My 2011 Grand Rounds on Frostbite

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

13. DEPARTMENT OF SURGERY
Superficial frostbite

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

15. DEPARTMENT OF SURGERY
Deep frostbite

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

31. DEPARTMENT OF SURGERY
Scintigraphy

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

34. DEPARTMENT OF SURGERY
30-year-old male

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

46. DEPARTMENT OF SURGERY
Rehabilitation

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

51. DEPARTMENT OF SURGERY
Extremity prostheses

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

54. DEPARTMENT OF SURGERY
Questions?