Cold damage to the extremities: frostbite and non-freezing cold injuries

Abstract

The treatment of cold injuries to the periphery has advanced substantially in the last 10 years and optimal outcomes are only likely to be achieved if a multidisciplinary team uses the full range of diagnostic and treatment modalities that are now available. The internet and satellite phones with digital images allow immediate access by patients from remote geographical locations to hospital based specialists who can assess cold injuries and advise on early field care. The severity of frostbite injuries can now be assessed with triple phase bone scanning, allowing early prediction of likely subsequent tissue loss. Early hyperbaric oxygen therapy appears to improve outcome and the use of intravenous drugs such as synthetic prostaglandin analogues infusions and tissue plasminogen activator have been shown to reduce amputation rates. In non-freezing cold injuries the early administration of analgesia, the avoidance of secondary exposure, and the use of infrared thermography to assess the injuries are among newer approaches being introduced.

A retrospective cohort study examining treatments and operative interventions for frostbite in a tertiary care hospital

“…Previous studies found elevated levels of prostaglandin and thromboxane in clear frostbite blister fluid. 13,23 These metabolites of arachidonic acid have been heavily implicated as mediators of progressive dermal ischemia in burn, frostbite, or ischemia/reperfusion injuries. 24 Debridement of clear blisters is included in the protocol as a means to remove these inflammatory agents and improve wound healing.…”

“…Severity of frostbite was categorized into superficial (1st and 2nd degree) or deep (3rd and 4th degree) ( Figure 1). 1,[10][11][12][13] Distribution of predisposing factors were compared between superficial and deep injuries using student t-tests for continuous variables and chi-squared or Fisher's exact tests for categorical variables. Patient encounters were reviewed to determine if the protocol was followed (Figure 2).…”

“…1 Despite these limitations, the McCauley protocol is frequently referenced in frostbite literature and medical textbooks as a standard guideline for frostbite treatment. 13,24,27 It should also be noted that as a guideline, it has undergone slight modifications since the original publication in 1983, and is now often quoted as "Treatment protocol for frostbite (after McCauley et al)" 13 or "Treatment protocol for frostbite (adapted from McCauley et al)" 24 . Smoking cessation, and regular ibuprofen (rather than aspirin) were not included in the original paper but are now generally accepted to be part of the protocol and were therefore included in our study.…”

“…Smoking cessation, and regular ibuprofen (rather than aspirin) were not included in the original paper but are now generally accepted to be part of the protocol and were therefore included in our study. 13,24,27 We used the McCauley protocol in our primary objective because we wanted to determine if a common, protocolled approach to treatment led to improved outcomes. Recognizing these limitations prior to beginning our study and the fact that physicians may use treatments outside of the protocol for frostbite injuries, we decided to include any treatments ordered for frostbite and whether they had an impact on operative interventions.…”

Variability in peripheral rewarming after cold stress among 255 healthy Norwegian army conscripts assessed by dynamic infrared thermography

“…Skin-surface temperature is highly dependent on blood circulation in the outer millimetres of the skin, which is controlled by a complex autonomic regulatory system as well as local factors. There are although research findings underpinning the fact that nerve function governing vessel diameter is essential in terms of regulation of peripheral microcirculation as part of the pathophysiology of cold injuries [5]. …”