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DEPARTMENT OF SURGERY




Coming in from the cold:
Management of Frostbite
  Amalia Cochran, MD, FACS
 Assistant Professor of Surgery
 Department of Surgery Grand
            Rounds
        16 March 2011
DEPARTMENT OF SURGERY




Disclosures
• None, other than cohabiting with a
  Siberian husky dog
DEPARTMENT OF SURGERY



Objectives
At the conclusion of this talk, attendees will be able to:
• Provide appropriate post-thaw management of frostbite
• Explain management options for acute (<24 hours)
   frostbite
• Describe management options for frostbite with
   delayed presentation
• Recognize the role and timing of surgery in the
   management of frostbite
• Understand rehabilitation after frostbite injury
DEPARTMENT OF SURGERY




A brief history of frostbite

    (From a mostly military
         perspective)
DEPARTMENT OF SURGERY



2nd   Punic War
• 218 BC
• Hannibal lost nearly
  half of his 46,000
  troops crossing the
  Alps
DEPARTMENT OF SURGERY



Revolutionary War
               • Washington lost 10% of
                 his troops in Winter,
                 1778
DEPARTMENT OF SURGERY



Napoleonic siege of Moscow
• Winter 1812
• Baron Dominique
  Jean Larrey
• First systematic
  medical observations
  on frostbite
• Friction + slow
  rewarming were SOC
  for >100 years
DEPARTMENT OF SURGERY




Alaska- 1925
• ==           • Bill Shannon-
                 Frostbite to face
               • Charlie Olson-
                 Frostbitten hands
               • Teams covered 675
                 miles in 127.5 hours
                 in windchill often
                 below -50 and
                 whiteout conditions
DEPARTMENT OF SURGERY



20th   Century Developments
• Germans and Russians begin rapid
  rewarming
  – Kirov Institute work in the 1930s
  – Translated into English post-WWII
• Winter 1941- Germans sustain >250K
  frostbite injuries attempting to take
  Moscow
DEPARTMENT OF SURGERY



20th   Century Developments
• 1960- Mills (Alaska) published first major
  series using rapid rewarming
• 1966- Meryman publishes Cryobiology,
  which includes scientific bases for
  frostbite injury
DEPARTMENT OF SURGERY




Some basic definitions
DEPARTMENT OF SURGERY



Superficial frostbite
•   “First and second degree"
•   Clear vesicles
•   Limited, if any, dermal involvement
DEPARTMENT OF SURGERY




Superficial frostbite
DEPARTMENT OF SURGERY



Deep frostbite
•   “Third and fourth degree"
•   Hemorrhagic vesicles
•   Subdermal injury
•   May include injury to level of tendon and bone
•   Development of thick black eschar over 1-2
    weeks following injury
DEPARTMENT OF SURGERY




Deep frostbite
DEPARTMENT OF SURGERY



Acute v. delayed presentation
• Acute
  o Presentation to definitive care within 24 hours post-
    thaw
• Delayed
  o Presentation >24 hours post-thaw (or much, much
    later)
DEPARTMENT OF SURGERY




Post-thaw management

    Basic Principles
DEPARTMENT OF SURGERY



Timing of evaluation
• Evaluation of severity/ depth of injury does not occur
  until rewarming is complete
   o Rewarming results in near-complete resolution of
     symptoms and findings with frostnip
   o Clinical appearance of true frostbite evolves over
     time
        Skin blebs may take hours to days to develop
DEPARTMENT OF SURGERY



To debride, or not to debride
•   Pros
      o High levels of PGF 2α andTXB2 in blister fluid
      o Decreased levels of PGE2 in blister fluid
      o Chemokine milieu results in progressive dermal
        ischemia
•   Cons
      o Hemorrhage results from damage to subdermal
        structures
      o Debridement might exacerbate damage to soft
        tissues
DEPARTMENT OF SURGERY



Visual assessment of tissues
DEPARTMENT OF SURGERY



Basic care
• Meticulous wound care and blockade of the
  inflammatory response
   o Gentle daily cleansing*
   o Mechanical protection with padding/ splints/
      elevation
   o Topical aloe vera with meticulous mechanical
      protection*
        Interrupts arachadonic acid pathway


* Heggers, Ann Emerg Med, 1987; Mohr, Hand Clin, 2009
DEPARTMENT OF SURGERY



Antibiotics
• Prophylactic antibiotics?
   o Generally, no
   o Exception: Severe edema
       Increased permeability to skin flora = increased
        likelihood of soft tissue infection
• Antibiotics should be initiated if cellulitis is present or if
  obvious conversion to wet gangrene
DEPARTMENT OF SURGERY



How I do it
• Debridement of blisters
• Topical aloe gel
• No prophylactic antibiotics in absence of remarkable
  edema
DEPARTMENT OF SURGERY




Non-surgical therapies for
        frostbite
DEPARTMENT OF SURGERY



Pharmacologic management
 o Ibuprofen
      Specific blockade of TXA2
 o Pentoxyfilline
      Improves red blood cell deformability
      Decreases blood viscosity
      May work synergistically with aloe vera
      400 mg TID X 2-6 weeks
 o Iloprost****
      Prostacyclin analogue with vasodilatory
       properties
      Not available in the U.S.
DEPARTMENT OF SURGERY




Pain management
• Narcotics are appropriate
  – Post-thaw areas of frostbite are painful
• Ongoing risk of neuropathic pain
  – May persist for months to years
  – Not always associated with amputations
  – GABA analogues (e.g. Gabapentin)
DEPARTMENT OF SURGERY



Hyperbaric oxygen
• Extremely limited but promising data
• One series, one case report with delayed
  presentations*
  • Both with good functional outcomes
• Success with delayed presentations +
  good functional outcomes= provocative
  • Need for multicenter trials
 *Ward, Proc R Soc Med, 1968; von Heimburg, Burns, 2001
DEPARTMENT OF SURGERY




  Imaging

What and when?
DEPARTMENT OF SURGERY



Scintigraphy
• Long-standing evidence of correlation of 48-hour
  findings with outcomes*
   o Perfusion and blood-pooling phases demonstrate
     at-risk tissue areas
   o Bone phase shows deep tissue and bone infarction
• Excellent correlation between scintigraphic findings
  and surgical needs in multiple studies#
   o Some favor bone scans 7-10 days post-injury


*Mehta and Wilson, Radiology, 1989; Salimi, AJR, 1984
# Cauchy, J Hand Surg Am, 2000; Cauchy, Eur J Nuc Med, 2000
DEPARTMENT OF SURGERY



Scintigraphy and surgical timing
• Protocols for scintigraphy followed by early surgery
• Greenwald
  o Early scintigraphy with operation 7-10 days post-
    injury
• Cauchy
  o Early scintigraphy (days 2-7) with operation 10-15
    days post-injury
• Rationale:
  o Decreases waiting time for patients
  o Decreases infection risk in gangrenous digits
  o Expedites rehabilitation

 Greenwald, PRS, 1998; Cauchy, J Hand Surg Am, 2000
DEPARTMENT OF SURGERY



Scintigraphy
DEPARTMENT OF SURGERY



MRI/ MRA
• Early study showed possible advantages over 99Tc
  scans*
   o Direct visualization of occluded vessels
   o ?Better delineation of viable tissue
• Subsequent study less favorable#
   o Limited soft-tissue in digits hampers utility
   o MRI/MRA no better than 99Tc scanning for
     delineation of amputation sites

*Barker, Ann Plastic Surg, 1997
#Murphy, J Trauma, 2000
DEPARTMENT OF SURGERY



Angiography
• Primarily used to evaluate candidacy for thrombolytic
  therapy
• Risks associated with arterial access, invasive study
DEPARTMENT OF SURGERY




30-year-old male
DEPARTMENT OF SURGERY



Thrombolytics
• First demonstration of possible utility more than 20
  years ago*
   o Animal model, IV urokinase
• Minneapolis and Utah data#
   o Improved digit salvage with t-PA when administered
     within 24 hours of thaw
   o Limited data, retrospective controls
   o ? Functional outcomes


* Zdeblick, J Hand Surg Am, 1988
# Bruen, Arch Surg, 2007; Twomey, J Trauma, 2005
DEPARTMENT OF SURGERY



Angiography- Left Foot
     Pre t-PA        Post t-PA
DEPARTMENT OF SURGERY



Angiography- Right Foot
     Pre t-PA        Post t-PA
DEPARTMENT OF SURGERY



How we do it
• Scintigraphy for delayed presentations with at-risk
  digits
   o During first week after injury if possible
• Angiography for at-risk digits, hands, feet
   o Less than 24 hours post-thaw
   o Risks of thrombolytics vs. risks of digital loss
   o Requires ICU monitoring capabilities
DEPARTMENT OF SURGERY




Newest publication
• Controlled trial of Prostacyclin + t-PA
• 47 patients
  – Blufomedil + aspirin only (controls)
  – Prostacyclin + control mgmt
  – Prostacyclin + t-PA + control mgmt
• Proximal lesions more common in
  prostacyclin/ TPA group
Cauchy, NEJM, January 13, 2011
DEPARTMENT OF SURGERY



Number of Amputated Digits (Fingers or Toes) According to Treatment, Severity of Frostbite,
                                and Time to Treatment.




Cauchy E et al. N Engl J Med 2011;364:189-190.
DEPARTMENT OF SURGERY




Surgical Management of
       Frostbite
DEPARTMENT OF SURGERY



A few key principles
• Historical data demonstrated worse
  outcomes with early surgery*
• Greenwald and Cauchy protocols
  (described above) for early intervention
    – Limited use to date
• Most surgeons await demarcation of
  tissues, delaying for weeks to months#
* Mills, Alaska Med, 1993
# Jurkovich, Surg Clinics North Am, 2007; Mohr, Hand Clin, 2009
DEPARTMENT OF SURGERY




Options at present
• Early surgical intervention, guided by
  bone scan vs.
• Use of clinical findings to guide delayed
  surgical intervention (4 weeks to 3
  months post-injury)
DEPARTMENT OF SURGERY



8 weeks post-injury
DEPARTMENT OF SURGERY



3 months post-amputation
DEPARTMENT OF SURGERY




Rehabilitation
DEPARTMENT OF SURGERY



Loss of fingers
• Functional compensation for missing
  fingertips or digits
• Loss of thumb (opposition) is most
  devastating functionally
• Prosthetics are mostly cosmetic
• Toe transfer or pollicization of index
  finger are complex surgical options
DEPARTMENT OF SURGERY



Toe transfer




Photo, National University Hospital Hand Microsurgery, Singapore
DEPARTMENT OF SURGERY



Loss of toes
• Great toe amputation
  may require custom
  orthotic because of
  changes in weight
  loading to the foot
• Transmetatarsal
  amputation also may
  require “fillers”
DEPARTMENT OF SURGERY



Limb amputations
• Most commonly at level of forearm or
  below knee (transtibial)
• Functional amputations
  – Amenable to prostheses
     • Myoelectric hand/ arm
  – Not necessarily lifestyle limiting
DEPARTMENT OF SURGERY



Extremity prostheses
DEPARTMENT OF SURGERY



Summary
• Basic management involves wound care,
  padding, pain management
• Adjuncts includethrombolytics,
  hyperbaric,prostacyclin
• Rehabilitation is readily possible
• Need for frostbite registry or multicenter
  trials
DEPARTMENT OF SURGERY




A satisfactory outcome
DEPARTMENT OF SURGERY




Questions?

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Frostbite Grand Rounds- 2011

  • 1. DEPARTMENT OF SURGERY Coming in from the cold: Management of Frostbite Amalia Cochran, MD, FACS Assistant Professor of Surgery Department of Surgery Grand Rounds 16 March 2011
  • 2. DEPARTMENT OF SURGERY Disclosures • None, other than cohabiting with a Siberian husky dog
  • 3. DEPARTMENT OF SURGERY Objectives At the conclusion of this talk, attendees will be able to: • Provide appropriate post-thaw management of frostbite • Explain management options for acute (<24 hours) frostbite • Describe management options for frostbite with delayed presentation • Recognize the role and timing of surgery in the management of frostbite • Understand rehabilitation after frostbite injury
  • 4. DEPARTMENT OF SURGERY A brief history of frostbite (From a mostly military perspective)
  • 5. DEPARTMENT OF SURGERY 2nd Punic War • 218 BC • Hannibal lost nearly half of his 46,000 troops crossing the Alps
  • 6. DEPARTMENT OF SURGERY Revolutionary War • Washington lost 10% of his troops in Winter, 1778
  • 7. DEPARTMENT OF SURGERY Napoleonic siege of Moscow • Winter 1812 • Baron Dominique Jean Larrey • First systematic medical observations on frostbite • Friction + slow rewarming were SOC for >100 years
  • 8. DEPARTMENT OF SURGERY Alaska- 1925 • == • Bill Shannon- Frostbite to face • Charlie Olson- Frostbitten hands • Teams covered 675 miles in 127.5 hours in windchill often below -50 and whiteout conditions
  • 9. DEPARTMENT OF SURGERY 20th Century Developments • Germans and Russians begin rapid rewarming – Kirov Institute work in the 1930s – Translated into English post-WWII • Winter 1941- Germans sustain >250K frostbite injuries attempting to take Moscow
  • 10. DEPARTMENT OF SURGERY 20th Century Developments • 1960- Mills (Alaska) published first major series using rapid rewarming • 1966- Meryman publishes Cryobiology, which includes scientific bases for frostbite injury
  • 11. DEPARTMENT OF SURGERY Some basic definitions
  • 12. DEPARTMENT OF SURGERY Superficial frostbite • “First and second degree" • Clear vesicles • Limited, if any, dermal involvement
  • 14. DEPARTMENT OF SURGERY Deep frostbite • “Third and fourth degree" • Hemorrhagic vesicles • Subdermal injury • May include injury to level of tendon and bone • Development of thick black eschar over 1-2 weeks following injury
  • 16. DEPARTMENT OF SURGERY Acute v. delayed presentation • Acute o Presentation to definitive care within 24 hours post- thaw • Delayed o Presentation >24 hours post-thaw (or much, much later)
  • 17. DEPARTMENT OF SURGERY Post-thaw management Basic Principles
  • 18. DEPARTMENT OF SURGERY Timing of evaluation • Evaluation of severity/ depth of injury does not occur until rewarming is complete o Rewarming results in near-complete resolution of symptoms and findings with frostnip o Clinical appearance of true frostbite evolves over time  Skin blebs may take hours to days to develop
  • 19. DEPARTMENT OF SURGERY To debride, or not to debride • Pros o High levels of PGF 2α andTXB2 in blister fluid o Decreased levels of PGE2 in blister fluid o Chemokine milieu results in progressive dermal ischemia • Cons o Hemorrhage results from damage to subdermal structures o Debridement might exacerbate damage to soft tissues
  • 20. DEPARTMENT OF SURGERY Visual assessment of tissues
  • 21. DEPARTMENT OF SURGERY Basic care • Meticulous wound care and blockade of the inflammatory response o Gentle daily cleansing* o Mechanical protection with padding/ splints/ elevation o Topical aloe vera with meticulous mechanical protection*  Interrupts arachadonic acid pathway * Heggers, Ann Emerg Med, 1987; Mohr, Hand Clin, 2009
  • 22. DEPARTMENT OF SURGERY Antibiotics • Prophylactic antibiotics? o Generally, no o Exception: Severe edema  Increased permeability to skin flora = increased likelihood of soft tissue infection • Antibiotics should be initiated if cellulitis is present or if obvious conversion to wet gangrene
  • 23. DEPARTMENT OF SURGERY How I do it • Debridement of blisters • Topical aloe gel • No prophylactic antibiotics in absence of remarkable edema
  • 24. DEPARTMENT OF SURGERY Non-surgical therapies for frostbite
  • 25. DEPARTMENT OF SURGERY Pharmacologic management o Ibuprofen  Specific blockade of TXA2 o Pentoxyfilline  Improves red blood cell deformability  Decreases blood viscosity  May work synergistically with aloe vera  400 mg TID X 2-6 weeks o Iloprost****  Prostacyclin analogue with vasodilatory properties  Not available in the U.S.
  • 26. DEPARTMENT OF SURGERY Pain management • Narcotics are appropriate – Post-thaw areas of frostbite are painful • Ongoing risk of neuropathic pain – May persist for months to years – Not always associated with amputations – GABA analogues (e.g. Gabapentin)
  • 27. DEPARTMENT OF SURGERY Hyperbaric oxygen • Extremely limited but promising data • One series, one case report with delayed presentations* • Both with good functional outcomes • Success with delayed presentations + good functional outcomes= provocative • Need for multicenter trials *Ward, Proc R Soc Med, 1968; von Heimburg, Burns, 2001
  • 28. DEPARTMENT OF SURGERY Imaging What and when?
  • 29. DEPARTMENT OF SURGERY Scintigraphy • Long-standing evidence of correlation of 48-hour findings with outcomes* o Perfusion and blood-pooling phases demonstrate at-risk tissue areas o Bone phase shows deep tissue and bone infarction • Excellent correlation between scintigraphic findings and surgical needs in multiple studies# o Some favor bone scans 7-10 days post-injury *Mehta and Wilson, Radiology, 1989; Salimi, AJR, 1984 # Cauchy, J Hand Surg Am, 2000; Cauchy, Eur J Nuc Med, 2000
  • 30. DEPARTMENT OF SURGERY Scintigraphy and surgical timing • Protocols for scintigraphy followed by early surgery • Greenwald o Early scintigraphy with operation 7-10 days post- injury • Cauchy o Early scintigraphy (days 2-7) with operation 10-15 days post-injury • Rationale: o Decreases waiting time for patients o Decreases infection risk in gangrenous digits o Expedites rehabilitation Greenwald, PRS, 1998; Cauchy, J Hand Surg Am, 2000
  • 32. DEPARTMENT OF SURGERY MRI/ MRA • Early study showed possible advantages over 99Tc scans* o Direct visualization of occluded vessels o ?Better delineation of viable tissue • Subsequent study less favorable# o Limited soft-tissue in digits hampers utility o MRI/MRA no better than 99Tc scanning for delineation of amputation sites *Barker, Ann Plastic Surg, 1997 #Murphy, J Trauma, 2000
  • 33. DEPARTMENT OF SURGERY Angiography • Primarily used to evaluate candidacy for thrombolytic therapy • Risks associated with arterial access, invasive study
  • 35. DEPARTMENT OF SURGERY Thrombolytics • First demonstration of possible utility more than 20 years ago* o Animal model, IV urokinase • Minneapolis and Utah data# o Improved digit salvage with t-PA when administered within 24 hours of thaw o Limited data, retrospective controls o ? Functional outcomes * Zdeblick, J Hand Surg Am, 1988 # Bruen, Arch Surg, 2007; Twomey, J Trauma, 2005
  • 36. DEPARTMENT OF SURGERY Angiography- Left Foot Pre t-PA Post t-PA
  • 37. DEPARTMENT OF SURGERY Angiography- Right Foot Pre t-PA Post t-PA
  • 38. DEPARTMENT OF SURGERY How we do it • Scintigraphy for delayed presentations with at-risk digits o During first week after injury if possible • Angiography for at-risk digits, hands, feet o Less than 24 hours post-thaw o Risks of thrombolytics vs. risks of digital loss o Requires ICU monitoring capabilities
  • 39. DEPARTMENT OF SURGERY Newest publication • Controlled trial of Prostacyclin + t-PA • 47 patients – Blufomedil + aspirin only (controls) – Prostacyclin + control mgmt – Prostacyclin + t-PA + control mgmt • Proximal lesions more common in prostacyclin/ TPA group Cauchy, NEJM, January 13, 2011
  • 40. DEPARTMENT OF SURGERY Number of Amputated Digits (Fingers or Toes) According to Treatment, Severity of Frostbite, and Time to Treatment. Cauchy E et al. N Engl J Med 2011;364:189-190.
  • 41. DEPARTMENT OF SURGERY Surgical Management of Frostbite
  • 42. DEPARTMENT OF SURGERY A few key principles • Historical data demonstrated worse outcomes with early surgery* • Greenwald and Cauchy protocols (described above) for early intervention – Limited use to date • Most surgeons await demarcation of tissues, delaying for weeks to months# * Mills, Alaska Med, 1993 # Jurkovich, Surg Clinics North Am, 2007; Mohr, Hand Clin, 2009
  • 43. DEPARTMENT OF SURGERY Options at present • Early surgical intervention, guided by bone scan vs. • Use of clinical findings to guide delayed surgical intervention (4 weeks to 3 months post-injury)
  • 44. DEPARTMENT OF SURGERY 8 weeks post-injury
  • 45. DEPARTMENT OF SURGERY 3 months post-amputation
  • 47. DEPARTMENT OF SURGERY Loss of fingers • Functional compensation for missing fingertips or digits • Loss of thumb (opposition) is most devastating functionally • Prosthetics are mostly cosmetic • Toe transfer or pollicization of index finger are complex surgical options
  • 48. DEPARTMENT OF SURGERY Toe transfer Photo, National University Hospital Hand Microsurgery, Singapore
  • 49. DEPARTMENT OF SURGERY Loss of toes • Great toe amputation may require custom orthotic because of changes in weight loading to the foot • Transmetatarsal amputation also may require “fillers”
  • 50. DEPARTMENT OF SURGERY Limb amputations • Most commonly at level of forearm or below knee (transtibial) • Functional amputations – Amenable to prostheses • Myoelectric hand/ arm – Not necessarily lifestyle limiting
  • 52. DEPARTMENT OF SURGERY Summary • Basic management involves wound care, padding, pain management • Adjuncts includethrombolytics, hyperbaric,prostacyclin • Rehabilitation is readily possible • Need for frostbite registry or multicenter trials
  • 53. DEPARTMENT OF SURGERY A satisfactory outcome

Editor's Notes

  1. T. Willey Angios