The evolution of the Helsinki frostbite management protocol

Abstract

Prompt referral to a facility where interventional radiology and 24/7 laboratory services are available, and the combined use of tPA and iloprost, may improve outcome after severe frostbite.

The Use of tPA in the Treatment of Frostbite: A Systematic Review

“…The 8 case series reported on 128 patients. 17,[27][28][29][30][31][32][33] Three studies were case reports. [34][35][36] A total of 208 patients were included in the treatment groups.…”

Management of severe frostbite with iloprost, alteplase and heparin: a Yukon case series

“…Beginning in the 1990s, a growing body of evidence has popularized the use of iloprost in frostbite, first in Europe and now in Canada. 6,11,15,16,21,24,27 Iloprost, a synthetic prostacyclin analogue, is a potent vasodilator that inhibits platelet aggregation and enhances fibrinolytic activity by releasing endogenous tissue plasminogen activator. 29 To our knowledge, there is a single randomized controlled trial published to date showing the benefit of iloprost combined to alteplase and heparin.…”

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2019 Update

“…72 In a Finnish study, iloprost was partially beneficial with digit salvage rate of 78% in 4 persons: 2 with contraindication for tPA, 1 with failed tPA therapy, and 1 with vasospasm without thrombosis on angiography. 55 One patient with minimal response to tPA had complete reperfusion with iloprost.…”

“…Evidence supports use of heparin as adjunctive therapy in tPA protocols, as described previously. Heparin has been used in conjunction with iloprost as well; the 5 patients in the 1994 Groechenig iloprost study, 71 the 1 Israeli traveler with excellent outcome in the Kathmandu study, 74 and 4 patients in the Finnish study 55 were treated with low molecular weight heparin (enoxaparin) in addition to iloprost. Whether low molecular weight heparin offers additional benefit when combined with iloprost requires further investigation; currently data are insufficient for a recommendation on this combination.…”