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Frostbite Grand Rounds- 2011

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My 2011 Grand Rounds on Frostbite

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Frostbite Grand Rounds- 2011

  1. 1. DEPARTMENT OF SURGERYComing in from the cold:Management of Frostbite Amalia Cochran, MD, FACS Assistant Professor of Surgery Department of Surgery Grand Rounds 16 March 2011
  2. 2. DEPARTMENT OF SURGERYDisclosures• None, other than cohabiting with a Siberian husky dog
  3. 3. DEPARTMENT OF SURGERYObjectivesAt 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. 4. DEPARTMENT OF SURGERYA brief history of frostbite (From a mostly military perspective)
  5. 5. DEPARTMENT OF SURGERY2nd Punic War• 218 BC• Hannibal lost nearly half of his 46,000 troops crossing the Alps
  6. 6. DEPARTMENT OF SURGERYRevolutionary War • Washington lost 10% of his troops in Winter, 1778
  7. 7. DEPARTMENT OF SURGERYNapoleonic siege of Moscow• Winter 1812• Baron Dominique Jean Larrey• First systematic medical observations on frostbite• Friction + slow rewarming were SOC for >100 years
  8. 8. DEPARTMENT OF SURGERYAlaska- 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. 9. DEPARTMENT OF SURGERY20th 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. 10. DEPARTMENT OF SURGERY20th Century Developments• 1960- Mills (Alaska) published first major series using rapid rewarming• 1966- Meryman publishes Cryobiology, which includes scientific bases for frostbite injury
  11. 11. DEPARTMENT OF SURGERYSome basic definitions
  12. 12. DEPARTMENT OF SURGERYSuperficial frostbite• “First and second degree"• Clear vesicles• Limited, if any, dermal involvement
  13. 13. DEPARTMENT OF SURGERYSuperficial frostbite
  14. 14. DEPARTMENT OF SURGERYDeep 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
  15. 15. DEPARTMENT OF SURGERYDeep frostbite
  16. 16. DEPARTMENT OF SURGERYAcute 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. 17. DEPARTMENT OF SURGERYPost-thaw management Basic Principles
  18. 18. DEPARTMENT OF SURGERYTiming 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. 19. DEPARTMENT OF SURGERYTo 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. 20. DEPARTMENT OF SURGERYVisual assessment of tissues
  21. 21. DEPARTMENT OF SURGERYBasic 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. 22. DEPARTMENT OF SURGERYAntibiotics• 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. 23. DEPARTMENT OF SURGERYHow I do it• Debridement of blisters• Topical aloe gel• No prophylactic antibiotics in absence of remarkable edema
  24. 24. DEPARTMENT OF SURGERYNon-surgical therapies for frostbite
  25. 25. DEPARTMENT OF SURGERYPharmacologic 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. 26. DEPARTMENT OF SURGERYPain 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. 27. DEPARTMENT OF SURGERYHyperbaric 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. 28. DEPARTMENT OF SURGERY ImagingWhat and when?
  29. 29. DEPARTMENT OF SURGERYScintigraphy• 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. 30. DEPARTMENT OF SURGERYScintigraphy 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
  31. 31. DEPARTMENT OF SURGERYScintigraphy
  32. 32. DEPARTMENT OF SURGERYMRI/ 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. 33. DEPARTMENT OF SURGERYAngiography• Primarily used to evaluate candidacy for thrombolytic therapy• Risks associated with arterial access, invasive study
  34. 34. DEPARTMENT OF SURGERY30-year-old male
  35. 35. DEPARTMENT OF SURGERYThrombolytics• 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. 36. DEPARTMENT OF SURGERYAngiography- Left Foot Pre t-PA Post t-PA
  37. 37. DEPARTMENT OF SURGERYAngiography- Right Foot Pre t-PA Post t-PA
  38. 38. DEPARTMENT OF SURGERYHow 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. 39. DEPARTMENT OF SURGERYNewest 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 groupCauchy, NEJM, January 13, 2011
  40. 40. DEPARTMENT OF SURGERYNumber 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. 41. DEPARTMENT OF SURGERYSurgical Management of Frostbite
  42. 42. DEPARTMENT OF SURGERYA 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. 43. DEPARTMENT OF SURGERYOptions 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. 44. DEPARTMENT OF SURGERY8 weeks post-injury
  45. 45. DEPARTMENT OF SURGERY3 months post-amputation
  46. 46. DEPARTMENT OF SURGERYRehabilitation
  47. 47. DEPARTMENT OF SURGERYLoss 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. 48. DEPARTMENT OF SURGERYToe transferPhoto, National University Hospital Hand Microsurgery, Singapore
  49. 49. DEPARTMENT OF SURGERYLoss 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. 50. DEPARTMENT OF SURGERYLimb amputations• Most commonly at level of forearm or below knee (transtibial)• Functional amputations – Amenable to prostheses • Myoelectric hand/ arm – Not necessarily lifestyle limiting
  51. 51. DEPARTMENT OF SURGERYExtremity prostheses
  52. 52. DEPARTMENT OF SURGERYSummary• Basic management involves wound care, padding, pain management• Adjuncts includethrombolytics, hyperbaric,prostacyclin• Rehabilitation is readily possible• Need for frostbite registry or multicenter trials
  53. 53. DEPARTMENT OF SURGERYA satisfactory outcome
  54. 54. DEPARTMENT OF SURGERYQuestions?

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