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BURN Clinical Profiles of Frostbite in University Airlangga Teaching

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BURN Clinical Profiles of Frostbite in University Airlangga Teaching BURN Clinical Profiles Of Frostbite In University Airlangga Teaching Hospital Surabaya – A Case Report Background: We report 3 adults who suffered frostbite of the hand and face following Mount Denali Expedition (6192 meters above sea level). The Thomas Eduardus Sudrajat patients get rewarming and analgetics as a first treatment. All cases Wahyu Nugroho presented to our institution on day 11th following the injury. One was Beta Subakti Nata’atmadja performed amputation on day 71st after injury. Methods: All cases received standart antibiotic treatment as well as 3 days hospital observation. At first, no surgery were performed in any case. Regular wound evaluation and rehabilitation then managed in outpatient basis. On day 71st, amputation of 3rd and 4th finger was performed on one patient. Results: All cases showed remarkable improvements of wound epithelialization, resolution of edema, range of motion, and general condition. Demarcation of any devitalized tissue showed clear margination during the period of observation. Such a condition were found in one of the case which showed prominent necrotic part on his 3rd and 4th finger. Hence, we perform debridement and amputation of 3rd and 4th finger. Conclusions: Although frostbite is rare in tropical countries, it may happen in particular those who partake in extreme cold activity such as mountain climbing and winter sports. Prevention and the right management will ensure a good outcome. After an appropriate conservative management at the onset, surgeons must opt for surgical management provided the demarcation of the wound becomes clear. Long-term follow-up management is necessary to achieve a good functional outcome. Preservation and if necessary reconstruction of the finger should become a priority in the patient management. rostbite is the most common cold injury bite is the most common cold injury4, in in mountaineering and is frequently civilian life, frost bite is uncommon despite F seen in high altitude climbers1. Frostbite populations of about 100 million at risk in is a thermal injury and the clinical features of areas where sub-zero temperatures occur at frostbite relate to the initial freezing and the some period of the year3. Among subsequent thawing of tissue, and the mountaineers at high altitude this cases still severity is dependent upon the temperature occur regularly4. and duration of exposure2. Injury due to cold Frostbite is a thermal injury and the may be general or local. Local cold injury may clinical features of frostbite related to the occur at temperatures above freezing (wet- initial freezing and the subsequent thawing of cold conditions), as in immersion or trench tissue, and the severity is dependent upon the foot. At temperatures below freezing (dry-cold temperature and duration of exposure. The conditions), frost bite occurs; the tissues wide spectrum of injuries observed range freeze and ice crystals form in between the from minimal tissue loss and mild long-term cells3. Local cold injury may or may not be sequelae, to extensive necrosis and associated with hypothermia. Although frost subsequent amputation. Such severe injuries can have devastating consequences in young, otherwise fit individuals2. Disclosure: The authors herely declare they have no financial interest in the information discussed in this article 5 Jurnal Plastik dan Rekonstruksi • January 2019 Clinical Presentation and initial lesion on day 0 after rapid rewarming, Classification b) radiotracer uptake in bone scan on day 2, c) skin blisters on day 2. Symptoms Patients initially describe a cold numbness with accompanying sensory loss2. Superficial frostbite 1st degree The extremity feels cold to touch and it feels − Partial skin freezing clumsy, “like a block of wood”. Thawing and − Erythema, edema, and hyperemia reperfusion is often intensely painful and pain − No blisters or necrosis may persist for weeks or months, even after − Occasional skin desquamation (5-10 day tissue demarcation. Residual tingling later) sensation starting after one week has been Full-thickness skin freezing 2nd degree described and may be due to an ischaemic − Erythema, substantial edema neuritis7. Symptoms are exacerbated by warm − Vesicles with clear fluid environments. Other sensory deficits include − Blisters, desquamation and black eschar spontaneous burning and electric current-like (gangrene) formed sensations and may persist for years after the − Deep frostbite 3rd Degree 2 initial injury . − Full-thickness skin & subcutaneous freezing − Violaceous/haemorrhagic blisters Signs − Skin necrosis Initial appearances are often − Blue-grey discoloration deceptively benign. However with thawing, 4th Degree frozen tissue may appear mottled blue, − Full-thickness skin, subcutaneous tissue, muscle, tendon and bone freezing yellowish-white or waxy. Following rapid − Little edema rewarming, there is an initial hyperemia even − Initially mottled, deep red or cyanotic in severe cases, often with a purplish − Eventually dry, black and mummified discoloration2. Classification Frostbite injury has been classified as Maintenance of the central core either mild/superficial (no tissue loss) or temperature is essential to life and this may severe/deep (with loss of tissue)2, and this be carried out at the expense of the classification is based upon final outcome peripheral expendable structures such as the (Table 1). Cauchy et al8 proposed a predictive toes and fingers3. Cold damages tissues classification system that is based on the through cellular injury and vascular topography of the lesion(s) and early 99 impairment. Cellular injury may be due to technetium bone scanning. Using these intracellular water crystallization, techniques it is now possible accurately to temperature-induced protein changes and 5 predict the likely outcome as early as two days membrane damage . Vasoconstriction, (Table 2). endothelial injury and thromboembolism contribute to vascular insufficiency and Frostnip ischemia. Overtime, necrosis and gangrene Skin becomes white and loses sensation. becomes apparent1. Mummification and On rewarming becomes hyperemic and autoamputation may occur6. paraesthetic. Recovers completely. paraesthesia persists for some weeks. Case Presentation Cauchy et al proposed a new classification of We report 3 adults who suffered frostbite lesions involving the extremities and frostbite of the hand and face following Mount is based upon findings after initial rewarming Denali Expedition (6192 meters above sea and on day 2 after admission. Parameters a) level) in early June 2017. At the summit (6192 6 Volume 04, Number 1 • Clinical Profiles Of Frostbite m) 2 patient felt extremely cold. When they applied and sent to local clinics by helicopter. took off his gloves to take pictures, they felt On the local clinic the patients is given Silver even colder and had severe pain in all of their sulfadiazine dressing on is fingers and tetanus fingers. They was shivering and had numbness toxoid injection was given. Blistered areas and tingling in his extremities. They also felt were not debrided. they was given analgesics fatigued with loss of appetite and they drank and the patient go back to Indonesia. very little fluid. By the time they descended to base camp, they had swelling of the fingers Case 1 with darkening of the skin of some of his fingers. They also got reddish on his nose and cheek Gradually, the swelling in the fingers turned into blisters, some of which ruptured spontaneously. Table 1: Classification of cold injury Pre Post according to severity2 Treatment Treatment Radiotracer Initial Grade uptake on Skin blisters lesion bone scan Not None None 1 indicated Hypo- Distal fixation of Clear fluid 2 phalanx radiotracer Absence of Middle Haemorrhagic Pre Treatment Post uptake on 3 phalanx on digits Treatment digits Absence of Haemorrhagic Carpal Case 3 uptake on on 4 or tarsal carpal/tarsal carpal/tarsal Table 2: Cauchy predictive classification of frostbite8 Grade Outcome 1 No amputation, no long term sequelae Pre Post Soft tissue amputation with fingernail Treatment Treatment 2 sequelae Bone amputation on digit. Functional On day 11th after injury the patient 3 sequelae arrived at our hospital, the first patients finger More extensive amputation, may develop 4 was turning to black on the distal phalanx and thrombosis or sepsis. Functional sequelae have some blister on his right hand. his nose got dark colored but his does not feel pain, the One patient stays in the basecamp got sensation is a little decreased. his nose slightly swollen and turn darker with The second patient got blister both of his painful on touch. He got no blister nor swollen hand and dark colored nose with decreased finger. sensation on his nose. The finger is painful to When the two climber reached base touch. The third patient (who doesn’t go to the camp, their hands and feet had already thawed summit) got blacked nose with decreased spontaneously. The patients get rewarming as sensation. first treatment. Povidone-iodine dressing was 7 Jurnal Plastik dan Rekonstruksi • January 2019 After 3 days of intravenous antibiotics blood flow in the affected area, eventually administration, the patient treated as leading to thrombosis and to tissue ischemia7. outpatient and have routine follow up for regular wound evaluation and rehabilitation. Case 1 The first patient got his 3rd and 4th finger getting darked and mumificated. On day 71st after injury, the patient performed amputation. The dark coloured nose is faded and barely seen, and the sensation
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