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A New Proposal for Management of Severe Frostbite in the Austere Environment.
Wilderness Environ Med. 2016 Mar; 27(1):92-9.WE

Abstract

Despite advances in outdoor clothing and medical management of frostbite, individuals still experience catastrophic amputations. This is a particular risk for those in austere environments, due to resource limitations and delayed definitive treatment. The emerging best therapies for severe frostbite are thrombolytics and iloprost. However, they must be started within 24 hours after rewarming for recombinant tissue plasminogen activator (rt-PA) and within 48 hours for iloprost. Evacuation of individuals experiencing frostbite from remote environments within 24 to 48 hours is often impossible. To date, use of these agents has been confined to hospitals, thus depriving most individuals in the austere environment of the best treatment. We propose that thrombolytics and iloprost be considered for field treatment to maximize chances for recovery and reduce amputations. Given the small but potentially serious risk of complications, rt-PA should only be used for grade 4 frostbite where amputation is inevitable, and within 24 hours of rewarming. Prostacyclin has less risk and can be used for grades 2 to 4 frostbite within 48 hours of rewarming. Until more field experience is reported with these agents, their use should probably be restricted to experienced physicians. Other modalities, such as local nerve blocks and improving oxygenation at high altitude may also be considered. We submit that it remains possible to improve frostbite outcomes despite delayed evacuation using resource-limited treatment strategies. We present 2 cases of frostbite treated with rt-PA at K2 basecamp to illustrate feasibility and important considerations.

Authors+Show Affiliations

IFREMMONT: Institut de Recherche et de Formation en Medecine de Montagne, Hôpital de Chamonix, Chamonix, France (Dr Cauchy); Hôpitaux des Pays du Mont-Blanc, Sallanches, France (Dr Cauchy). Electronic address: cauchy@ifremmont.com.University of Colorado Denver School of Medicine, Department of Emergency Medicine, Aurora, CO (Drs Davis and Hackett).Emergency Service, Lausanne University Hospital, Lausanne, Switzerland (Dr Pasquier); Air-Glaciers SA and GRIMM, Sion, Switzerland (Dr Pasquier).Rural Partners in Medicine, LLC, Steamboat Springs, (Dr Meyer).University of Colorado Denver School of Medicine, Department of Emergency Medicine, Aurora, CO (Drs Davis and Hackett); Institute for Altitude Medicine, Telluride, CO (Dr Hackett).

Pub Type(s)

Journal Article

Language

eng

PubMed ID

26948558

Citation

Cauchy, Emmanuel, et al. "A New Proposal for Management of Severe Frostbite in the Austere Environment." Wilderness & Environmental Medicine, vol. 27, no. 1, 2016, pp. 92-9.
Cauchy E, Davis CB, Pasquier M, et al. A New Proposal for Management of Severe Frostbite in the Austere Environment. Wilderness Environ Med. 2016;27(1):92-9.
Cauchy, E., Davis, C. B., Pasquier, M., Meyer, E. F., & Hackett, P. H. (2016). A New Proposal for Management of Severe Frostbite in the Austere Environment. Wilderness & Environmental Medicine, 27(1), 92-9. https://doi.org/10.1016/j.wem.2015.11.014
Cauchy E, et al. A New Proposal for Management of Severe Frostbite in the Austere Environment. Wilderness Environ Med. 2016;27(1):92-9. PubMed PMID: 26948558.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - A New Proposal for Management of Severe Frostbite in the Austere Environment. AU - Cauchy,Emmanuel, AU - Davis,Christopher B, AU - Pasquier,Mathieu, AU - Meyer,Eric F, AU - Hackett,Peter H, PY - 2015/04/19/received PY - 2015/09/26/revised PY - 2015/11/30/accepted PY - 2016/3/8/entrez PY - 2016/3/8/pubmed PY - 2017/1/10/medline KW - field treatment KW - frostbite KW - prostacyclin KW - thrombolytics SP - 92 EP - 9 JF - Wilderness & environmental medicine JO - Wilderness Environ Med VL - 27 IS - 1 N2 - Despite advances in outdoor clothing and medical management of frostbite, individuals still experience catastrophic amputations. This is a particular risk for those in austere environments, due to resource limitations and delayed definitive treatment. The emerging best therapies for severe frostbite are thrombolytics and iloprost. However, they must be started within 24 hours after rewarming for recombinant tissue plasminogen activator (rt-PA) and within 48 hours for iloprost. Evacuation of individuals experiencing frostbite from remote environments within 24 to 48 hours is often impossible. To date, use of these agents has been confined to hospitals, thus depriving most individuals in the austere environment of the best treatment. We propose that thrombolytics and iloprost be considered for field treatment to maximize chances for recovery and reduce amputations. Given the small but potentially serious risk of complications, rt-PA should only be used for grade 4 frostbite where amputation is inevitable, and within 24 hours of rewarming. Prostacyclin has less risk and can be used for grades 2 to 4 frostbite within 48 hours of rewarming. Until more field experience is reported with these agents, their use should probably be restricted to experienced physicians. Other modalities, such as local nerve blocks and improving oxygenation at high altitude may also be considered. We submit that it remains possible to improve frostbite outcomes despite delayed evacuation using resource-limited treatment strategies. We present 2 cases of frostbite treated with rt-PA at K2 basecamp to illustrate feasibility and important considerations. SN - 1545-1534 UR - https://www.unboundmedicine.com/medline/citation/26948558/A_New_Proposal_for_Management_of_Severe_Frostbite_in_the_Austere_Environment_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S1080-6032(15)00460-3 DB - PRIME DP - Unbound Medicine ER -