frostbite injuries. Creating this protocol in collaboration with our more “frostbite-experienced” trauma surgeons, along with the input from our IR colleagues on SIR Connect, has allowed us to quickly learn about this disease and feel comfortable treating it.


Additional commentary Frostbite, or cold thermal injury, occurs when tissue is exposed to temperatures below its freezing point for a long duration, resulting in progression through sequential stages of pre-freezing (vasoconstriction and ischemia), freeze-thawing (after which cell damage promotes cycles of vasodilation and vasoconstriction), vascular stasis (hypoxia, acidosis, interstitial edema), and both early and late ischemia (a culmination of inflammatory and thrombotic cascades).3


When severe injury is


observed, angiography offers both a diagnostic and therapeutic approach which moves beyond standard rewarming techniques to alleviate microvascular thrombosis.


Although it appears that early intervention can help preserve digit function and reduce tissue loss, the magnitude of benefit and the approach that one should take are unclear.


Historically, data on intra-arterial (IA) or intravenous (IV) therapy has involved retrospective studies with small cohort sizes. For instance, Twomey et al. observed a reduction in predicted amputations1


while Bruen


et al. demonstrated a significantly lower incidence of amputation (10 percent vs. 41 percent) in patients suffering from severe frostbite.4


A


randomized controlled trial by Cauchy et al.5


observed amputation rates as low as 3 percent when combination


IA thrombolysis and iloprost (a prostacyclin analogue with vasodilator properties) were utilized. This study joined a small body of retrospective series and case reports/series6–10 suggesting that iloprost may serve a role in the treatment of severe frostbite. Recent retrospective studies are better powered and observe digit salvage rates of 69–83 percent8,11–13 utilizing protocols incorporating combinations of an IA thrombolytic (tPA; tenecteplase), anticoagulation (heparin; aspirin), and a vasodilator (alprostadil; nicardipine; nitroglycerin; papervine). Thus, the algorithm developed by Dr. Azene and his colleagues reflects current trends in patient selection and multidisciplinary management of frostbite injuries.


More online


See the online version at bit.ly/2Fef76b for the Gundersen Health System frostbite protocol flowchart.


References


1. Twomey JA, Peltier GL, Zera RT. An open-label study to evaluate the safety and efficacy of tissue plasminogen activator in treatment of severe frostbite. J Trauma. 2005;59(6):1350– 1354; discussion 1354–1355.


2. Johnson AR, Jensen HL, Peltier G, DelaCruz E. Efficacy of intravenous tissue plasminogen activator in frostbite patients and presentation of a treatment protocol for frostbite patients. Foot & Ankle Specialist. 2011;4(6):344–348.


3. Millet JD, Brown RK, Levi B, et al. Frostbite: Spectrum of imaging findings and


guidelines for management. Radiographics. 2016;36(7):2154–2169.


4. Bruen KJ, Ballard JR, Morris SE, Cochran A, Edelman LS, Saffle JR. Reduction of the incidence of amputation in frostbite injury with thrombolytic therapy. Arch Surg. 2007;142(6):546–551; discussion, 551–543.


5. Cauchy E, Cheguillaume B, Chetaille E. A controlled trial of a prostacyclin and rt-PA in the treatment of severe frostbite. New England Journal of Medicine. 2011;364(2):189–190.


6. Groechenig E. Treatment of frostbite with iloprost. Lancet. 1994;344(8930):1152–1153.


7. Poole A, Gauthier J. Treatment of severe frostbite with iloprost in northern Canada. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne. 2016;188(17–18):1255–1258.


8. Lindford A, Valtonen J, Hult M, et al. The evolution of the Helsinki frostbite management protocol. Burns. 2017;43(7):1455–1463.


9. Pandey P, Vadlamudi R, Pradhan R, Pandey KR, Kumar A, Hackett P. Case report: Severe frostbite in extreme altitude climbers—The Kathmandu iloprost experience. Wilderness & Environmental Medicine. 2018;29(3):366–374.


10. Cauchy E, Davis CB, Pasquier M, Meyer EF, Hackett PH. A new proposal for management of severe frostbite in the austere environment. Wilderness Environ Med. 2016;27(1):92–99.


11. Gonzaga T, Jenabzadeh K, Anderson CP, Mohr WJ, Endorf FW, Ahrenholz DH. Use of intra-arterial thrombolytic therapy for acute treatment of frostbite in 62 patients with review of thrombolytic therapy in frostbite. J Burn Care Res. 2016;37(4):e323–334.


12. Tavri S, Ganguli S, Bryan RG, et al. Catheter- directed intraarterial thrombolysis as part of a multidisciplinary management protocol of frostbite injury. J Vasc Interv Radiol. 2016;27(8):1228–1235.


13. Patel N, Srinivasa DR, Srinivasa RN, et al. Intra- arterial thrombolysis for extremity frostbite decreases digital amputation rates and hospital length of stay. Cardiovasc Intervent Radiol. 2017;40(12):1824–1831.


sirweb.org/irq | 33


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40