A 28-year-old woman comes to the urgent care center at a ski resort due to frostbite. She dropped one of her gloves while riding the chairlift and was unable to find it while skiing down the slope. By the time the patient returned to the resort, she was experiencing numbness and paresthesias in her left hand. Her medical history is unremarkable, and her only regular medication is an oral contraceptive. The patient does not smoke and drinks alcohol only on social occasions. Temperature is 36.7 C (98 F), blood pressure is 108/65 mm Hg, and pulse is 88/min. Examination shows stiff, pale skin at the fourth and fifth digits of the left hand. Vesicles and small bullae are seen at the lateral aspect of the fingertips. The affected digits show absent light-touch sensation and capillary refill. Which of the following is the most appropriate next step in management of this patient's injury?

Question

A 28-year-old woman comes to the urgent care center at a ski resort due to frostbite.  She dropped one of her gloves while riding the chairlift and was unable to find it while skiing down the slope.  By the time the patient returned to the resort, she was experiencing numbness and paresthesias in her left hand.  Her medical history is unremarkable, and her only regular medication is an oral contraceptive.  The patient does not smoke and drinks alcohol only on social occasions.  Temperature is 36.7 C (98 F), blood pressure is 108/65 mm Hg, and pulse is 88/min.  Examination shows stiff, pale skin at the fourth and fifth digits of the left hand.  Vesicles and small bullae are seen at the lateral aspect of the fingertips.  The affected digits show absent light-touch sensation and capillary refill.  Which of the following is the most appropriate next step in management of this patient's injury?

Quizplus · Accepted Answer

11ec25c8_d494_04eb_bc81_d1dd92d2d20d_MD0003_00 Frostbite is characterized by freezing of tissue, leading to disruption of cell membranes, ischemia, vascular thrombosis, and inflammatory changes. Severity can range from superficial pallor and anesthesia to blistering, eschar formation, or deep-tissue necrosis and mummification. Affected tissues typically have a stiff or waxy texture. Most cases involve the face, ears, or distal limbs. Initial management of frostbite is based on rapid rewarming in a 37-39 C (98.6-102.2 F) water bath. Aggressive analgesia should be offered due to the potential of severe pain in the rewarming process. Hot air rewarming is not recommended due to the difficulty of maintaining precise temperature control (Choice D). In the field, rewarming can be accomplished by holding the affected limbs against the rescuer's abdomen. However, it should not be attempted if there is a possibility of refreezing before definitive care can be provided as it can worsen tissue damage. After rewarming, careful wound care should be provided to reduce the risk of secondary infection. (Choice A) Severe frostbite injuries may require multiple debridement procedures, but initial assessment may overestimate the extent of tissue damage. Debridement is not indicated until the tissue is rewarmed and an accurate survey of devitalized tissue can be performed. (Choice B) Intravenous infusion of warmed fluids is indicated in the management of systemic hypothermia but is not effective in frostbite injury. (Choice C) Calcium channel blockers (eg, nifedipine, amlodipine) are useful in the management of Raynaud phenomenon. Neurovascular injury in frostbite can lead to chronic Raynaud symptoms, but calcium channel blockers are not indicated in the acute injury. (Choice F) Thrombolytic therapy (eg, tissue plasminogen activator) can be considered for deep frostbite injury that is expected to require extensive amputation, although the evidence is limited. It is not advised in limited, distal frostbite. Educational objective: Initial management of frostbite is based on rapid rewarming of affected tissues in a 37-39 C (98.6-102.2 F) water bath. Hot air rewarming is not recommended, and rewarming should not be attempted if there is a possibility of refreezing before definitive care can be provided. References: Frostbite of the hand. (http://www.ncbi.nlm.nih.gov/pubmed/25154574)

A 28-Year-Old Woman Comes to the Urgent Care Center at a Ski