A 24-year-old man comes to the physician with cold extremities and loss of feeling in his hands. He is a mountaineer who was on an expedition to climb Mt. Rainier. His group became lost in a storm and was stranded at high altitude due to reduced visibility and high winds. The patient had several hours of exposure to very low ambient temperatures before being rescued. He had on 2 pairs of gloves, including a woolen inner pair and an outer shell. However, the outer shell was damaged during the climb.
Vital signs are within normal limits. Examination shows that the first through third digits are white, cold, numb, and firm distal to the first interphalangeal joint.
The fingers are immersed rapidly in water heated to 38 C (100.4 F). After 30 minutes, the fingers are purplish-red between the proximal interphalangeal and distal interphalangeal joints.
Which of the following is the best next step in managing this patient?

Question

A 24-year-old man comes to the physician with cold extremities and loss of feeling in his hands.  He is a mountaineer who was on an expedition to climb Mt. Rainier.  His group became lost in a storm and was stranded at high altitude due to reduced visibility and high winds.  The patient had several hours of exposure to very low ambient temperatures before being rescued.  He had on 2 pairs of gloves, including a woolen inner pair and an outer shell.  However, the outer shell was damaged during the climb.
Vital signs are within normal limits.  Examination shows that the first through third digits are white, cold, numb, and firm distal to the first interphalangeal joint.
The fingers are immersed rapidly in water heated to 38 C (100.4 F).  After 30 minutes, the fingers are purplish-red between the proximal interphalangeal and distal interphalangeal joints.
Which of the following is the best next step in managing this patient?

Quizplus · Accepted Answer

Frostbite is a severe and localized cold-induced injury most commonly affecting the ears, nose, cheeks, chin, fingers, and toes. It is further classified as first degree (superficial localized pallor and surrounding edema), second degree (large blisters that may form eschar), third degree (deeper and smaller hemorrhagic blisters), and fourth degree (tissue necrosis extending to muscle and bone). Diagnosis is usually clinical in susceptible individuals (eg, the homeless, mountaineers, soldiers, those stranded or working in the cold). Technetium (Tc)-99 scintigraphy may predict long-term viability of affected tissue. Treatment involves rapid rewarming with water heated to 37-39 C (98.6-102.2 F) (not hot) to reduce tissue damage and analgesics (eg, opioids) for pain control. After thawing is complete (usually in 15-30 minutes), localized tissue usually appears red or purple and is soft to the touch. After rewarming, the affected areas are usually air dried and covered with a first layer of nonadherent gauze using aseptic technique. Other treatment measures include tetanus prophylaxis, possible splinting to prevent contractures, daily hydrotherapy, and elevation of the affected area (to reduce edema). Severe frostbite may require early surgical consultation for possible tissue debridement, escharotomy, or amputation. (Choice A) There is insufficient data on whether hyperbaric oxygen therapy is useful in the treatment of frostbite. (Choice B) Limited evidence for thrombolytics suggests benefit in severe frostbite patients at high risk for life-altering amputation (eg, multiple digits, proximal amputation) and who present < 24 hours from injury without contraindications to tissue plasminogen activator use. However, clinicians must assess the risk/benefit ratio for each patient. < (Choice D) Occlusive dressings may extend tissue damage and are usually avoided. (Choice E) Prophylactic antibiotics are given only for signs of infection, which are not present in this patient. Educational objective: Frostbite is a severe and localized cold-induced injury. It is best treated with rapid rewarming with water temperatures of 37-39 C (98.6-102.2 F). After rewarming, the affected areas are usually air dried and covered with nonadherent gauze. Daily hydrotherapy with subsequent dressing changes and elevation of the affected area aid the healing of superficial frostbite. __________ References: A clinical review of the management of frostbite. (http://www.ncbi.nlm.nih.gov/pubmed/21465915)

A 24-Year-Old Man Comes to the Physician with Cold Extremities