HWN Suggests

POTD: Winter is Coming

THAWING: Do NOT attempt until the risk of refreezing is eliminated. Refreezing will cause even more severe damage. Rapid active rewarming is the core of therapy and should be initiated as soon as possible. Best performed in a circulating water bath around 37°C to 39°C. Frostbitten faces can be thawed using warm water compresses, and ears may be thawed with small bowls of warm water. Immersion rewarming can be discontinued when the affected area developed a red or purple appearance and becomes pliable to the touch.

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 A drug to treat frostbite is finally available

Iloprost works by expanding the blood vessels (called a vasodilator) of patients and stopping blood clots from forming. As frostbite causes constriction of blood vessels, this suggests one mechanism through which iloprost helps heal frostbitten tissue is by reversing this constriction.

 Brrr! ED Presentation, Evaluation, and Management of Cold Related Injuries

Cold related injury can be broadly divided into freezing and non-freezing conditions based on their clinical presentation and the degree of injury. Frostbite is the major injury involving tissue freezing. Non-freezing injuries include frostnip, chilblains/pernio, immersion or “trench” foot, and cold urticaria. Treatment is usually supportive, with recognition and prevention as major goals of therapy.

 Frostbite: How to Classify and Treat It

Frostbite is a freezing injury of peripheral tissues. It is characterized by extracellular crystal formation and micro-vascular thrombi that lead to localized cell death and inflammation, placing the digits or limbs involved at risk for amputation.

 TPA in Frostbite

Additional research remains to be done on this topic. At this time, however, it is reasonable to give your patients – a hand – when it comes to severe frostbite. Consider tPA.

Articles of Interest

Emergency Management of Frostbite

Do not use dry heat, such as heaters or fires. Air is a poor conductor of thermal energy resulting in a slower thaw. It is also harder to control the temperature using these methods which may result in burns​1,5​

Iloprost for Frostbite

A 6hr IV Iloprost infusion for 5 days is a reasonable treatment for patients with severe frostbite that would otherwise be at risk of amputation and presenting within 72 hours of rewarming.

REBEL Core Cast 48.0 Frostbite

Critical ED treatment starts with rewarming in a warm, NOT HOT, water bath, analgesia and wound care.

Surviving Sepsis, Angle Closure Glaucoma, Bougies, Frostbite, Hot/Altered Patient, Central Cord Syndrome View Larger Image

If you think there is a chance of deep injury, consider using tPA and/or iloprost... 3rd degree or higher: IV iloprost 2 ng/kg per min infusion, 6 h/d, for 5 days. 4th degree: tPA 3 mg IV bolus then 1 mg/hr and heparin within 12 hours of rewarming.

Tasty Morsels of EM 129 – #FRCEM Hypothermia and Frostbite

Frostnip = nose, face or fingers white on exposure but with rapid recovery when removed from cold exposure. Paraesthesiae but no long term tissue damage. Superfical frostbite = skin and subcut tissues. numb and waxy appearing. Painful rewarming with later blistering. Deep frostbite = muscles, nerves and even bone. White and hard appearing. Remains white even after rewarming. Becomes necrotic and separates.

Trick of the Trade: DIY Circulating Water Bath for Frostbite Treatment

You can create a make-shift circulating bath using supplies that are readily available in most emergency departments: a plastic tub, a sink with a faucet, and a portable thermometer.

Resources

BC Emergency Medicine Network

tPA dose is typically a 3 mg bolus (30 mL of 0.1 mg/mL solution) followed by infusion of 1 mg/mL (10 mL/hr) until specialists (eg, vascular, burn, radiology) recommend discontinuation. Heparin is administered concurrently: 500 units/hr.Intra-arterial angiography or IV pyrophosphate scanning should be used to evaluate the initial injury and monitor progress after tPA administration as directed by local protocol and resources.

StatPearls

Frostbite, also known as freezing cold injury (FCI) is tissue damage as a result to cold exposure, occurring at temperatures below 0 degrees C. It is included in a spectrum of injury, from FCI to non-FCI and frostnip.