Frostbite: a practical approach to hospital management

Abstract

Frostbite presentation to hospital is relatively infrequent, and the optimal management of the more severely injured patient requires a multidisciplinary integration of specialist care. Clinicians with an interest in wilderness medicine/freezing cold injury have the awareness of specific potential interventions but may lack the skill or experience to implement the knowledge. The on-call specialist clinician (vascular, general surgery, orthopaedic, plastic surgeon or interventional radiologist), who is likely to receive these patients, may have the skill and knowledge to administer potentially limb-saving intervention but may be unaware of the available treatment options for frostbite. Over the last 10 years, frostbite management has improved with clear guidelines and management protocols available for both the medically trained and winter sports enthusiasts. Many specialist surgeons are unaware that patients with severe frostbite injuries presenting within 24 h of the injury may be good candidates for treatment with either TPA or iloprost. In this review, we aim to give a brief overview of field frostbite care and a practical guide to the hospital management of frostbite with a stepwise approach to thrombolysis and prostacyclin administration for clinicians.

Keywords: Frostbite; Heparin; Hypothermia; Iloprost; Rewarming; TPA; Thrombolysis.

Figure 1

Immediate hospital management of frostbite injury.

Figure 2

Algorithm for the use of rTPA and iloprost in the management of frostbite injuries.

Figure 3

Intra-arterial administration of rTPA and heparin and administration of intravenous iloprost. (a) Algorithm for the intra-arterial administration of tTPA and heparin for in-hospital thrombolysis of severe frostbite injury. (b) Algorithm for the administration of intravenous iloprost for in-hospital thrombolysis of severe frostbite injury.