environmental conditions favorable for frostbite
Weather Conditions & Frostbite
 Ambient air temperature
 Frost nip doesn’t 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
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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
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24 young, healthy male subjects (med students)
Placed in a climatic chamber
4 emolients tested on ½ 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
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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 (37-39oC)
 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
Hospital Management of Frostbite
 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)
 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
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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.
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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.
Hospital Management of Frostbite
 Vasodilator therapy
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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
L Hand
R Hand
tPA 1mg/hr
Heparin 500u/hr
24 Hrs
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 4th 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
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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
•Treat
hypothermia
or trauma
•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
Mimickers of Frostbite
 Chilblains/Pernio
 Trench Foot
 Raynaud’s 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:
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Anesthesia
Edema
Parasthesias
Anhydrosis
Muscluar atrophy
Ulceration
Gangrene
 Long-term Sequellae:
 Hypersensitivity to cold and weight bearing
Raynaud’s Phenomenon
 Epidemiology
 2% of the population
 Pathophysiology
 Episodic reduction in peripheral blood flow
 Cold exposure
 Stress
Raynaud’s 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
References
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Arias-Santiago SA, Giron-Prieto MS, Callejas-Rubio JL, Fernandez-Pungnaire MA, Ortega-Centeno
N. Lupus Pernio or Chilblain Lupus?: Two Different Entities. Chest 2009; 136: 946-947.
Beitner R, Chen-Zion M, Sofer-Bassukevitz, Morgenstern H, Ben-Porat H. Treatment of Frostbite
with the Calmodulin Antagonists Thioridazine and Trifluoperazine. Gen. Pharmac. Vol. 20, No. 5,
pp. 641-646, 1989.
Biem J, Keohncke N, Classen D, Dosman J. Out of the cold: management of hypothermia and
frostbite. Canadian Medical Association Journal, February 4, 2003; 168 (3).
Bilgic S, Ozkan H, Ozenc S, Safaz I, Yildiz C. Treating frostbite. Canadian Family Physician 2008;
54: 361-3.
Bird D. Identification and Management of Frostbite Injuries. Emergency Nurse; Dec 1999-Jan
2000; 7, 8; pg. 17.
Bourne MH, Piepkorn MW, Clayton F, Leonard LG. Analysis of Microvascular Changes in
Frostbite Injury. Journal of Surgical Research, 40, 26-35 (1986).
Bouwman DL, Morrison S, Lucas CE, Ledgerwood AM. Early Sympathetic Blockade for Frostbite
– Is it of Value? The Journal of Trauma, Vol 20, No 9, September 1980.
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.
Bruen KJ, Gowski WF. Treatment of Digital Frostbite: Current Concepts. Journal of Hand Surgery
2009 (March); Vol 34A, pp. 553-554.
Cauchy E, Cheguillaume B, Chetaille E. A Controlled Trial of a Prostacyclin and rt-PA in the
Treatment of Severe Frostbite. New England Journal of Medicine 2011; 364:2, 189-190.
References
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