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EMERGENCY DEPARTMENT
Kristina A. Wiraputri
Emergency Department EKA Hospital Pekanbaru
2nd ASM on EM - Malang 2014
Topics
Definition
Epidemiology
Pathophysiology
Clinical Presentation
ED Evaluation
ED Management
Disposition
Common Pitfalls
Definition
the freezing and crystallizing of fluids in the
interstitial and cellular spaces as a
consequence of prolonged exposure to
freezing temperatures
◦ Homelessness
◦ Work related injuries
◦ Recreational
Risk Factors
Inadequate shelter
Inadequate or constrictive clothing
Winter season
Wind chill factor
High altitude
Prolonged exposure to cold
Prolonged exposure to moisture
Immobilization
Malnutrition and exhaustion
Previous cold injury
Acclimatization to tropical climates
Improper behavioral response to cold ambient temperature
Extremes of age
Homelessness
Altered mental status
Exposure to drugs with vasoconstrictive effects
Exposure to chronic hand or arm vibration
• negligible cutaneous blood flow <00C
• skin starts freezingfrostbite injury cascade initiated
• neurapraxia occurs 100C
• loss of cutaneous sensation
• vasoconstriction interrupted by rhythmic bursts of vasodilatation occurring <150C
3-5 times per hour and lasting 5-10 minutes (hunter’s response)
• Maximal vasoconstriction reached 150C
• Cutaneous blood flow 20-50 ml/min
(1) Pathophysiology
Pathophysiology (2)
Prefreeze State
◦ Tissue cooling
◦ Increased viscosity
◦ Capillary constriction-dilation cycle
Frozen State
◦ Extracellular ice crystal formation
◦ Intracellular dehydration & hyperosmolarity
◦ Fluid shifts across cell membranes
◦ Intracellular ice crystal formation
Pathophysiology (3)
◦ Penis
◦ Scrotum
◦ Cornea
ED Evaluation (1)
Physical examination
◦ Core temperature
◦ Neurologic & vascular exam
◦ Wound description
Laboratory studies
◦ Not for frostbite per se
◦ Evaluating concomittant illness or associated
conditions
Radiology studies
◦ Limited for trauma
ED Management (1)
Rapid rewarming
◦ Gently circulating water at 40-42 0C for 15-30 mins or until
thawing is complete (soft, flushed & pliable)
Adequate analgesia with iv opiates
Blisters care
Tetanus prophylaxis
Anti-inflammatory agents
◦ Topical aloe vera cream (Dermaide) q 6 hours
◦ Ibuprofen 12 mg/kg PO in divided doses
Elevate injured extremity
Benzyl penicillin 600 mg q 6 hours for 48-72h or
Penicillin G 500.000 U IV
Photographic records of wounds
McCauley RL, Hing DN, Robson MC, et al. Frostbite injuries: a rational
approach based on the pathophysiology. J Trauma 1983.
ED Management (2)
IV prostaglandin E1
Topical bacitracin or silver sulfadiazine
Oral methimazole (a thromboxane synthetase
inhibitor)
Topical methylprednisolone acetate (a
phospholipase A2 inhibitor)
Sympathetic blockade with reserpine
Low-molecular-weight dextran
Intraarterial rtPA
Disposition
Goal: ensure that patient will not re-enter the
same environment causing injury
Frostnip may be discharged to follow-up with
PHC provider
All frostbite to be admitted, need specialized