Bleeding Complications in Patients With Severe Frostbite Injury

Abstract

Frostbite is caused by exposure to cold temperatures and can lead to severe injury resulting in amputations. Tissue plasminogen activator (tPA) is a thrombolytic agent that has demonstrated efficacy preventing amputation in frostbite patients. The goal of frostbite management with tPA is to salvage tissue without causing clinically significant bleeding complication. The purpose of this study was to characterize bleeding complications in severe frostbite patients managed with and without tPA. Retrospective chart review of severe frostbite patients admitted to a single ABA verified burn center. Bleeding events were grouped: category 0: no bleed; category 1: bleed not resulting in change or intervention; category 2: bleed resulting in change of management; and category 3: bleed resulting in change of management and intervention. Over a 7-year period, 188 patients were included in the study. Most patients had no documentation suggesting a bleeding complication; 69.7% category 0, 19.1% category 1, 4.8% category 2, and 6.4% category 3. There was no significant difference in category 2 or 3 bleeding complications between patients treated with or without tPA. Overall, 9 of the 143 patients (6.3%) treated with tPA had a category 2 or 3 bleeding complication within 12 hours of tPA completion and 12 of 143 (8.4%) within 24 hours of tPA completion. Based on the low risk of severe bleeding and significant benefit relative to limb or digit salvage demonstrated in this study, we conclude that tPA is safe and effective for the treatment of frostbite in appropriately selected patients.

Frostbite treatment: a systematic review with meta-analyses

“…Use of thrombolytics is associated with a risk of hemorrhage. A study of bleeding complications in patients with severe frostbite treated using intravenous tPA found that 8% of patients developed bleeding that necessitated changes in management [ 42 ].…”

Iloprost for the treatment of frostbite: a scoping review

“…In the early 1990s, the Hennepin County Medical Center in Minneapolis piloted the use of thrombolytics in the treatment of frostbite [ 12 ]. Thrombolytics or recombinant tissue plasminogen activators (rtPA) work by binding to fibrin in a thrombus and activating plasminogen, which causes local fibrinolysis and prevents enlargement of blood clots in frostbitten extremities [ 13 ]. Several thrombolytics, mainly alteplase, have been used in the treatment of frostbite with over 15 published studies, totalling over 300 patients [ 4 , 14 ].…”

“…Thrombolytics carry a risk of bleeding and haemorrhage. In a recent study detailing bleeding complications in severe frostbite patients treated with intravenous alteplase, 8.4% of patients had bleeding resulting in change of management or intervention [ 13 ].…”