title: A New Proposal for Management of Severe Frostbite in the Austere Environment.
abstract: Despite advances in outdoor clothing and medical management of frostbite, individuals still experience catastrophic amputations. This is a particular risk for those in austere environments, due to resource limitations and delayed definitive treatment. The emerging best therapies for severe frostbite are thrombolytics and iloprost. However, they must be started within 24 hours after rewarming for recombinant tissue plasminogen activator (rt-PA) and within 48 hours for iloprost. Evacuation of individuals experiencing frostbite from remote environments within 24 to 48 hours is often impossible. To date, use of these agents has been confined to hospitals, thus depriving most individuals in the austere environment of the best treatment. We propose that thrombolytics and iloprost be considered for field treatment to maximize chances for recovery and reduce amputations. Given the small but potentially serious risk of complications, rt-PA should only be used for grade 4 frostbite where amputation is inevitable, and within 24 hours of rewarming. Prostacyclin has less risk and can be used for grades 2 to 4 frostbite within 48 hours of rewarming. Until more field experience is reported with these agents, their use should probably be restricted to experienced physicians. Other modalities, such as local nerve blocks and improving oxygenation at high altitude may also be considered. We submit that it remains possible to improve frostbite outcomes despite delayed evacuation using resource-limited treatment strategies. We present 2 cases of frostbite treated with rt-PA at K2 basecamp to illustrate feasibility and important considerations.
authors.affiliation: IFREMMONT: Institut de Recherche et de Formation en Medecine de Montagne, Hôpital de Chamonix, Chamonix, France (Dr Cauchy); Hôpitaux des Pays du Mont-Blanc, Sallanches, France (Dr Cauchy). Electronic address: cauchy@ifremmont.com.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Cauchy
authors.affiliation: University of Colorado Denver School of Medicine, Department of Emergency Medicine, Aurora, CO (Drs Davis and Hackett).
authors.forename: Christopher B
authors.initials: CB
authors.lastname: Davis
authors.affiliation: Emergency Service, Lausanne University Hospital, Lausanne, Switzerland (Dr Pasquier); Air-Glaciers SA and GRIMM, Sion, Switzerland (Dr Pasquier).
authors.forename: Mathieu
authors.initials: M
authors.lastname: Pasquier
authors.affiliation: Rural Partners in Medicine, LLC, Steamboat Springs, (Dr Meyer).
authors.forename: Eric F
authors.initials: EF
authors.lastname: Meyer
authors.affiliation: University of Colorado Denver School of Medicine, Department of Emergency Medicine, Aurora, CO (Drs Davis and Hackett); Institute for Altitude Medicine, Telluride, CO (Dr Hackett).
authors.forename: Peter H
authors.initials: PH
authors.lastname: Hackett
mesh_terms: D000071251:Extreme Environments; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005627:Frostbite / Q000188:drug therapy / Q000628:therapy*; D006801:Humans; D006931:Hyperbaric Oxygenation / Q000706:statistics & numerical data; D009407:Nerve Block / Q000706:statistics & numerical data; D010525:Peripheral Nerves / Q000187:drug effects; D044062:Prostaglandins I / Q000627:therapeutic use*; D015912:Thrombolytic Therapy / Q000379:methods*
chemical_list: D005343:Fibrinolytic Agents; D044062:Prostaglandins I
keywords: field treatment; frostbite; prostacyclin; thrombolytics