Jack frostbite nipping at your medial three fingertips bilaterally

Jack frostbite nipping at your medial three fingertips bilaterally

Visual Journal of Emergency Medicine 5 (2016) 50–51 Contents lists available at ScienceDirect HOSTED BY Visual Journal of Emergency Medicine journa...

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Visual Journal of Emergency Medicine 5 (2016) 50–51

Contents lists available at ScienceDirect

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Visual Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/visj

Visual case discussion

Jack frostbite nipping at your medial three fingertips bilaterally Carla Sterling a,n, Mark Silverberg b a b

Clinical Instructor, SUNY Downstate/Kings County Hospital, Brooklyn, NY, United States Associate Residency Program Director, Associate Professor of EM, SUNY Downstate/Kings County Hospital, Brooklyn, NY, United States

art ic l e i nf o Article history: Received 16 June 2016 Accepted 21 June 2016 Keywords: Frostbite Autoamputation Cold injury Demarcation

1. Visual case disscusion This is a case of a 33 year old man, with a history of paranoid schizophrenia, who presented with known frostbite of the 3rd though 5th digits of both hands, from the level of the proximal interphalangeal joints (PIP), distally. The patient was first seen in our emergency department in the first week of march, with evidence of frostbite. He was seen by the hand surgery specialist and it was determined that the effected portions would autoamputate, and to follow up periodically in the hand clinic, or the emergency department for development of systemic or local signs of infection, or for increased pain, which is what brought him in the day the photo was taken. Our patient demonstrates grade IV frostbite, with complete tissue death to the level of the bone, and evidence of initiation of autoamputation. Our patient was examined, with no signs of infection, and referred to hand clinic for the following week. Return precautions were given to both the patient and his sister, with whom he lives and is his primary caregiver. These precautions included systemic signs of infection, such as fever, as well as local signs of infection, including worsened swelling, erythema, warmth proximal to the frostbitten tissue, or drainage of serosanguinous fluid or pus. Frostbite occurs when body tissues are damaged due to exposure to temperatures below their freezing points. There are four phases, and four grades of frostbite. The first phase is the “prefreeze” when tissues are cooled without crystal formation. This phase begins the dysregulation of blood vessels, initiating ischemia, and patient will experience paresthesias. The second phase “freeze-thaw” occurs with crystal formation intra- or n

Corresponding author.

http://dx.doi.org/10.1016/j.visj.2016.06.007 2405-4690/& 2016 Elsevier Inc. All rights reserved.

Fig. 1. Frostbite of the 3rd, 4th, and 5th digits bilaterally. Mummification and autoamputation is seen in these digits.

extracellularly, and causes cellular protein and lipid derangements with shifting of cellular electrolytes, and results in cell membrane lysis and cell death. The third phase “vascular stasis” results in microvasuclar leakage and thrombosis due to intermittent microvascular constriction and dilation. The “late ischemic” phase causes the destruction of microvascular circulation, because of activation of coagulation cascades via inflammatory marker influx to the area of injury. What results is microvascular embolic showers and thrombus formation in the larger vessels. Patients are at highest

C. Sterling, M. Silverberg / Visual Journal of Emergency Medicine 5 (2016) 50–51

risk for reperfusion injuries during this phase. During any of the four phases of frostbite, refreezing will significantly worsen course of injury and clinical outcome. Frostbite is graded according to the level of injury and extent of damage, and is divided into four categories. Frostnip is not actually frostbite, and constitutes a superficial non-freezing cold weather injury caused by intense vasoconstriction. Ice crystals form only on the surface of the skin and there is no long-term tissue damage. Symptoms will resolve rapidly once areas affected by frostnip are protected from the cold, but frostnip is a sign of impending frostbite and actions should be taken to avoid further injury. First-degree frostbite also has no gross tissue infarction, and presents with erythema and usually edema of the affected skin. Patients will also develop firm raised yellow or white plaques, and complain of paresthesias. Seconddegree frostbite will cause development of superficial vesicles with clear or milky fluid in them, with surrounding edema and erythema. Third degree frostbite causes development of blisters that involve deeper layers of dermis, but not below the level of the dermis. The blisters tend to be hemorrhagic because they involve the dermal vascular plexus. Fourth degree frostbite involves all levels of the dermis, and extends beyond the avascular fascial layers into muscle and bone. Grades of frostbite are sometimes simplified by dividing them into superficial versus deep frostbite, the former having no anticipated tissue loss. Treatment of frostbite is multifactorial. Prevention of cold weather injury is the first approach in all cases, but when cold weather injury is present the most important step is to remove the patient or the affected body area from further injury. That means removal of any wet or frozen clothing, and protection from refreezing injury. If refreezing is a risk, it is better not to thaw as refreezing can worsen outcome. The following treatments are level 1C recommendations. When frostbite is present with concomitant hypothermia, the first step is to treat hypothermia. Hydration is paramount because hypovolemia can impede recovery from frostbite. Use warm oral or IV fluids. Any frozen extremity should be protected from further trauma, including avoidance of ambulation on frozen toes or feet, or climbing with frozen fingers or hands. Analgesia during rewarming. If rapid rewarming is not available and refreezing is not a risk, passive thawing should be allowed. Antibiotics should be administered for patients with significant polytrauma, or signs of

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infection such as cellulitis or abscess. Tetanus should be administered in the same indications as for other trauma. Bulky dressings should be applied to the affected body parts with care taken not to wrap too tightly to swollen, edematous extremities, with the limb elevated above the level of the heart. Rapid rewarming in the field with water heated to 37-39C (98.6-102.2F) should be initiated if refreezing injury is not a risk. Since water should be circulated around the effected body part, it will need continuous warming. This is a level 1b recommendation. Controversies in treatment: 1. tPA: The theory is that if a patient sustains deep frostbite, using tPA or other thrombolytics might salvage tissue that otherwise would be irreversibly damaged after freezing injury. Considering the mechanisms of the higher grades of frostbite, this makes sense, and has been validated in trials at Mass General, Hennepin, and other facilities. This is not a treatment for superficial frostbite injuries. 2. HBO: There have been case series but no controlled trials. The theory is to increase tissue oxygenation and decrease bacterial load in the tissues. However, the data is too limited to make recommendations. Frostbite occurs when body tissues are damaged due to exposure to temperatures below their freezing point. There are four phases, and four grades of frostbite. The first phase is the “prefreeze” when tissues are cooled without crystal formation. This phase begins the dysregulation of blood vessels, initiating ischemia, and the patient will experience paresthesias (Fig. 1).

Appendix A. Supporting information Supplementary data associated with this article can be found in the online version at http://dx.doi.org/10.1016/j.visj.2016.06.007.

References 1. Keil, et al. Freezing and non-freezing cold weather injuries: a systematic review. Br Med Bull 2015;117(1):79–93. http://dx.doi.org/10.1093/bmb/ldw001. 2. McIntosh, et al. Wilderness medical society practice guidelines for the prevention and treatment of frostbite. Wilderness Environ Med 2011;22(2):156–166. http://dx.doi.org/10.1016/j.wem.2011.03.003.