Anyone work with frostbite patients in here?

[flightdoc09]

Are any podiatrists here that are well versed in the care of frostbite? I'm working on a project to create a quick reference for frostbite care and looking for anyone that can help. The main thing I'm really looking for is pictures. I'm trying to get a collection that shows multiple examples of each type of frost bite, but especially pictures that show it in the early stages and how it evolves, as well as atypical cases that look more mild than they really are. The goal being to help identify patients that may benefit from emergent transfer to a center that can administer TPA (or iloprost that's just been approved) or do other interventions that can save digits and such.

Haven't been able to find a ton online that show what I'm looking for. I know frostbite is usually taken care of by burn units, but I figure podiatry likely gets involved at some institutions that have them on staff.

Please let me know if you can help, or know of anyone that works in a cold environment and could maybe help. Thanks

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[Dermato Fight Club]

I was born/raised/went to school/practice in florida.

I had my first “frost bite” patient about 6 years ago come in after a vacation to colorado.

I said why did you come to me? I always skipped that chapter in school.

 

[Bluecollarmed]

Midwest here. Don't see a ton of it as like you say they go to burn. Raynauds though...every other patient some days. I had a patient in residency with a calc fracture we were fixing on one side but they consulted burn unit for mild frostbite to his toes lol.

 

[Feli]

It doesn't have to be super cold, just gets cold overnight.
A good amount of IHS pts falling asleep (usually intoxicated), frostbite.

I never did any pics (peak Covid at the time, can't bumble with all the PPE and camera)...
Just painted w betadine, did amp a few months later as indicated.

There are plenty of frostbite cases in those IHS hospitals in high deserts, but they're not exactly academic or go-getter type of docs overall.

 

[Retrograde_Nail]

I see frostbite on a regular basis. We get a lot of intoxicated native Americans falling asleep outside or a lot of homelessness exposed to the elements. I live in an area where we get few weeks in the negatives during the long winter.

We also see frostbite in polytrauma/MVC patients who get ejected from the car and are exposed to the elements and get frostbite before being rescued.

We have developed an algorithm to try and salvage frostbite injuries which is early administration of tPA and we will get vascular or IR involved to see if there is anything we can do endovascularly.

We also put these patients in the hyperbaric oxygen chamber as well.

 

[Sweatshirt]

I've had 2 recently. One guy ended up needing a BKA because of how much damage there was (was outside in the snow for about 30 hours without shoes). The other lady had it at 3 digits but it was just superficial and they bounced back after watching closely for 8 weeks and occasional debridements of the edges. Will try to find pics on Monday

 

[flightdoc09]

I see frostbite on a regular basis. We get a lot of intoxicated native Americans falling asleep outside or a lot of homelessness exposed to the elements. I live in an area where we get few weeks in the negatives during the long winter.

We also see frostbite in polytrauma/MVC patients who get ejected from the car and are exposed to the elements and get frostbite before being rescued.

We have developed an algorithm to try and salvage frostbite injuries which is early administration of tPA and we will get vascular or IR involved to see if there is anything we can do endovascularly.

We also put these patients in the hyperbaric oxygen chamber as well.

Have you heard of iloprost? I'm not affiliated with the company, but found out recently it has been approved in the US. Still pretty expensive - would probably cost 20-40k per person. But seems more effective than tPA. Though the studies are small/limited.

Have you noticed benefits of hyperbarics? My understanding is the evidence is pretty weak. Kinda makes sense that it may help.

If you can get your hands on pictures, or start taking any, and willing to share, please let me know. I recently had a frostbite case that I may have misdiagnosed as superficial, that was deeper than originally thought. I even consulted a few other docs, and a burn unit, and they all said superficial, nothing to do. Still early (3 weeks), so TBD on how things shake out. But it is starting to look somewhere between Cauchy 2-3.

Hence why I'm trying to look for those atypical presentations.

 

[DYK343]

Ive got a fair amount. All young and quite sad stories.
It always "doesnt look that bad" until about 2 weeks later when the forefoot is dead.
Topical nitroglycerin in addition to the above.

 

[flightdoc09]

Ive got a fair amount. All young and quite sad stories.
It always "doesnt look that bad" until about 2 weeks later when the forefoot is dead.
Topical nitroglycerin in addition to the above.

What do you apply the topical nitroglycerin to? I tried that on my patient. I applied it to the toes, from the tip to just a little proximal of where it appeared to be the healthy tissue margin. I'm wondering if I should've applied much more. I also gave aspirin, then scheduled ibuprofen.

Iloprost is supposedly a very potent vasodilator, so I figured nitroglycerin wouldn't hurt anything, and could help. But all the literature is pretty iffy on if it does anything. Also thought about giving lovenox, but again literature was spotty and I had already given ASA.

 

[air bud]

Need to spend more time in IHS facilities in the mountain West ...then you will see a ton of it. Agree with everything said here.

 

[DYK343]

What do you apply the topical nitroglycerin to? I tried that on my patient. I applied it to the toes, from the tip to just a little proximal of where it appeared to be the healthy tissue margin. I'm wondering if I should've applied much more. I also gave aspirin, then scheduled ibuprofen.

Iloprost is supposedly a very potent vasodilator, so I figured nitroglycerin wouldn't hurt anything, and could help. But all the literature is pretty iffy on if it does anything. Also thought about giving lovenox, but again literature was spotty and I had already given ASA.

The margin of viable vs non vialbe appearing tissue/demarcation line.

Youre right. Scant evidence in literature nitroglycerin works. Last time I checked literature it was mostly case studies. Not sure if anything published since.

But in a 22yo who passed out drunk on way home from bar whos looking at B/L guillotine TMA its something else that can be added to the above treatments.

 

[MicroPod]

I’ve had a couple of frostbite patients referred to me recently (IHS). The issue is getting them to actually show up to their appt. I guess they will show up somewhere eventually if/when it gets bad.

 

[XCY999]

Do not amputate too early for frostbite, sometime worthy to wait for couple days even weeks for tissues recovery or gain a clear margin, unless there’s an immediate threat like infection or systemic compromise - so that any potential for tissue salvage is maximized.

 

[Feli]

Do not amputate too early for frostbite, sometime worthy to wait for couple days even weeks for tissues recovery or gain a clear margin, unless there’s an immediate threat like infection or systemic compromise - so that any potential for tissue salvage is maximized.

It's months, man... that's what I said above. The research consistently supports this.
You need not just the injury area border - but the whole plantar flap - to be maximized.
The vessels were severely damaged, nerves damaged... and these are often not healthy patients to begin with (EtOH, mental illness, polysub, rough social situations, etc).

 

[air bud]

Related....anyone with experience on vasopressor induced ischemia..... recently had to do bilateral TMA on someone with this.

 

[Bluecollarmed]

Related....anyone with experience on vasopressor induced ischemia..... recently had to do bilateral TMA on someone with this.

Lectured on this in residency. Symmetric peripheral gangrene. Nasty stuff but surprisingly there’s mixed evidence on vasopressors even being directly involved

 

[air bud]

Lectured on this in residency. Symmetric peripheral gangrene. Nasty stuff but surprisingly there’s mixed evidence on vasopressors even being directly involved

This lady was on like 3 or 4 in the ICU for 3 weeks. Started around 1 week in....sadly I didn't get consulted until too late. Hands recovered. Feet didn't. Triphasic flow, palpable pulses. Had DVT multiple extremity, PE also ...certainly weird DIC like stuff going on

 

[flightdoc09]

Related....anyone with experience on vasopressor induced ischemia..... recently had to do bilateral TMA on someone with this.

Saw it once. Individual with an EF of 10-15%. Was on max of everything, even on CRRT. Could only lay flat or he'd pass out. He eventually accepted comfort care. But all those digits were cyanotic and would have eventually gone.

I am curious about what can be done though.

Also saw a post op patient that had phenylephrine infiltrate in her hand IV. Hand got a bit dusky and swollen, but vascular just kept it on a heating pad and said it'll be ok.

 

[PTPuser]

I'm at a busy shop with lots of homeless, addicts and knife / gun club. We see one at least every week. Betadine WTD, abx, bone scan and watch for demarcation.

 

[PTPuser]

Related....anyone with experience on vasopressor induced ischemia..... recently had to do bilateral TMA on someone with this.

Just had a lady who lost all 4 limbs from vasopressor induced.

 

[air bud]

Just had a lady who lost all 4 limbs from vasopressor induced.

Wait limbs?? ****

 

[PTPuser]

Wait limbs?? ****

Yup... It was a salami effect. So sad. TMA, then BKA and then hip dis-articulation and both hands.

 

[air bud]

Yup... It was a salami effect. So sad. TMA, then BKA and then hip dis-articulation and both hands.

Gonna need "salami effect" explained to me

 

[HaimFeldman]

Gonna need "salami effect" explained to me

 

[eyeeye_captain]

View attachment 399958

With this in mind, I don’t recommend Googling Fournier’s gangrene…

 

[Feli]

Gonna need "salami effect" explained to me

 

[dtrack22]

Just had a frostbite patient who’s 5th toe essentially auto-amputated. Was hanging on by a thread in wound care clinic. Didn’t even have to cut anything, just grabbed it and it popped off, then billed for the partial toe amp…

Gonna need a partial hallux amp here shortly, but the rest of the toes will probably survive as long as they don’t get infected.

 

[flightdoc09]

Just had a frostbite patient who’s 5th toe essentially auto-amputated. Was hanging on by a thread in wound care clinic. Didn’t even have to cut anything, just grabbed it and it popped off, then billed for the partial toe amp…

Gonna need a partial hallux amp here shortly, but the rest of the toes will probably survive as long as they don’t get infected.

How bad do they/did the other toes look? Any areas of cyanosis/ecchymosis? Was it 3rd or 4th degree to begin with? Know how it was on the Cauchy scale?

 

[dtrack22]

How bad do they/did the other toes look?

Left foot was all just distal tips of toes. Right hallux was well demarcated at the IPJ with full thickness necrosis. But all dry and stable.

Any areas of cyanosis/ecchymosis?

No, but I saw him for the first time a month or so after the initial injury

Was it 3rd or 4th degree to begin with? Know how it was on the Cauchy scale?

Not sure about initial presentation. I would wager the toes ranged from grade 1 to grade 3 based on current demarcation

 

[PTPuser]

With this in mind, I don’t recommend Googling Fournier’s gangrene…

Rotated through Anesthesia and we had one and it smells worse than feet.