1	Treatment of Lower Extremity Frostbite Andrew L. Vincent, DPM Chief Resident St. Vincent Charity Hospital Cleveland, OH
2	Introduction Cold related injury characterized by freezing of tissue True frequency is unknown Disease of morbidity Males>Females Mean age 38-41 Hands,nose,ears,corneas,cheeks and shins 47% of all reported frostbite cases involve the foot and ankle
3	Cold Injuries Non freezing Chilblain or pernio Windy, humid weather 32-60°F Trench foot Wet, cold shoe gear below 50°F > 12hours Immersion foot Direct immersion in water below 50°F >12hours Freezing Frostbite Prolonged exposure to temps 35 to 45°F after 7-18hours
4	Predisposing Factors Local Homeless and indigent populations Altered mental status Drugs, EtOH, Head Trauma, Psychiatric illness Other Soldiers and laborers working in cold weather Individuals stranded in cold weather Winter outdoor enthusiasts Mountain frostbite Extremes of age Previous cold injury Underlying illness
5	Pathophysiology Unknown Ischemia ý Hypoxia ý Tissue Necrosis Direct freezing of tissues Pre-freeze Freeze-thaw Vascular Stasis Ischemia
6	Classification Traditional 1^st Degree 2^nd Degree 3^rd Degree 4^th Degree Present Superficial Deep
7	Treatment Hemodynamic Stability Typical Scenarios Thawing extremity Adjunctive Therapy Frozen extremity RAPID REWARMING RAPID REWARMING RAPID REWARMING
8	Adjunctive Therapy Low Molecular Weight Dextran Heparin and Coumadin® Trental® Iloprost® Sympathetic Nerve Blocks Hyberbaric Oxygen Therapy NSAIDS PLETAL®
9	Pletal® FDA approved for intermittent claudication Synthetic adenosine monophosphate phosphodiesterase inhibitor Inhibits platelet aggregation and enhances smooth muscle cell vasodilation Very safe Use cautiously in patients on anticoagulants Absolute contraindications include known hypersensitivity and CHF
10	St. Vincent Charity Hospital Treatment Protocol Hemodynamic Stability Hypothermia Sepsis Injury Assessment Frozen Parts Partially Frozen/Thawing
11	St. Vincent Charity Hospital Treatment Protocol Frozen Parts Narcotic Analgesics Rapid rewarming w/ sterile water at 104°F for 20 minutes Area dried thoroughly and carefully Loose DSD applied Hospital Admission Pain management Ancillary service consults NSAIDS PLETAL®
12	St. Vincent Charity Hospital Treatment Protocol Partially Frozen/Thawing Hemodynamically Stable DSD and surgical shoe Local wound care as needed Delay surgical intervention Ancillary consultations Patient education and support
13	St. Vincent Charity Hospital Treatment Protocol Ultimate goal- Preserve function and minimize morbidity Surgical Intervention Timing DEMARCATION, DEMARCATION, DEMARCATION Procedure Debridement- with or without skin grafting Dermal and Epidermal tissue involvement Amputation Painful, mummified, non-functional tissues
14	Case Presentation-J.D. 49 y/o male with frostbite injury.
15	Case Presentation-E.S. 47 y/o male with frostbite injury
16	Case Presentation-M.D. 45 y/o female with frostbite injury
17	Long Term Sequelae Hypersensitivity Chronic ulcerations Hyperhidrosis/Anhidrosis Intrinsic muscle atrophy Joint abnormalities Flexion contractures Skin Fissuring Cold intolerance Intractable pain Autonomic dysfunction Toenail fungal infections Arthritis Vasospasm Epiphyseal arrest
18	Summary and Conclusions Prompt diagnosis and proper treatment Utilization of medical subspecialties and ancillary services Rapid rewarming of frozen parts Delay surgical intervention Patient education Pletal®
19	Final Thoughts That’s not right ………..Sum Ting Wong See me ASAP ………..Kum Hia Nao He’s washing his automobile ………..Wa Shing Ka This is a tow away zone ……….No Pah King Staying out of site ……….Lei Ying Lo Your body odor is offensive ………Yu Stin Ki Pu Are you harboring a fugitive ………Hu Yu Hai Ding
20	Thank You