- Email: [email protected]
Frostbite: Case Report, Practical Summary of ED Treatment
TRAUMA NOTEBOOK
Frostbite: Case Report, Practical Summary of ED Treatment Author: Ruth McGillion, RN, BSN, ONC, Portland, Ore Section Editor: Maureen Harrahill, RN, MS, ACNP-CS
Ruth McGillion is Nursing Practice and Education Coordinator, Ortho/Trauma, Oregon Health & Science University, Portland, Ore. For correspondence, write: Ruth McGillion, Nursing Practice and Education Coordinator, Ortho/Trauma, Oregon Health & Science University, 3181 SW Sam Jackson Park Road—UHS8K, Portland, OR 97239-3098; E-mail: [email protected]. J Emerg Nurs 2005;31:500Q2. 0099-1767/$30.00 Copyright n 2005 by the Emergency Nurses Association. doi: 10.1016/j.jen.2005.07.002
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ate last fall, hikers in a mountainous area found a 57-year-old woman sitting in a snow bank in light clothing and running shoes. She told the hikers that she had been out in the woods for several days on a ‘‘spiritual journey.’’ Her vital signs on arrival at the emergency department were as follows: temperature, 32.98C (91.28F); blood pressure, 136/115 mm Hg; heart rate, 120 beats per minute; respiratory rate, 16 breaths per minute; and Spo2, 100% on room air. Her shoes and socks were frozen to her feet, and we had to cut them off before we started rewarming her. Both her feet appeared pale and frozen, and she was unable to move either foot initially. She had a weak pulse by Doppler, detected only in the right posterior tibial artery. We placed a large femoral line to infuse warmed saline, in addition to using multiple warming blankets and a Bair HuggerR. We warmed her feet by running warm water over them until they felt warm, which took about 20 minutes. By the time she was admitted to the ICU, her temperature had increased to 36.88C (98.28F). She was able to flex and extend her ankles and could weakly wiggle her toes. She had decreased sensation and ‘‘burning’’ discomfort of both feet. After 24 hours in the ICU, the left foot injury demarcated at the toes and the right foot injury demarcated at mid foot. Subsequently, the patient was transferred to the ward and a cellulitis of the right leg appeared to develop. She had fever spikes as high as 38.98C (1028F). The patient stated she was ‘‘allergic’’ to all Western medicine and was unwilling to accept any antibiotic therapy. At this time, a psychiatric consult was initiated with eventual involvement of the hospital Ethics Committee and the Palliative
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Care Team. The patient continued to refuse all treatment other than occasional pain medication administration and visits from her acupuncturist. She consented to dressing changes to her feet. While the patient continued to be intermittently febrile, the appearance of the right leg improved. She was discharged to an adult foster care home 20 days after admission. Discussion
Frostbite is a cold-induced injury that usually affects the extremities. It is classified as superficial or deep.1 Superficial frostbite affects the skin and subcutaneous tissue. When rewarmed, the skin will have clear blisters, which is a good prognostic indicator.1 Deep frostbite affects the tissues, bones, tendons, and joints. When deep frostbitten tissue is rewarmed, the skin forms hemorrhagic blisters, a poor prognostic indicator.1 Physiologically, tissue damage from cold temperatures has two mechanisms: (1) direct cellular injury at the time of the exposure from ice crystals, and (2) progressive ischemia-related tissue damage resulting from vasoconstriction, endothelial injury, and the presence of inflammatory mediators.1,2 Treatment includes rewarming the extremity, providing pain relief, minimizing the inflammatory process, and preventing complications.
[One..] objective is to provide adequate analgesia, which will be particularly important as sensation returns to the affected extremity. The pain can be intense. . . . Rapid rewarming is the first treatment objective. In the emergency department, the frostbitten extremity should be placed in a warm water bath for 15 to 30 minutes.2 A mild antibacterial agent, such as hexachlorophene, can be added to the bath. The water temperature should be between 408C (1048F) and 428C (107.68F).2 The frostbitten tissue is so fragile that meeting this narrow temperature range is important; warmer water could cause a burn, and cooler water could affect the survival of the tissues. The team should ensure the extremity is protected
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from the sides of the bath container to prevent any additional tissue damage. Similarly, the extremity should not be massaged as it rewarms. The goals of the water bath are to see the skin color change to reddish purple and to feel the tissue become pliable. The second treatment objective is to provide adequate analgesia, which will be particularly important as sensation returns to the affected extremity. The pain can be intense for the patient.
The water temperature should be between 40 8C (1048F) and 428C (107.6 8F). The frostbitten tissue is so fragile that meeting this narrow temperature range is important; warmer water could cause a burn, and cooler water could affect the survival of the tissues. The only way to effectively prevent progressive vascular ischemia is to block the production of prostaglandins and thromboxane inflammatory mediators through the use of ibuprofen and topical aloe vera.2 Elevating the affected extremity can help decrease edema as well. Preventing complications is the last treatment objective. Some patients may have a cold diuresis from suppression of antidiuretic hormone, so replacing fluid and monitoring fluid balance is important. Also, because the damaged tissue is tetanus-prone, the patient may need prophylaxis. Careful skin care is essential to prevent further damage or infection. Using a soft fabric, such as wool with aloe vera, between the toes and fingers to keep them separate can help prevent skin from re-injury and sloughing. The use of a blanket cradle or boot may help prevent further mechanical trauma to the injured tissue. Finally, never attempt to rewarm a frost-bitten part if there is a chance that refreezing could occur, for example, in transit from the scene of injury. An old saying goes, ‘‘Frostbite in January, amputate in July.’’ Surgical debridement is usually a late treatment option. It is difficult in the early stages to accurately assess
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the true extent of the tissue damage. The only reason to debride early is if there are signs of infection, particularly gas gangrene.
The only way to effectively prevent progressive vascular ischemia is to block the production of prostaglandins and thromboxane inflammatory mediators through the use of ibuprofen and topical aloe vera. Elevating the affected extremity can help decrease edema as well. Follow up
Our patient was readmitted approximately 1 month after discharge for surgical amputation and debridement of several gangrenous toes on her right foot. Her surgery and recovery were uneventful, and she was discharged back to her adult foster care home after 5 days with dressing changes and follow-up care in our trauma clinic. REFERENCES 1. Biem J, Koehncke N, Classen D, Dosman J. Out of the cold: management of hypothermia and frostbite. Can Med Assoc J 2003;168:305-11. 2. Murphy J, Banwell P, Roberts A, McGrouther D. Frostbite: pathogenesis and treatment. J Trauma 2000;48:171-88.
Contributions for this column are welcomed and encouraged. Submissions should be sent to: Maureen Harrahill, RN, MS, ACNP-CS 1404 SE Malden, Portland, OR 97202 503 494-6007 . [email protected]
502
JOURNAL OF EMERGENCY NURSING
31:5
October 2005
Frostbite: Case Report, Practical Summary of ED Treatment Author: Ruth McGillion, RN, BSN, ONC, Portland, Ore Section Editor: Maureen Harrahill, RN, MS, ACNP-CS
Ruth McGillion is Nursing Practice and Education Coordinator, Ortho/Trauma, Oregon Health & Science University, Portland, Ore. For correspondence, write: Ruth McGillion, Nursing Practice and Education Coordinator, Ortho/Trauma, Oregon Health & Science University, 3181 SW Sam Jackson Park Road—UHS8K, Portland, OR 97239-3098; E-mail: [email protected]. J Emerg Nurs 2005;31:500Q2. 0099-1767/$30.00 Copyright n 2005 by the Emergency Nurses Association. doi: 10.1016/j.jen.2005.07.002
500
L
ate last fall, hikers in a mountainous area found a 57-year-old woman sitting in a snow bank in light clothing and running shoes. She told the hikers that she had been out in the woods for several days on a ‘‘spiritual journey.’’ Her vital signs on arrival at the emergency department were as follows: temperature, 32.98C (91.28F); blood pressure, 136/115 mm Hg; heart rate, 120 beats per minute; respiratory rate, 16 breaths per minute; and Spo2, 100% on room air. Her shoes and socks were frozen to her feet, and we had to cut them off before we started rewarming her. Both her feet appeared pale and frozen, and she was unable to move either foot initially. She had a weak pulse by Doppler, detected only in the right posterior tibial artery. We placed a large femoral line to infuse warmed saline, in addition to using multiple warming blankets and a Bair HuggerR. We warmed her feet by running warm water over them until they felt warm, which took about 20 minutes. By the time she was admitted to the ICU, her temperature had increased to 36.88C (98.28F). She was able to flex and extend her ankles and could weakly wiggle her toes. She had decreased sensation and ‘‘burning’’ discomfort of both feet. After 24 hours in the ICU, the left foot injury demarcated at the toes and the right foot injury demarcated at mid foot. Subsequently, the patient was transferred to the ward and a cellulitis of the right leg appeared to develop. She had fever spikes as high as 38.98C (1028F). The patient stated she was ‘‘allergic’’ to all Western medicine and was unwilling to accept any antibiotic therapy. At this time, a psychiatric consult was initiated with eventual involvement of the hospital Ethics Committee and the Palliative
JOURNAL OF EMERGENCY NURSING
31:5
October 2005
TRAUMA NOTEBOOK/McGillion
Care Team. The patient continued to refuse all treatment other than occasional pain medication administration and visits from her acupuncturist. She consented to dressing changes to her feet. While the patient continued to be intermittently febrile, the appearance of the right leg improved. She was discharged to an adult foster care home 20 days after admission. Discussion
Frostbite is a cold-induced injury that usually affects the extremities. It is classified as superficial or deep.1 Superficial frostbite affects the skin and subcutaneous tissue. When rewarmed, the skin will have clear blisters, which is a good prognostic indicator.1 Deep frostbite affects the tissues, bones, tendons, and joints. When deep frostbitten tissue is rewarmed, the skin forms hemorrhagic blisters, a poor prognostic indicator.1 Physiologically, tissue damage from cold temperatures has two mechanisms: (1) direct cellular injury at the time of the exposure from ice crystals, and (2) progressive ischemia-related tissue damage resulting from vasoconstriction, endothelial injury, and the presence of inflammatory mediators.1,2 Treatment includes rewarming the extremity, providing pain relief, minimizing the inflammatory process, and preventing complications.
[One..] objective is to provide adequate analgesia, which will be particularly important as sensation returns to the affected extremity. The pain can be intense. . . . Rapid rewarming is the first treatment objective. In the emergency department, the frostbitten extremity should be placed in a warm water bath for 15 to 30 minutes.2 A mild antibacterial agent, such as hexachlorophene, can be added to the bath. The water temperature should be between 408C (1048F) and 428C (107.68F).2 The frostbitten tissue is so fragile that meeting this narrow temperature range is important; warmer water could cause a burn, and cooler water could affect the survival of the tissues. The team should ensure the extremity is protected
October 2005
31:5
from the sides of the bath container to prevent any additional tissue damage. Similarly, the extremity should not be massaged as it rewarms. The goals of the water bath are to see the skin color change to reddish purple and to feel the tissue become pliable. The second treatment objective is to provide adequate analgesia, which will be particularly important as sensation returns to the affected extremity. The pain can be intense for the patient.
The water temperature should be between 40 8C (1048F) and 428C (107.6 8F). The frostbitten tissue is so fragile that meeting this narrow temperature range is important; warmer water could cause a burn, and cooler water could affect the survival of the tissues. The only way to effectively prevent progressive vascular ischemia is to block the production of prostaglandins and thromboxane inflammatory mediators through the use of ibuprofen and topical aloe vera.2 Elevating the affected extremity can help decrease edema as well. Preventing complications is the last treatment objective. Some patients may have a cold diuresis from suppression of antidiuretic hormone, so replacing fluid and monitoring fluid balance is important. Also, because the damaged tissue is tetanus-prone, the patient may need prophylaxis. Careful skin care is essential to prevent further damage or infection. Using a soft fabric, such as wool with aloe vera, between the toes and fingers to keep them separate can help prevent skin from re-injury and sloughing. The use of a blanket cradle or boot may help prevent further mechanical trauma to the injured tissue. Finally, never attempt to rewarm a frost-bitten part if there is a chance that refreezing could occur, for example, in transit from the scene of injury. An old saying goes, ‘‘Frostbite in January, amputate in July.’’ Surgical debridement is usually a late treatment option. It is difficult in the early stages to accurately assess
JOURNAL OF EMERGENCY NURSING
501
TRAUMA NOTEBOOK/McGillion
the true extent of the tissue damage. The only reason to debride early is if there are signs of infection, particularly gas gangrene.
The only way to effectively prevent progressive vascular ischemia is to block the production of prostaglandins and thromboxane inflammatory mediators through the use of ibuprofen and topical aloe vera. Elevating the affected extremity can help decrease edema as well. Follow up
Our patient was readmitted approximately 1 month after discharge for surgical amputation and debridement of several gangrenous toes on her right foot. Her surgery and recovery were uneventful, and she was discharged back to her adult foster care home after 5 days with dressing changes and follow-up care in our trauma clinic. REFERENCES 1. Biem J, Koehncke N, Classen D, Dosman J. Out of the cold: management of hypothermia and frostbite. Can Med Assoc J 2003;168:305-11. 2. Murphy J, Banwell P, Roberts A, McGrouther D. Frostbite: pathogenesis and treatment. J Trauma 2000;48:171-88.
Contributions for this column are welcomed and encouraged. Submissions should be sent to: Maureen Harrahill, RN, MS, ACNP-CS 1404 SE Malden, Portland, OR 97202 503 494-6007 . [email protected]
502
JOURNAL OF EMERGENCY NURSING
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October 2005