Solved on
By Ezana Azene, MD, PhD, Mithil B. Pandhi, DO, and Sudhen B. Desai, MD
Severe frostbite
This column summarizes patient cases posted to SIR Connect (SIR’s popular online member community), the responses from other SIR members and how that feedback helped the original poster. To see how SIR’s online community can help you, visit SIR Connect at
connect.sirweb.org
Original post The trauma surgeons at my hospital have asked me to develop a protocol for catheter-directed therapy of severe frostbite injuries (tPA and vasodilator). The published protocols vary substantially in thrombolytic bolus (yes/no, dose, route . . . some IV?), thrombolytic infusion dose rate, choice and bolus dose/dose rate of vasodilator (if used at all), and degree of heparinization (full vs low dose, PTT monitoring vs no monitoring).
I would greatly appreciate guidance/ suggestions from those of you with experience in this area. Any protocols you can share would also be greatly appreciated. Thank you. —Ezana Azene, MD, PhD
Read the full discussion thread at
bit.ly/2DPts7l.
Author background Residency and IR fellowship at Johns Hopkins. Five years in clinical IR practice.
What are your current practice preferences for managing severe frostbite injury? Frostbite is common in the Upper Midwest and we have been sending severe frostbite patients to a burn center 2 hours away. After consulting with this burn center, our trauma surgeons approached our group about helping them develop a protocol for treating frostbite patients locally with thrombolytic agents and catheter-based techniques.
What prompted you to reach out on SIR Connect about the topic? We were developing a protocol from scratch and after reviewing the literature, I discovered there were many different published techniques for treating severe frostbite. Although it appears that early intervention can help preserve digit function and reduce tissue loss, the magnitude of benefit and the
32 IRQ | WINTER 2019
approach that one should take are unclear. Options in the literature include systemic thrombolysis, catheter-directed thrombolysis and an intra-arterial vasodilator. Patient selection criteria are also variable. I sought the advice of my colleagues on SIR Connect to benefit from their experience.
What post(s) were most valuable to you? Dr. Michael Braun’s post was helpful. He described his experience with systemic thrombolysis using the Hennepin County Medical Center (MN) protocol.1,2
Although
HCMC has a lot of experience safely treating severe frostbite injuries with systemic thrombolysis, I was still a little hesitant to include systemic thrombolysis as an option in our protocol. Dr. Braun’s comments helped to reassure me. Although our protocol doesn’t include systemic thrombolysis as the first-line option, we include it as an option for patients who are unable to undergo CDT within a certain amount of time after initial cold injury or thawing.
How would you have approached this case in the absence of SIR Connect? In addition to reviewing the literature, I would have contacted friends in the IR community and the authors of the most important papers in this area.
Did you collaborate with the trauma service members on the protocol? If so, how did collaboration guide the process? The protocol was created with collaboration from our trauma surgeons, who provided input on selection criteria.
Do you find that the new protocol will make the outcome easier to achieve or lead you to an outcome that you did not think could have been achieved otherwise? My IR partners and I have limited experience treating patients with severe
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