FrostbitePerils and Pearls

Joy Boyd RN BNAbby MacLeod PT

2013-01-26

Foreword

� No financial or ethical conflicts to declare

� Please mute cellphones

Frostbite

Horrendous Injuries with

Limb Involvement

What is Frostbite?� Defined as the damage sustained by tissues subjected

to temperatures below their freezing point (-0.5 to -2 degrees C.) (Mohr)

� Superficial: injures the skin and tissues just underneath, and usually does not cause permanent injury

� Deep: damages muscle, nerves, vasculature and bone. Causes tissue death, mummification, and usually results in auto- or surgical amputation

Pathophysiology� Pre-frostbite stage is called frost-nip, where the vessels

react between vasodilation and vasoconstriction in response to the cold insult. It is painful, but reversible upon rewarming.

� Progresses to deeper tissue cell injury when ice crystals form in the extra-cellular spaces, then into the actual cells and microvasculature.

� Intravascular intimal damage is followed by the formation of microemboli. Vascular flow is occluded.

� Inflammatory mediators are released, causing edema, blistering, spasm, loss of movement and sensation. (Mohr et al)

Who� Adult men age 30-49 are most commonly affected� ETOH/Drug users� Homeless � Military personnel� Outdoor workers and enthusiasts (hunters, Nordic skiers etc)� High altitude climbers� Mentally ill/challenged� Those in unforeseen circumstances (vehicle breakdown)� Those with no common sense (teens who value their “coolness”

over safety) (Spears)

� The unacclimatised, inexperienced (Mohr et al)

Factors Affecting Incidence� Clothing or lack thereof � ETOH/ Drug influence� Lack of shelter (Hallam et al)� Malnourishment/Dehydration� Low O2 sats from COPD or high altitude� Diabetes, PVD, Raynaud’s, neuropathy, paraplegia etc (Akhtar et al)

� Tight, wet clothing� High wind chill, duration in the cold (Twomey et al)

� Medications- beta blockers, sedatives etc� Growing participation in winter-related outdoor activities

What gets bitten?� Extremities are most susceptible sites ~90%

� Ears, nose, cheeks, forehead, penis (Mohr, Imray et al)

Clinical Signs and Symptoms� Frost-nip: intact sensation, with prickly, burning, itching

pain described, with no blistering in rewarmed state

� Second degree: edema, clear to milky blisters

� Third degree: deep injury (subdermal plexus destruction) resulting in hemorrhagic blisters; skin is deep purpley-red, soft and boggy; sensation is decreased; edematous

� Fourth degree: skin is mottled, waxy, cyanotic, insensate, infarcted areas mummify (Mohr)

Frostnipped Toes

Second Degree

Frostbite to Cheeks

Necrotic Fingers

Mummified Toes

Thick Eschar Toe

Treatment pre-ER� Do not use snow or ice to thaw� Never rub or massage the areas involved� Do not use hot water bottles, open fires or heaters

to thaw� Remove jewelry� Do not allow re-freezing� Do wrap in warm blanket� Give warm fluid drinks, ASA or Ibuprofen� Offload/elevate

ER Assessment� Location of frostbite� When/where/how/duration of exposure� Describe appearance of lesions, draw pictures in

chart� Too soon to estimate the degree of damage in ER! � Tetanus status� Medical history/allergies� Predisposing factors

Treatment in ER� Priority is to melt the ice crystals, re-perfuse the limb, tenuate the

inflammatory cascade that causes reperfusion (Mohr)

� Rapid rewarming in 40-42 degree water for ~ 30 minutes will bring hyperemic flush to the area. Hydrotherapy or warm water basins/ wet towels best (Gabriel)

� Assess pulse response with Doppler� Provide adequate analgesia for the severe pain that ensues� Td booster� Blister debridement (or not----controversial). Leave hemorrhagic

intact. (Mechem)

� +/- Silver dressings, silicone non-stick, loose wraps/padding and offload

� All patients should be referred to Burn Clinic

Warm Water Immersion

Treatment post-ER� Sympathectomy: not a first-line treatment except in well-

selected patients. Iloprost has superseded this� Hyperbaric Oxygen: no benefit until 5-10 days post-

thaw, so not recommended� Anti-thrombotics-several US centres report a 75%

success digit salvage rate (Mohr, Hallam)

� Hospitalization/burn physio for lesion treatments� Surgery* � Long-term physio/debilitation requirements� Psychological evaluation

Hemorrhagic Blister

Clear Blisters

Clear Blisters

Hyperemia Post-Thaw

Frostbite to Sole

Mixed Blister Typesclear and hemorrhagic

DI Investigations� Tc Bone scintiscan is an accurate predictor of

potential digit loss (Twomey et al)

� Angiogram

� MRA, MRI (Chauchy et al)

� Doppler US to determine need for fasciotomy

Medications � ASA� Pentoxifylline (Trental)� Topical aloe vera gel (antiprostaglandin effect)� Ketorolac gel� Narcotics� Ibuprofen� IA Papaverine/tPA/TNK/Nitroglycerine * � Heparin/Warfarin� Iloprost

Frostbite Patients� At FMC are managed by the Burn Team

� Requiring hospitalization are admitted to the burn unit

� Who can be managed at home are seen in the Burn Clinic for serial consistent care

Referrals� From ERs, Urgent Care Centres

� Walk-in clinics

� Family physicians

� Rural and outlying centres

� Self referrals

Multi-disciplinary Team� Doctors� Nurses� Occupational

Therapists� Physiotherapists� Psychologists� Social Workers� Prosthetists/Orthotists

Assessment and Documentation in Burn Clinic

� Review of event, progression of symptoms, and interventions to date

� Past medical history, allergies, medications� Risk factors (diabetes, PVD, Smoking)� Location and degree of injury� Wound Care and dressings� Pain management

A and D (cont’d)� ROM, functional assessment for ADLs, IADLs

and hand dominance� Mobility, gait, balance biomechanics and need

for walking aids � Social history and living arrangement� Occupation, recreational, and leisure activities� Wound management

� Controversial i.e., expose vs. dressing, blisters!

Principles of Wound Care� Maintain a moist environment� Manage exudate� Fill dead space� Assess need for antimicrobial cleansing and

dressings� Primary and secondary dressings� Reduce pain and allow movement

Dressing Choices� Silver impregnated*

� Transparent films

� Alginates*

� Foams*

� Cadexomer iodine*

� Silicone coated*

� Collagen Matrix

� Polymeric membrane

� Composite dressings

� Honey impregnated

Sequelae� Pain syndromes� Sensory loss/numbness.

Susceptibility to recurrent frostbite

� Hyperhidrosis� Arthritis. Joint stiffness,

immobility� Amputation/

disfigurement� Disability. Loss of

livelihood

� Nail abnormalities and scarring

� Depression. Addictions. Poverty.

� Need for prosthetics/orthotics. Aids to daily living

� Delayed healing/poorer outcomes in smokers (Doran et al )

Joint Damage

Amputation

Deep Tissue Injury Toe

Necrotic Fingers

Catastrophic LossPost-op Amputation

Mummification of digits

Frostbite Fingers

Case Presentation� Homeless 37 year old male with “weird feelings”

in legs� Vague, unreliable historian� History of cold exposure over past few weeks� Exam

� ++ cold feet, no pulses, no sensation� Compartment syndrome bilaterally. Elevated CK. Bone

scan revealed devascularized bone to mid-calf� Blisters, both intact and broken on feet

Outcome� 4 compartment fasciotomies

� Bilateral below-knee amputation last Sunday

Pre-Amputation

Rehab Physio

Healing Slowly

Prevention/Reduction of Severity of Injury

� Dress for the weather (non-constrictive layers are best)

� Wear hats, mitts, socks and waterproof shoes� Avoid smoking and alcohol� Be aware of the weather forecast� Drive with a safety kit/blankets/candles/phone in

car� Indigents-get into a shelter!� Think twice about going out in cold weather

Even animals are not exempt.

Endword� Frostbite has been a major crippler for centuries, but the

treatment has not improved much over the last few decades. Many products were tried but abandoned as ineffective i.e. Dextran, Heparin, Urokinase, sympathectomy, hyperbaric oxygen etc. (Mohr)

� Thrombolytics are showing some promise, but have not been embraced in Canada

� Outcomes have improved with the use of silver dressings and consistent care in the Burn Clinic

Thank You� Please complete your evaluations.

� Contacts:� joy.boyd@shaw.ca � joy.boyd@albertahealthservices.ca� abby.macleod@albertahealthservices.ca

� Downloads of session at:� http://www.notitia.com/acutewoundcare.html

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Imray C, Oakley E. Cold still kills: Cold-related illnesses in military practice. J R Army Med Corps 2006; 152: 218-222

Stoppler M. emedicinehealth.com/frostbite/article_em.htm 2010

Spears, T. Fashion Sense Outweighs Common Sense Among Some Canadian Teens, Physicians Complain. Can Med Assoc J. Mar 1 1995; 152 (5).

Hallam MJ, Cubison T, Dheansa B, Imray C. Managing Frostbite. BMJ 2010;341:c5864

Akhtar M, Mashood A, Khan M. Frostbite in Gangrene: role of classification. Prof Med J June 2006; 13(2); 284-290

Twomey J, Peltier G, Zera R. An open label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite.J Trauma 2005;59:1350-1355

Jenabzadeh K, Ahrenholz DH. Cold Injury. Hand Clin. 2009; 25(4):481-96.

Mechem C. Emergent Management of Frostbite. www.emedicine.medscape.com/article/770296-overview (2011)

Catlinarcticsurvey.com/2009/03/25/68

Kahn J, Lidove O, Laredo J, Bletry O. Frostbite Arthritis. Ann Rheum Dis 2005;64:966-967.

Doran N, Minassian A, Potenza B. skinandallergynews.com. Mar 1 2008.

Bruen K, Ballard J, Morris S, Cochran A, Edelman L, Saffle J. Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy. Arch Surg 2007:142:546-53

Mohr W, Jenabzadeh K, Ahrenholz D. Cold Injury. Hand Clin 25 (2009) 481-496.

Gabriel V. PM and R specialist in Burns and Polytrauma. Foothills Medical Centre Dec 2012. personal communication.

Chauchy E. The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities: A retrospective study of 92 severe frostbite injuries. J Hand Surgery 2000 Sept; 25 969-78

Bhatnagar A, Sawroop K,Chopra MK,Sinnha N, Kashyap R. Eur J Nucl Med Mol Imaging. Magnetic resonance unmasks frostbite injury. 2000 Feb; 29 (2) 170-5.

Raman SR, Jamil Z, Cogsgrove J. J Emerg Med 2011 May; 28 (5): 450. Barker JR, Haws MJ, Brown RE, Kucan JO, Moore WD. Magnetic resonance imaging of severe frostbite injuries. Ann Plast Surg.1997 Mar; 38(3): 275-9

References (cont’d)