Pediatric frostbite: A 10-year single-center retrospective study

Accelerated Frostbite-induced Acroosteolysis in Pediatric Insensate Hand: A Case Report and Literature Review

In pediatric patients, frostbite is a well-documented cause of epiphyseal cartilage destruction and subsequent growth deformity of the affected phalanges. Cases of full acroosteolysis also referred to as phalangeal osteolysis, of distal phalanges as soon as 3 months after cold exposure have yet to be reported. We describe a complicated case of frostbite-associated phalangeal osteolysis in the dominant hand of a 9-year-old patient, in the context of post-traumatic insensate hand after sustaining prior electrical burn injuries. This case demonstrates the unique sequela of pediatric frostbite injury involving early loss of the distal phalanx through resorption of the bone and parallel soft tissue retraction, rendering early plastic surgery reconstruction impractical. Reconstructive strategies for frostbite injury in pediatric patients will need to account for the individualized dynamic tissue changes that develop in the months after cold exposure.

Psychosocial and personal predisposing factors of frostbite injury and associated amputation: a systematic review

OBJECTIVE

To date, systematic reviews of frostbite injuries predominantly focus on the treatment of frostbite, which narrows the scope of prevention and disregards the impact of frostbite-related predisposing factors. Comprehensively synthesizing relevant evidence to understand the psychosocial and personal predisposing factors to frostbite injury and related amputation would provide new insight into frostbite injury prevention. This review investigated the psychosocial and personal predisposing factors of frostbite injury and associated amputation.

METHODS

Databases, including Embase, PubMed, and PsycINFO, were systematically searched for relevant studies. Two independent reviewers performed the screening, data extraction, and quality assessment. Inclusion criteria were studies that reported cold injury, predisposing factors for frostbite injury or related amputations, and assessed the relationship between a predisposing factor and the frostbite injury or amputation outcome based on a descriptive or inferential test.

RESULTS

Thirty-six (36) studies met the inclusion criteria; 29 reported on both frostbite injury and amputations, and seven reported on only frostbite injury. Six psychosocial predisposing factors were observed in 28 out of the 36 studies reviewed, which included people experiencing homelessness, low socioeconomic status, alcohol intoxication/abuse, smoking, psychiatric disorders, and substance use. Personal predisposing factors identified included inadequate/improper winter clothing, delay in seeking medical care, and lack of knowledge of how to deal with the cold.

CONCLUSIONS

While it is crucial to allocate additional resources and research toward improving the treatment of individuals affected by frostbite injuries and associated limb loss, it is equally important to direct efforts toward addressing the psychosocial and personal predisposing factors that predispose individuals to these injuries and amputations.

Frostbite in the Pediatric Population: A Comprehensive Review and a Prospective Canadian Survey

INTRODUCTION

Frostbite in the pediatric population, where skeletal maturity has not been achieved, can have important repercussions on subsequent growth. Yet, the optimal management of frostbite injuries in children remains vague. This review aims to summarize the current evidence for frostbite management in children and understand Canadian practice trends on this topic.

METHODS

A review using Medline, Scopus, Web of Science, and gray literature was performed to identify relevant literature on the clinical manifestations, diagnostic methods, and treatment options in pediatric frostbite. An online survey was sent to plastic surgeons through the Canadian Society of Plastic Surgeons (CSPS) mailing list to further identify national practices and trends for pediatric frostbite management.

RESULTS

A total of 109 articles were reviewed. No article provided a specific algorithm for pediatric frostbite, with existing recommendations suggesting the use of adult guidelines for treating children. Our survey yielded 9 responses and highlighted the rarity of pediatric frostbite cases, with no responder treating more than 10 cases per year. Most (55.6%) do not use a pediatric-specific treatment algorithm, whereas 30% apply adult guidelines. A conservative approach focusing on rewarming (55.6%), limb elevation (50%), and tetanus status verification (66.7%) was predominant. Imaging and surgical interventions seem to be reserved for severe cases.

CONCLUSIONS

The current literature for pediatric frostbite management lacks specificity. Canadian practices vary, with a trend toward a conservative approach. The limited evidence and rarity of experience highlight the need for further research, ideally in a collaborative multicentric manner, to create a consensus for pediatric frostbite care.

Routinely collected burn clinical data in Canada: Determining the knowledge gap

Unlike other developed countries that hold national burn registries to monitor burn injury and care, Canada relies on single-centre secondary datasets and administrative databases as surveillance mechanisms. The objective of this study was to determine the knowledge gap faced in Canada for not having a dedicated burn registry. A comprehensive scoping review was conducted to identify the burn literature that has arisen from secondary datasets in Canada. Literature of all study designs was included with the exception of case reports and cases series. Once data extraction was concluded, a thematic framework was constructed based on the information that arose from nations that hold national burn registries. Eighty-eight studies were included. Twelve studies arose from national datasets, and 18 from provincial databases, most of which were from Ontario and British Columbia. Only seven studies were conducted using a combination of Canadian units' single-centre datasets. The majority of included studies (58%) resulted from non-collaborative use of single-centre secondary datasets. Research efforts were predominantly conducted by burn units in Ontario, British Columbia, Manitoba and Alberta. A significant number of the included studies were outdated and several provinces/territories had no published burn data whatsoever. Efforts should be made towards the development of systems to surveil burn injury and care in Canada. This study supports the development of a nation-wide burn registry to bridge this knowledge gap.

Exploring the Development of a Canadian Frostbite Care Network and the Future of Frostbite Care in Canada Using a Qualitative Approach

INTRODUCTION

The Canadian Frostbite Collaborative project is exploring frostbite patient care needs and current practices in Canada to inform the development of a Canadian frostbite care network (CFCN) as a national quality improvement initiative.

METHODS

Using a quantitative and qualitative approach, this study aimed to define the landscape of current frostbite practices, challenges, and interest in future work.

RESULTS

Current frostbite care practices were initially assessed through semistructured phone interviews of Canadian healthcare providers. Canadian healthcare providers managing frostbite in a range of health disciplines and contexts then participated in focus group sessions discussing the potential roles and opportunities as well as potential challenges in developing a CFCN. Roles and opportunities for a network in advancing frostbite care included facilitating research, educating stakeholders, facilitating collaboration, standardizing care, and advocating for frostbite care. Challenges identified in frostbite care and network development included managing resources, navigating the Canadian healthcare system, overcoming low numbers, and communicating with policymakers and frontline providers.

CONCLUSIONS

Formalizing a CFCN may provide important opportunities and support in overcoming critical barriers to providing high-quality frostbite care across Canada.

Hypothermia and cold injuries in children and young people

Although hypothermia and cold injuries are rare in children and young people in the UK, the risk is persistent and requires urgent medical management when it does occur. This article outlines some considerations for professionals who may be caring for hypothermic patients or those at risk of becoming hypothermic.

Pediatric Environmental Cold Injuries

Cold weather injuries are relevant concerns for children during winter sports and outdoor activities. To mitigate the risk of cold injury in this high-risk population, providers can educate parents on proper outdoor attire as well as the added risks of wind and water exposure. There are 2 types of environmental cold injuries: freezing injuries and nonfreezing injuries. Frostbite is a freezing injury from direct contact with cold air or surfaces. The extent of injury depends on the depth to which the freezing extends. Treatment involves rewarming the frozen tissue with warm water baths and considering analgesia. Hypothermia is a nonfreezing cold injury, and it can occur even when ambient temperatures are above freezing. When there is a decrease in the body's core temperature, hypothermia progresses from mild to severe symptoms. Treatment of hypothermia is threefold but is also dependent on the core body temperature, as colder core temperatures will require more aggressive warming techniques. Hypothermia treatment involves passive protection from further heat loss (ie, removing wet clothing), which helps the body to warm itself. Treatment also involves active external rewarming wherein a heat source, such as a heated blanket, is used to increase body temperature. Active internal rewarming is the delivery of heat inside the patient's body, such as warmed intravenous fluids.

Environmental scan of mental health supports across Canadian burn centers: A healthcare providers’ perspective

BACKGROUND

Early mental health care and psychosocial support after burn injury provided by a variety of specialists and non-mental health professionals is instrumental in prevention of long-term mental health sequalae such as post-traumatic stress, depressive or substance use disorders. Diversity of mental health supports available to burn survivors vary across geography, resulting in variation of long-term mental health outcomes following burn injury.

METHODS

A mixed-methods study utilizing a semi-structured questionnaire to explore resources available for burn survivors in Canada as an inpatient, outpatient, and more broadly in the aftercare community. Interviews were completed with 17 Canadian burn centers, with a variety of burn care professionals.

RESULTS

In the continuum of burn care, a lack of available mental health professionals in certain regions and in the outpatient and community phases was observed. Emerging themes demonstrated the need for regular screening for mental health concerns among burn survivors and providing up to date discharge resources. In addition, increasing educational opportunities available to burn care staff with respect to burn survivor mental health was emphasized. Lastly, the importance of proactive and prolonged psychological support for burn survivors as they progress through an outpatient, rehabilitation and community setting was underlined.

CONCLUSIONS

Identification of burn care practices and resources across Canada provides the opportunity to compare, unify and improve gaps in care that exist across the Canadian burn network.

The psychological impact of paediatric burn injuries: a systematic review

OBJECTIVE

To review and synthesise qualitative literature regarding the psychological outcomes following paediatric burn injuries, and to determine if children and adolescents who experience a burn injury have elevated risk of psychopathology following the injury.

DESIGN

Systematic review of quantitative and qualitative studies.

DATA SOURCES

Informit health, Medline, Embase, and PsycINFO were searched from January 2010 to December 2020.

DATA EXTRACTION AND SYNTHESIS

Two reviewers screened articles, and one reviewer extracted data (with cross-checking from another reviewer) from the included studies and assessed quality using an established tool. Narrative synthesis was used to synthesise the findings from the quantitative studies, and thematic synthesis was used to synthesise the findings of included qualitative studies.

RESULTS

Searches yielded 1240 unique titles, with 130 retained for full-text screening. Forty-five studies from 17 countries were included. The psychological outcomes included in the studies were mental health diagnoses, medication for mental illness, depression, anxiety, stress, fear, post-traumatic stress, post-traumatic growth, emotional issues, self-harm, self-esteem, self-concept, stigmatisation, quality of life, level of disability, resilience, coping, and suicidality.

CONCLUSIONS

Our findings highlight paediatric burn patients as a particularly vulnerable population following a burn injury. Studies suggest elevated anxiety and traumatic stress symptoms, and higher rates of psychopathology in the long-term. Further research is recommended to determine the psychological outcomes in the other mental health domains highlighted in this review, as findings were mixed. Clinical care teams responsible for the aftercare of burn patients should involve psychological support for the children and families to improve outcomes.

ACSM Expert Consensus Statement: Injury Prevention and Exercise Performance during Cold-Weather Exercise

ABSTRACT

Cold injury can result from exercising at low temperatures and can impair exercise performance or cause lifelong debility or death. This consensus statement provides up-to-date information on the pathogenesis, nature, impacts, prevention, and treatment of the most common cold injuries.

Nonfreezing Cold Injury in a Pediatric Hiker

Nonfreezing cold injury has been primarily described in military populations as a result of prolonged exposure to wet environments and cold, but not freezing, temperatures. This type of injury occurs less commonly in the civilian population and in children, but poses a risk for short-term debilitating extremity pain, tissue damage, and infection and for long-term chronic neuropathic pain and temperature intolerance. We describe a case of nonfreezing cold injury in a pediatric hiker.

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

BACKGROUND

We identified the need to modernize frostbite management in our northern centre and implemented a treatment protocol in 2015. Our aim was to describe the clinical course of patients presenting to the hospital since the implementation of the protocol.

METHODS

This was a retrospective case series from Whitehorse General Hospital, Whitehorse, Yukon Territory, Canada. We reviewed the charts of patients who presented to the hospital with grade 2-4 frostbite and were treated as per our protocol between Feb. 9, 2015, and Feb. 8, 2020. Patients with grade 2-4 frostbite received iloprost; in addition, those with grade 4 frostbite received alteplase and heparin. We determined the number of digits affected and salvaged, and the time from presentation to the emergency department to treatment initiation. We also examined patients' demographic characteristics, predisposing events, frostbite severity and adverse drug reactions.

RESULTS

In 22 patients treated for grade 2-4 frostbite, 142 digits were affected: 59 with grade 2 frostbite, 25 with grade 3 frostbite and 58 with grade 4 frostbite; of the 142, 113 (79.6%) were salvaged. All 29 digits amputated had grade 4 frostbite. The mean time from presentation to iloprost initiation was reduced from 32.9 hours in 2015 to 3.0 hours in 2020. Sports (10 cases [45%]) and alcohol use (6 [27%]) were the most common precipitating events, with alcohol use tending to result in more severe injury (grade 4 in 5 of 6 cases). Adverse reactions with iloprost (e.g., headache) were common but mild. Adverse reactions with alteplase (e.g., bleeding) were less common but of greater clinical significance.

INTERPRETATION

Over the study period, our protocol contributed to improvement in frostbite care at our institution, resulting in a digit salvage rate comparable to other published results. Our 5-year experience shows that advanced medical care of frostbite can be achieved, even at a rural centre.