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Ma X, Pouoh JT, Hogue BT, Bougie E. Frostbite in the Pediatric Population: A Comprehensive Review and a Prospective Canadian Survey. Pediatr Emerg Care 2024; 40:611-617. [PMID: 38206303 DOI: 10.1097/pec.0000000000003109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
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.
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Affiliation(s)
- Xiya Ma
- From the Division of Plastic Surgery, Université de Montréal, Montreal, Quebec, Canada
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Wibbenmeyer L, Lacey AM, Endorf FW, Logsetty S, Wagner ALL, Gibson ALF, Nygaard RM. American Burn Association Clinical Practice Guidelines on the Treatment of Severe Frostbite. J Burn Care Res 2024; 45:541-556. [PMID: 37045447 DOI: 10.1093/jbcr/irad022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
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.
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Affiliation(s)
- Lucy Wibbenmeyer
- Department of Surgery, University of Iowa, Iowa City, IA 52242, USA
| | | | | | - Sarvesh Logsetty
- Departments of Surgery, Psychiatry, and Children's Health, University of Manitoba, Winnipeg, Manitoba R3E 3P5, Canada
| | - Anne L L Wagner
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, USA
| | - Angela L F Gibson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
| | - Rachel M Nygaard
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN 55415, USA
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Poole A, Ahmed Y, Davidson M. The Occasional frostbite. CANADIAN JOURNAL OF RURAL MEDICINE 2024; 29:30-36. [PMID: 38358103 DOI: 10.4103/cjrm.cjrm_2_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 04/11/2023] [Indexed: 02/16/2024]
Affiliation(s)
- Alexander Poole
- Whitehorse General Hospital, Yukon Hospital Corporation, Whitehorse, Yukon, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Yousuf Ahmed
- Department of Emergency Medicine, Dalhousie University, Saint John, Canada
- Department of Family Medicine, Dalhousie University, Saint John, Canada
| | - Malcolm Davidson
- Temerty School of Medicine, University of Toronto, Toronto, ON, Canada
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Raleigh S, Samson M, Nygaard R, Endorf F, Walter J, Masters T. Bedside Fluorescence Microangiography for Frostbite Diagnosis in the Emergency Department. West J Emerg Med 2022; 23:872-877. [DOI: 10.5811/westjem.2022.8.55020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Sarah Raleigh
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Margot Samson
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota
| | - Rachel Nygaard
- Hennepin County Medical Center, Department of Surgery, Minneapolis, Minnesota
| | - Fredrick Endorf
- Hennepin County Medical Center, Department of Surgery, Minneapolis, Minnesota
| | - Joseph Walter
- Hennepin County Medical Center, Department of Hyperbaric Medicine, Minneapolis, Minnesota
| | - Thomas Masters
- Hennepin County Medical Center, Department of Emergency Medicine, Minneapolis, Minnesota; Hennepin County Medical Center, Department of Hyperbaric Medicine, Minneapolis, Minnesota
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Endorf FW, Alapati D, Xiong Y, DiGiandomenico C, Rasimas CS, Rasimas JJ, Nygaard RM. Biopsychosocial factors associated with complications in patients with frostbite. Medicine (Baltimore) 2022; 101:e30211. [PMID: 36042625 PMCID: PMC9410586 DOI: 10.1097/md.0000000000030211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cold weather injuries can be devastating and life changing. Biopsychosocial factors such as homelessness and mental illness (especially substance use disorders [SUDs]) are known risk factors for incurring frostbite. Based on clinical experience in an urban level 1 trauma center, we hypothesized that complications following frostbite injury would be influenced by homelessness, SUDs, and other forms of mental illness. The aim of this study was to examine the relationship between biopsychosocial factors and both amputations and unplanned hospital readmissions after cold injuries. Patients admitted with a diagnosis of frostbite between the winters of 2009 and 2018 were included in this retrospective cohort study. Descriptive statistics and multivariable regression assessed factors associated with outcomes of interest. Of the 148 patients in the study, 40 had unplanned readmissions within 1 year. Readmitted patients were significantly less likely to have a stable living situation (48.7% vs 75.0%, P = .005) and more likely to have an SUD (85.0% vs 60.2%, P = .005) or other psychiatric disorder (70.0% vs 50.9%, P = .042). Homelessness and SUDs were independent predictors of unplanned readmission. Overall, 18% of frostbite injuries resulted in amputation. Any history of drug and/or alcohol use independently predicted amputations. The study results suggest that additional hospital and community resources may need to be marshaled to prevent vulnerable patients with biopsychosocial risk factors from having complications after frostbite. Complications place a high downstream burden on healthcare systems. Clinicians caring for frostbite patients with comorbid conditions can use these findings to inform care and discharge decisions.
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Affiliation(s)
| | - Deepak Alapati
- Department of Psychiatry, Hennepin Healthcare, Minneapolis, MN, USA
| | - Yee Xiong
- Department of Psychiatry, Hennepin Healthcare, Minneapolis, MN, USA
| | | | | | - Joseph J. Rasimas
- Department of Psychiatry, Hennepin Healthcare, Minneapolis, MN, USA
- *Correspondence: Joseph J. Rasimas, Department of Psychiatry, Hennepin Healthcare, 165 Viking Drive East, Little Canada, MN 55117, USA (e-mail: )
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FROSTBITE OF THE UPPER EXTREMITIES: HOT ISSUES IN DIAGNOSIS AND SURGICAL TREATMENT (review). Burns 2022; 48:1279-1286. [DOI: 10.1016/j.burns.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/16/2022] [Accepted: 03/12/2022] [Indexed: 11/24/2022]
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Rogers C, Lacey AM, Endorf FW, Gopal P, Whitley A, Gayken J, Fey R, Schmitz K, Nygaard RM. The Effects Of Rapid Rewarming On Tissue Salvage In Severe Frostbite Injury. J Burn Care Res 2021; 43:906-911. [PMID: 34791315 DOI: 10.1093/jbcr/irab218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Frostbite is a high morbidity injury caused by soft tissue freezing, which can lead to digit necrosis requiring amputation. Rapid rewarming is a first line treatment method that involves placing affected digits into a warm water bath. This study aims to assess the clinical practices for frostbite at facilities outside of dedicated burn centers, and any impact these practices have on tissue salvage. Retrospective chart review at a single burn center identified frostbite patients admitted directly or as transfers over a seven-year period. Records were reviewed to identify initial treatment strategies. If given, time to thrombolytics from admit was noted. Tissue salvage rates were calculated from radiologically derived tissue at-risk scores and final amputation scores. One-hundred patients were transferred from outside facilities, and 108 were direct admissions (N=208). There was no significant difference in group demographics. Rapid rewarming was the initial treatment modality more commonly in direct admit patients (P=0.016). The use of rapid rewarming did not correlate with tissue salvage (P=0.112). Early use of thrombolytics had a positive impact on tissue salvage (P=0.003). Thrombolytics were given 1.2 hours earlier in direct admit patients (P=0.029), however there was no difference in tissue salvage rates between the groups (P=0.127). Efforts should focus on larger scale study to further assess the effectiveness of rapid rewarming. Although rapid rewarming did not significantly impact tissue salvage in this study, we continue to recommend its use over less studied treatment methods, and continue to view it as an important bridge to burn center transfer and administration of thrombolytic therapy.
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Affiliation(s)
| | | | | | - Punjabi Gopal
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Angela Whitley
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Jon Gayken
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Ryan Fey
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN
| | - Kyle Schmitz
- Department of Surgery, Hennepin Healthcare, Minneapolis, MN
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Lacey AM, Rogers C, Endorf FW, Fey RM, Gayken JR, Schmitz KR, Punjabi GV, Whitley AB, Masters TC, Moore JC, Nygaard RM. An Institutional Protocol for the Treatment of Severe Frostbite Injury-A 6-Year Retrospective Analysis. J Burn Care Res 2021; 42:817-820. [PMID: 33484248 DOI: 10.1093/jbcr/irab008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The treatment of severe frostbite injury has undergone rapid development in the past 30 years with many different diagnostic and treatment options now available. However, there is currently no consensus on the best method for management of this disease process. At our institution, we have designed a protocol for severe frostbite injury that includes diagnosis, medical treatment, wound cares, therapy, and surgery. This study assess the efficacy of our treatment since its implementation six years ago. During this time, all patients with severe frostbite injury were included in prospective observational trial of the protocol. We found that this protocol results in significant tissue salvage with over 80.7% of previously ischemic tissue becoming viable and not requiring amputation. We also were able to improve our center's efficiency over the course of six years and now our current average time from rapid rewarming to delivery of thrombolytics is under six hours.
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Affiliation(s)
| | | | | | - Ryan M Fey
- Hennepin Healthcare Medical Center, Minneapolis, Minnesota
| | - Jon R Gayken
- Hennepin Healthcare Medical Center, Minneapolis, Minnesota
| | - Kyle R Schmitz
- Hennepin Healthcare Medical Center, Minneapolis, Minnesota
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Joshi K, Goyary D, Mazumder B, Chattopadhyay P, Chakraborty R, Bhutia YD, Karmakar S, Dwivedi SK. Frostbite: Current status and advancements in therapeutics. J Therm Biol 2020; 93:102716. [PMID: 33077129 DOI: 10.1016/j.jtherbio.2020.102716] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 01/02/2023]
Abstract
Frostbite is a severe ischemic injury which occurs due to the tissue vascular damage after sub-zero temperature tissue exposure. Deep frostbite can result in necrosis and may need amputation of affected tissue. Though a serious injury, it is not very well understood, and further scientific exploration is needed. This work explores the current understanding of the pathophysiology of frostbite. We reviewed the current status of the diagnostics, the drugs, the therapies and the surgical practices for prevention and management of frostbite. Advances in nanotechnology and drug delivery had improved the therapeutic outcomes significantly. This review also explored the latest advancements and researches done for development of newer therapeutics and diagnostics for frostbite care.
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Affiliation(s)
- Kumud Joshi
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India; Department of Pharmaceutical Sciences, Dibrugarh University, Assam, India
| | - Danswrang Goyary
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India.
| | - Bhaskar Mazumder
- Department of Pharmaceutical Sciences, Dibrugarh University, Assam, India
| | | | - Reshmi Chakraborty
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
| | - Y D Bhutia
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
| | - Sanjeev Karmakar
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
| | - Sanjai Kumar Dwivedi
- Division of Pharmaceutical Technology, Defence Research Laboratory, Tezpur, Assam, India
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Lumbard DC, Lacey AM, Endorf FW, Gayken JR, Fey RM, Schmitz KR, Deisler RF, Calcaterra D, Prekker M, Nygaard RM. Severe Hypothermia and Frostbite Requiring ECMO and Four Limb Amputations. J Burn Care Res 2020; 41:1301-1303. [PMID: 32663261 DOI: 10.1093/jbcr/iraa113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Severe hypothermia and frostbite can result in significant morbidity and mortality. We present a case of a patient with severe hypothermia and frostbite due to cold exposure after a snowmobile crash. He presented in cardiac arrest with a core temperature of 19°C requiring prolonged cardiopulmonary resuscitation, active internal rewarming, venoarterial extracorporeal membrane oxygenation, and subsequently amputations of all four extremities. Although severe hypothermia and frostbite can be a fatal condition, the quick action of Emergency Medical Services, emergency physicians, trauma surgeons, cardiothoracic surgeons, intensivists, and the burn team contributed to a successful recovery for this patient including a good neurological outcome. This case highlights the importance of a strong interdisciplinary team in treating this condition.
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Affiliation(s)
| | | | | | | | - Ryan M Fey
- Department of Surgery, Minneapolis, Minnesota
| | | | | | | | - Matthew Prekker
- Division of Pulmonary and Critical Care Medicine, Hennepin Healthcare, Minneapolis, Minnesota
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Paine RE, Turner EN, Kloda D, Falank C, Chung B, Carter DW. Protocoled thrombolytic therapy for frostbite improves phalangeal salvage rates. BURNS & TRAUMA 2020; 8:tkaa008. [PMID: 32341921 PMCID: PMC7175769 DOI: 10.1093/burnst/tkaa008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 12/27/2019] [Accepted: 01/21/2020] [Indexed: 01/12/2023]
Abstract
Background Frostbite is a cold injury that has the potential to cause considerable morbidity and long-term disability. Despite the complexity of these patients, diagnostic and treatment practices lack standardization. Thrombolytic therapy has emerged as a promising treatment modality, demonstrating impressive digit salvage rates. We review our experience with thrombolytic therapy for severe upper extremity frostbite. Methods Retrospective data on all frostbite patients evaluated at our institution from December 2017 to March 2018 was collected. A subgroup of patients with severe frostbite treated with intra-arterial thrombolytic therapy (IATT) were analysed. Results Of the 17 frostbite patients treated at our institution, 14 (82%) were male and the median age was 31 (range: 19–73). Substance misuse was involved in a majority of the cases (58.8%). Five (29.4%) patients with severe frostbite met inclusion criteria for IATT and the remaining patients were treated conservatively. Angiography demonstrated a 74.5% improvement in perfusion after tissue plasminogen activator thrombolysis. When comparing phalanges at risk on initial angiography to phalanges undergoing amputation, the phalangeal salvage rate was 83.3% and the digit salvage rate was 80%. Complications associated with IATT included groin hematoma, pseudoaneurysm and retroperitoneal hematoma. Conclusions Thrombolytic therapy has the potential to greatly improve limb salvage and functional recovery after severe frostbite when treated at an institution that can offer comprehensive, protocoled thrombolytic therapy. A multi-center prospective study is warranted to elucidate the optimal treatment strategy in severe frostbite.
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Affiliation(s)
| | - Elizabeth Noel Turner
- Department of Surgery, Maine Medical Center, 22 Bramhall St, Portland, Maine 04102, USA
| | - Daniel Kloda
- Department of Radiology, Maine Medical Center, 22 Bramhall St, Portland, Maine 04102, USA
| | - Carolyne Falank
- Department of Surgery, Maine Medical Center, 22 Bramhall St, Portland, Maine 04102, USA
| | - Bruce Chung
- Department of Surgery, Maine Medical Center, 22 Bramhall St, Portland, Maine 04102, USA
| | - Damien Wilson Carter
- Department of Surgery, Maine Medical Center, 22 Bramhall St, Portland, Maine 04102, USA
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