An article in this months Archives of Surgery, entitled Reduction of the Incidence of Amputation in Frostbite Injury With Thrombolytic Therapy, describes the use of intra-arterial tPA in patients with frostbite injury to a digit and demonstrated impaired perfusion. The article concludes by proclaiming that this is the first clinically significant advancement in the management of frostbite in more than 25 years. Indeed, as any northern doc can tell you, management of frostbite is limited.
A patient presents to the emergency department after passing out in a snow bank. Surprisingly his core temperature is adequate, but his hands appear white and frozen. At present the standard treatment for this patient involves:
- pain control, usually with IV narcotics
- rewarming of his hands by immersion in saline warmed to 42 degrees C
- treatment of any hypothermia (with external, and often central rewarming)
- debridement of any blisters containing clear or white fluid (these blisters represent more superficial injury, and contain PGF-2A and thromboxane, both of which can cause deeper injury through inflammation)
- Hemmorhagic blisters are left intact as debridement can lead to increasing depth of injury, though aspiration can be considered.
- Administration of an anti-inflamatory drug (Ibuprofen)
- Tetanus booster if required
- Telling the patient that they may not, under any circumstances, smoke (most people are able to not smoke when their fingers are at risk)
- Surgical consultation (though early surgical intervention is avoided if possible, as even horrific looking injuries sometimes recover well)