An Institutional Protocol for the Treatment of Severe Frostbite Injury-A 6-Year Retrospective Analysis

Cold Injury

Cold injury has been documented for centuries and remains a concern for military personnel, winter recreationalists, and urban homeless populations. Treatment advances in the last decades have included thrombolytic and prostaglandin therapies however the mainstay remains early recognition and rapid rewarming. This chapter focuses on frostbite, with a brief overview of other cold related conditions.

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2024 Update

The Wilderness Medical Society convened an expert panel to develop a set of evidence-based guidelines for the prevention and treatment of frostbite. We present a review of pertinent pathophysiology. We then discuss primary and secondary prevention measures and therapeutic management. Recommendations are made regarding each treatment and its role in management. These recommendations are graded on the basis of the quality of supporting evidence and balance between the benefits and risks or burdens for each modality according to methodology stipulated by the American College of Chest Physicians. This is an updated version of the guidelines published in 2019.

American Burn Association Clinical Practice Guidelines on the Treatment of Severe Frostbite

This Clinical Practice Guideline addresses severe frostbite treatment. We defined severe frostbite as atmospheric cooling that results in a perfusion deficit to the extremities. We limited our review to adults and excluded cold contact or rapid freeze injuries that resulted in isolated devitalized tissue. After developing population, intervention, comparator, outcomes (PICO) questions, a comprehensive literature search was conducted with the help of a professional medical librarian. Available literature was reviewed and systematically evaluated. Recommendations based on the available scientific evidence were formulated through consensus of a multidisciplinary committee. We conditionally recommend the use of rapid rewarming in a 38 to 42°C water bath and the use of thrombolytics for fewer amputations and/or a more distal level of amputation. We conditionally recommend the use of "early" administration of thrombolytics (≤12 hours from rewarming) compared to "later" administration of thrombolytics for fewer amputations and/or a more distal level of amputation. No recommendation could be formed on the use of vascular imaging studies to determine the use of and/or the time to initiate thrombolytic therapy. No recommendation could be formed on the use of intravenous thrombolytics compared to the use of intra-arterial thrombolytics on fewer amputations and/or a more distal level of amputation. No recommendation could be formed on the use of iloprost resulting in fewer amputations and/or more distal levels of amputation. No recommendation could be formed on the use of diagnostic imaging modalities for surgical planning on fewer amputations, a more distal level of amputation, or earlier timing of amputation.

Microwave Therapy for Frostbite Management: A Case Series

Microwave body tightening and contouring is a common and efficient cosmetic medical procedure. The current study presents preliminary data about microwave treatment for body contouring where an innovative and unexpected benefit on frostbites was shown. This is a case series on two patients with frostbite treated with microwave therapy. The participants received the treatment for five sessions at 20-day intervals, including the beginning of the study. In addition to being satisfied with the treatment of their skin imperfections, the patients noticed a remarkable and progressive improvement in frostbite on their limbs. Both patients experienced a significant improvement in skin sensation and appearance and no side effects were observed. Our findings confirmed the safety and efficacy of microwave therapy in treating cellulite and skin laxity but rather a positively effect and a significant improvement in the treatment of frostbite as a secondary intention.

Proceedings of the 2021 American Burn Association State and Future of Burn Science Meeting

Periodically, the American Burn Association (ABA) has convened a State of the Science meeting on various topics representing multiple disciplines within burn care and research. In 2021 at the request of the ABA President, meeting development was guided by the ABA's Burn Science Advisory Panel (BSAP) and a subgroup of meeting chairs. The goal of the meeting was to produce both an evaluation of the current literature and ongoing studies, and to produce a research agenda and/or define subject matter-relevant next steps to advance the field(s). Members of the BSAP defined the topics to be addressed and subsequently solicited for nominations of expert speakers and topic leaders from the ABA's Research Committee. Current background literature for each topic was compiled by the meeting chairs and the library then enhanced by the invited topic and breakout discussion leaders. The meeting was held in New Orleans, LA on November 2nd and 3rd and was formatted to allow for 12 different topics, each with two subtopics, to be addressed. Topic leaders provided a brief overview of each topic to approximately 100 attendees, followed by expert-lead breakout sessions for each topic that allowed for focused discussion among subject matter experts and interested participants. The breakout and topic group leaders worked with the participants to determine research needs and associated next steps including white papers, reviews and in some cases collaborative grant proposals. Here, summaries from each topic area will be presented to highlight the main foci of discussion and associated conclusions.

Bedside Fluorescence Microangiography for Frostbite Diagnosis in the Emergency Department

Frostbite leads to progressive ischemia eventually causing tissue necrosis if not quickly reversed. Patients with frostbite tend to present to the emergency department (ED) for assessment and treatment. Acute management includes rewarming, pain management, and (when indicated) thrombolytic therapy. Thrombolytic therapy in severe frostbite injury may decrease rates of amputation and improve patient outcomes. Fluorescence microangiography (FMA) has been used to distinguish between perfused and non-perfused tissue. The purpose of this study was to evaluate the potential role of FMA in the acute care of patients with frostbite, specifically its role as a tool to identify perfusion deficit following severe frostbite injury, and to explore its role in time to tissue plasminogen activator (tPA). Methods: This retrospective analysis included all patients from December 2020–March 2021 who received FMA in a single ED as part of their initial frostbite evaluation. In total, 42 patients presented to the ED with concern for frostbite and were evaluated using FMA. Results: Mean time from arrival in the ED to FMA was 46.3 minutes. Of the 42 patients, 14 had clinically significant perfusion deficits noted on FMA and received tPA. Mean time to tPA (measured from ED arrival to administration of tPA) for these patients was 117.4 minutes. This is significantly faster than average historical times at our institution of 240-300 minutes. Conclusion: Bedside FMA provides objective information regarding perfusion deficits and allows for faster decision-making and improved times to tPA. Fluorescence microangiography shows promise for quick and efficient evaluation of perfusion deficits in frostbite-injured patients. This could lead to faster tPA administration and potentially greater rates of tissue salvage after severe frostbite injury.

Revision Surgery Following Severe Frostbite Injury Compared to Similar Hand and Foot Burns

Severe frostbite is associated with loss of digits or limbs and high levels of morbidity. The current practice is to salvage as much of the limb/digit as possible with the use of thrombolytic and adjuvant therapies. Sequelae from amputation can include severe nerve pain and poor wound healing requiring revision surgery. The aim of this study was to examine the rate of revision surgery after primary amputation and compare this to revision surgery in isolated hand/foot burns. Frostbite and burn patients from 2014 to 2019 were identified in the prospectively maintained database at a single urban burn and trauma center. Patients with primary amputations related to isolated hand/foot burns or frostbite were included in the study. Descriptive statistics included Student's t-test and Fisher's exact test. A total of 63 patients, 54 frostbite injuries and 9 isolated hand or foot burns, met inclusion criteria for the study. The rate of revision surgery was similar following frostbite and burn injury (24% vs 33%, P = .681). There were no significant differences in age, sex, or length of stay on the primary hospitalization between those that required revision surgery and those that did not. Neither the impacted limb nor the presence of infection or cellulitis on primary amputation was associated with future need for revision surgery. Of the 16 patients requiring revision surgery, 5 (31%) required additional debridement alone, 6 (38%) required reamputation alone, and 5 required both. A total of 6 patients (38%) had cellulitis or infection at the time of revision surgery. Time from primary surgery to revision ranged from 4 days to 3 years. Planned, delayed primary amputation is a mainstay of frostbite management. To our knowledge, this is the first assessment of revision surgery in the setting of severe frostbite injury. Our observed rate of revision surgery following frostbite injury did not differ significantly from revision surgery in the setting of isolated hand or foot burns. This study brings up important questions of timing and surgical planning in these complex patients that will require a multicenter collaborative study.

Socioeconomic and comorbid factors associated with frostbite injury in the United States

Frostbite largely impacts the extremities and often results in long term disability due to amputation. More regions are experiencing extremes in temperature which increases risk of frostbite injury. The aim of this study is to detail social and comorbid factors associated with frostbite injury compared to isolated hand or foot burns. We used the National Inpatient Sample from years 2016 to 2018 to identify admissions included in this study. Weighted incidence and multivariable analysis assessed characteristics and outcomes of frostbite and isolated hand or foot burn injury. In the United States, the estimated incidence of frostbite injury in those aged 15 and over was 0.95 per 100,000 persons and 4.44 per 100,000 persons with isolated hand and foot burns. Homelessness, mental health disorder, drug or alcohol abuse, and peripheral vascular disease were all associated with risk of frostbite injury when compared to burn injury. We found that other insurance was associated with amputation following burn injury, while Black race and homelessness were associated with amputation during a non-elective primary admission following frostbite injury. The differing risk factors associated with early amputation in frostbite and burn patients warrant a multicenter study including burn centers in North America.