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The evolution of the Helsinki frostbite management protocol.
Burns. 2017 Nov; 43(7):1455-1463.B

Abstract

BACKGROUND

Severe frostbite can result in devastating injuries leading to significant morbidity and loss of function from distal extremity amputation. The modern day management approach to frostbite injuries is evolving from a historically very conservative approach to the increasingly reported use of early interventional angiography and fibrinolysis with tPA. The aim of this study was to evaluate the results of our frostbite treatment protocol introduced 3 years ago.

METHODS

All frostbite patients underwent first clinical and then Doppler ultrasound examination. Angiography was conducted if certain clinical criteria indicated a severe frostbite injury and if there were no contraindications to fibrinolysis. Intra-arterial tissue plasminogen activator (tPA) was then administered at 0.5-1mg/h proximal to the antecubital fossa (brachial artery) or popliteal fossa (femoral artery) if angiography confirmed thrombosis, as well as unfractionated intravenous heparin at 500 units/h. The vasodilator iloprost was administered intravenously (0.5-2.0ng/kg/min) in selected cases.

RESULTS

20 patients with frostbite were diagnosed between 2013-2016. Fourteen patients had a severe injury and angiography was performed in 10 cases. The total number of digits at risk was 111. Nine patients underwent fibrinolytic treatment with tPA (including one patient who received iloprost after initial non response to tPA), 3 patients were treated with iloprost alone and 2 patients received neither treatment modality (due to contraindications). The overall digital salvage rate was 74.8% and the Hennepin tissue salvage rate was 81.1%. One patient developed a catheter-site pseudoaneurysm that resolved after conservative treatment.

CONCLUSIONS

Prompt referral to a facility where interventional radiology and 24/7 laboratory services are available, and the combined use of tPA and iloprost, may improve outcome after severe frostbite.

Authors+Show Affiliations

Helsinki Burn Centre, Department of Plastic Surgery, Töölö Hospital, Helsinki University Hospital, University of Helsinki, Finland. Electronic address: andrew.lindford@hus.fi.Helsinki Burn Centre, Department of Plastic Surgery, Töölö Hospital, Helsinki University Hospital, University of Helsinki, Finland.Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.Helsinki Burn Centre, Department of Plastic Surgery, Töölö Hospital, Helsinki University Hospital, University of Helsinki, Finland.Department of Radiology, HUS Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.Coagulation Disorders Unit, Department of Hematology, Helsinki University Hospital, Comprehensive Cancer Center, University of Helsinki, Helsinki, Finland.Helsinki University Hospital, Abdominal Center, Vascular Surgery, University of Helsinki, Helsinki, Finland.Helsinki Burn Centre, Department of Plastic Surgery, Töölö Hospital, Helsinki University Hospital, University of Helsinki, Finland.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

28778759

Citation

Lindford, Andrew, et al. "The Evolution of the Helsinki Frostbite Management Protocol." Burns : Journal of the International Society for Burn Injuries, vol. 43, no. 7, 2017, pp. 1455-1463.
Lindford A, Valtonen J, Hult M, et al. The evolution of the Helsinki frostbite management protocol. Burns. 2017;43(7):1455-1463.
Lindford, A., Valtonen, J., Hult, M., Kavola, H., Lappalainen, K., Lassila, R., Aho, P., & Vuola, J. (2017). The evolution of the Helsinki frostbite management protocol. Burns : Journal of the International Society for Burn Injuries, 43(7), 1455-1463. https://doi.org/10.1016/j.burns.2017.04.016
Lindford A, et al. The Evolution of the Helsinki Frostbite Management Protocol. Burns. 2017;43(7):1455-1463. PubMed PMID: 28778759.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - The evolution of the Helsinki frostbite management protocol. AU - Lindford,Andrew, AU - Valtonen,Jussi, AU - Hult,Maarit, AU - Kavola,Heli, AU - Lappalainen,Kimmo, AU - Lassila,Riitta, AU - Aho,Pekka, AU - Vuola,Jyrki, Y1 - 2017/08/01/ PY - 2016/12/11/received PY - 2017/04/10/revised PY - 2017/04/11/accepted PY - 2017/8/6/pubmed PY - 2018/6/5/medline PY - 2017/8/6/entrez KW - Amputation KW - Cold injury KW - Extremity salvage KW - Thrombolytic therapy SP - 1455 EP - 1463 JF - Burns : journal of the International Society for Burn Injuries JO - Burns VL - 43 IS - 7 N2 - BACKGROUND: Severe frostbite can result in devastating injuries leading to significant morbidity and loss of function from distal extremity amputation. The modern day management approach to frostbite injuries is evolving from a historically very conservative approach to the increasingly reported use of early interventional angiography and fibrinolysis with tPA. The aim of this study was to evaluate the results of our frostbite treatment protocol introduced 3 years ago. METHODS: All frostbite patients underwent first clinical and then Doppler ultrasound examination. Angiography was conducted if certain clinical criteria indicated a severe frostbite injury and if there were no contraindications to fibrinolysis. Intra-arterial tissue plasminogen activator (tPA) was then administered at 0.5-1mg/h proximal to the antecubital fossa (brachial artery) or popliteal fossa (femoral artery) if angiography confirmed thrombosis, as well as unfractionated intravenous heparin at 500 units/h. The vasodilator iloprost was administered intravenously (0.5-2.0ng/kg/min) in selected cases. RESULTS: 20 patients with frostbite were diagnosed between 2013-2016. Fourteen patients had a severe injury and angiography was performed in 10 cases. The total number of digits at risk was 111. Nine patients underwent fibrinolytic treatment with tPA (including one patient who received iloprost after initial non response to tPA), 3 patients were treated with iloprost alone and 2 patients received neither treatment modality (due to contraindications). The overall digital salvage rate was 74.8% and the Hennepin tissue salvage rate was 81.1%. One patient developed a catheter-site pseudoaneurysm that resolved after conservative treatment. CONCLUSIONS: Prompt referral to a facility where interventional radiology and 24/7 laboratory services are available, and the combined use of tPA and iloprost, may improve outcome after severe frostbite. SN - 1879-1409 UR - https://www.unboundmedicine.com/medline/citation/28778759/The_evolution_of_the_Helsinki_frostbite_management_protocol_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0305-4179(17)30250-4 DB - PRIME DP - Unbound Medicine ER -