Reduction of the Incidence of Amputation in Frostbite Injury With Thrombolytic Therapy

Bruen, Kevin J.; Ballard, James; Morris, Stephen; Cochran, Amalia; Edelman, Linda S.; Saffle, Jeffrey R.

doi:10.1001/archsurg.142.6.546

Cited by 167 publications

(90 citation statements)

References 27 publications

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“…These include anticoagulant therapy, hyperbaric oxygen, and improved imaging modalities that quantifies non-viable tissue. [4][5][6][7][8][9] Although these new treatments are promising, the McCauley protocol might be considered the standard of care. Importantly, the evidence supporting the protocol or the individual treatments within it is lacking.…”

Section: Introductionmentioning

confidence: 99%

A retrospective cohort study examining treatments and operative interventions for frostbite in a tertiary care hospital

Fabian

Taljaard

Perry

2016

CJEM

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Background: Frostbite is a common yet challenging injury to both diagnose and treat. McCauley's frostbite treatment protocol consists of 12 treatments that might well represent the standard of care. However, its effectiveness in preventing operative intervention has yet to be examined. Our objectives were to characterize frostbite injuries in Eastern Ontario, identify risk factors for deep injuries, and assess the protocol's efficacy in preventing operative outcomes. Methods: This cohort study examined patients with frostbite over ten years at a tertiary care hospital. Demographics and predisposing factors were recorded. Frostbite severity was categorized into superficial or deep. Treatments were recorded, including adherence to protocol and operative outcome. Results: Of the 265 frostbite patients identified, deep frostbite accounted for 56 (21.1%, 95% CI: 16.2-26.1%), of whom 20 (35.7%) had an operative outcome. Amputation occurred in 16 (28.6%) of deep injuries and debridement in 5 (8.9%). Risk factors for deep frostbite were older age (p = 0.002), smoking (p <0.001), male sex (p = 0.056) and alcohol abuse (p = 0.056). None of the patients with deep frostbite had all 12 treatments performed. Adherence to protocol ranged from 0.0% to 48.2% per treatment. The rate of operative intervention was 7.7% in patients with deep frostbite who did not have any McCauley's frostbite treatments and ranged from 0.0% to 100.0% per treatment in those who did receive treatments. Conclusions: The frostbite protocol was not regularly followed and therefore its efficacy in preventing operative intervention could not be determined. Further, none of the individual treatments in the protocol were associated with preventing operative intervention. We recommend that future research focus on identifying effective individual treatments.

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Section: Introductionmentioning

confidence: 99%

A retrospective cohort study examining treatments and operative interventions for frostbite in a tertiary care hospital

Fabian

Taljaard

Perry

2016

CJEM

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“…[1][2][3][4] The adage of "freezing in the winter and amputating in the spring" no longer holds. However, these advances in treatment have not gained widespread traction in northern Canadian centres, which for geographic reasons are likely to treat numerous patients with exposure to cold.…”

Section: Discussionmentioning

confidence: 99%

“…With its thrombolytic properties, it reverses the small-vessel thrombosis that occurs in frostbite and helps to restore perfusion to frostbitten digits. 12 In the published studies, [2][3][4] alteplase was associated with a decrease in the rate of amputation of severely frostbitten digits. Administration of the vasodilator iloprost before initiation of alteplase is thought to have an additive effect, but this has yet to be demonstrated in trials.…”

Section: Vasoactive Agentsmentioning

confidence: 99%

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Treatment of severe frostbite with iloprost in northern Canada

Poole

Gauthier

2016

CMAJ

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A 46-year-old man was evacuated by air ambulance to Whitehorse General Hospital from the Yukon Arctic Ultra race, a 692-km running race. He had been running for 27 hours in temperatures ranging from -45°C to -50°C. Wearing only thin gloves, he had repeatedly exposed his hands to cold air and cold objects to drink, eat and adjust his gear. He had been running on snow, wearing cross-country running shoes. Feeling numbness in his hands and feet, he stopped running and passively rewarmed his hands in his sleeping bag while waiting for rescue. He presented to the emergency department with pain and discomfort in his hands and feet.On presentation, the patient's core temperature was 36.8°C. He had evidence of grade 3 frostbite to the right hand, with hemorrhagic blistering into the proximal phalanges of the fourth and fifth digits (Figure 1). His left hand showed evidence of frostbite on the volar aspect of the distal phalanges of the second and fourth digits. He also had frostbite to his left first and second toe, his right foot and his nose. He had no other injuries. He was healthy and athletic, with no contributing medical history. He was a nonsmoker and had not consumed alcohol recently.The patient's hands and feet were placed in a whirlpool bath of water mixed with chlorhexidine at 38°C until they were pink and warm. He was given ibuprofen 600 mg by mouth every six hours and fentanyl and morphine intravenously for pain. Once the patient's hands and feet were rewarmed, the clear blisters were aspirated, after which aloe vera ointment and porous lowadherent wound dressings were applied.The patient was given iloprost intravenously, titrated to the maximum dose of 2 ng/kg per min, for six hours daily for five days. The infusion rate was increased gradually to avoid adverse effects (e.g., headaches or hypotension). He tolerated the infusion well.On follow-up six months later, the patient's hands and feet showed complete healing. Amputation had not been required, but he reported hypersensitivity to touch and temperature. Case 2A 43-year-old man presented to the emergency department of Whitehorse General Hospital after completing the 100-mile (161-km) event of the Yukon Arctic Ultra race. He ran in temperatures ranging from -30°C to -50°C for 64 hours and then rewarmed his feet in a hot tub at his hotel. On presentation, he reported that his toes were numb and white. He was given oral cephalexin and discharged home. He returned to the emergency department 48 hours later concerned about a loss of sensation in his great toes. He recognized that he had frostbite and was seeking an alternative approach to watchful waiting.The patient had grade 3 frostbite to both great toes, with some mild erythematous extension into the metatarsophalangeal area of his right foot (Figure 2).The patient was a healthy and athletic orthopedic surgeon, with no contributing medical history. He was a nonsmoker and consumed alcohol occasionally. He was an experienced adventurer and had travelled to both poles in the past.The oral antibiotic was sto...

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“…Simultaneous administration of a vasodilator and anticoagulation therapy are used as adjunctive treatments to reduce vasospasm, prevent new thrombi, and halt extension of existing clots (30). Thrombolysis is unlikely to benefit patients who present more than 24 hours after injury, use methamphetamines, or have evidence of multiple freeze-thaw-refreeze injuries (24,29,30). An algorithm for management of frostbite with angiography and thrombolytic therapy according to the available literature is provided (Fig 2).…”

Section: Radiographymentioning

confidence: 99%