Frostbite: experimental assessment of tissue damage using Tc-99m pyrophosphate. Work in progress

American Burn Association Clinical Practice Guidelines on the Treatment of Severe Frostbite

This Clinical Practice Guideline addresses severe frostbite treatment. We defined severe frostbite as atmospheric cooling that results in a perfusion deficit to the extremities. We limited our review to adults and excluded cold contact or rapid freeze injuries that resulted in isolated devitalized tissue. After developing population, intervention, comparator, outcomes (PICO) questions, a comprehensive literature search was conducted with the help of a professional medical librarian. Available literature was reviewed and systematically evaluated. Recommendations based on the available scientific evidence were formulated through consensus of a multidisciplinary committee. We conditionally recommend the use of rapid rewarming in a 38 to 42°C water bath and the use of thrombolytics for fewer amputations and/or a more distal level of amputation. We conditionally recommend the use of "early" administration of thrombolytics (≤12 hours from rewarming) compared to "later" administration of thrombolytics for fewer amputations and/or a more distal level of amputation. No recommendation could be formed on the use of vascular imaging studies to determine the use of and/or the time to initiate thrombolytic therapy. No recommendation could be formed on the use of intravenous thrombolytics compared to the use of intra-arterial thrombolytics on fewer amputations and/or a more distal level of amputation. No recommendation could be formed on the use of iloprost resulting in fewer amputations and/or more distal levels of amputation. No recommendation could be formed on the use of diagnostic imaging modalities for surgical planning on fewer amputations, a more distal level of amputation, or earlier timing of amputation.

Proceedings of the 2021 American Burn Association State and Future of Burn Science Meeting

Periodically, the American Burn Association (ABA) has convened a State of the Science meeting on various topics representing multiple disciplines within burn care and research. In 2021 at the request of the ABA President, meeting development was guided by the ABA's Burn Science Advisory Panel (BSAP) and a subgroup of meeting chairs. The goal of the meeting was to produce both an evaluation of the current literature and ongoing studies, and to produce a research agenda and/or define subject matter-relevant next steps to advance the field(s). Members of the BSAP defined the topics to be addressed and subsequently solicited for nominations of expert speakers and topic leaders from the ABA's Research Committee. Current background literature for each topic was compiled by the meeting chairs and the library then enhanced by the invited topic and breakout discussion leaders. The meeting was held in New Orleans, LA on November 2nd and 3rd and was formatted to allow for 12 different topics, each with two subtopics, to be addressed. Topic leaders provided a brief overview of each topic to approximately 100 attendees, followed by expert-lead breakout sessions for each topic that allowed for focused discussion among subject matter experts and interested participants. The breakout and topic group leaders worked with the participants to determine research needs and associated next steps including white papers, reviews and in some cases collaborative grant proposals. Here, summaries from each topic area will be presented to highlight the main foci of discussion and associated conclusions.

Carbon dots from Artemisiae Argyi Folium Carbonisata: strengthening the anti-frostbite ability

In this study, novel carbon dots (CDs) were discovered and separated from Artemisiae Argyi Folium Carbonisata (AAFC) aqueous extract. AAFC-CDs were characterised by a series of methods, mainly including electron microscopy, optical technology and X-ray photoelectron spectroscopy (XPS). Results displayed that AAFC-CDs with a quantum yield (QY) around 0.19% had a size distribution between 6.0 and 10.0 nm and possessed a nearly spherical shape, with a lattice spacing of 0.369 nm. In mice, AAFC-CDs reduced the tissue damage, ear frostbite, and body stiffness caused by cold, and provided energy by increasing the use of blood glucose. The mechanism may be by decreasing concentration of IL-1βk, TNF-α and reducing the rise in blood glucose levels caused by frostbite. This study is the first to indicate that CDs may be the active constituent of AAFC against frostbite, suggesting their potential for clinical applications.

Frostbite: Spectrum of Imaging Findings and Guidelines for Management

Frostbite is a localized cold thermal injury that results from tissue freezing. Frostbite injuries can have a substantial effect on long-term limb function and mobility if not promptly evaluated and treated. Imaging plays a critical role in initial evaluation of frostbite injuries and in monitoring response to treatment. A multimodality approach involving radiography, digital subtraction angiography (DSA), and/or multiphase bone scintigraphy with hybrid single photon emission computed tomography (SPECT)/computed tomography (CT) is often necessary for optimal guidance of frostbite care. Radiographs serve as an initial survey of the affected limb and may demonstrate characteristic findings, depending on the time course and severity of injury. DSA is used to evaluate perfusion of affected soft tissues and identify potential targets for therapeutic intervention. Angiography-directed thrombolysis plays an essential role in tissue preservation and salvage in deep frostbite injuries. Multiphase bone scintigraphy with technetium 99m-labeled diphosphonate provides valuable information regarding the status of tissue viability after initial treatment. The addition of SPECT/CT to multiphase bone scintigraphy enables precise anatomic localization of the level and depth of tissue necrosis before its appearance at physical examination and can help uncover subtle findings that may remain occult at scintigraphy alone. Multiphase bone scintigraphy with SPECT/CT is the modality of choice for prognostication and planning of definitive surgical care of affected limbs. Appropriate use of imaging to direct frostbite care can help limit the effects that these injuries have on limb function and mobility. ©RSNA, 2016.

Cold injury

The pathophysiology of true frostbite reveals that the direct injury produced during the initial freeze process has a minor contribution to the global tissue damage. However, rapid rewarming to reverse the tissue crystallization has essentially been the lone frostbite intervention for almost half a century. The major pathologic process is the progressive microvascular thrombosis following reperfusion of the ischemic limb, with the cold-damaged endothelial cells playing a central role in the outcome of these frozen tissues. Newer interventions offer the opportunity to combat this process, and this article offers a scientific approach to frostbite injuries of the upper extremities.

The cryobiology of cryosurgical injury

Cryosurgery, or tissue destruction by controlled freezing, has been investigated as a possible alternative to surgical intervention in the treatment of many diseases. This technique, which is under the larger category of thermal therapy, has its origins in the 1800s when advanced carcinomas of the breast and uterine cervix were treated with iced saline solutions. Since those early times, this technique has been used routinely to treat malignancies on the surface of the body (ie, dermatologic tumors) and has gained some acceptance as a clinical tool for the management of internal malignancies, including carcinoma of the prostate and kidney. The main advantages of the technique are the potential for less invasiveness and lower morbidity compared with surgical excision. The study of the destructive process of freezing is the focus of this article and is divided into 2 main areas: (1) understanding the mechanism by which freezing destroys tissue, and (2) understanding the thermal history that causes tissue destruction. The term "thermal history," as used in this article, will mean the time-temperature history experienced by the tissue during a thermal insult.

Imaging of frostbite injury by technetium-99m-sestamibi scintigraphy: a case report

The appearance of superficial tissue is often an unreliable indicator of deep-tissue viability in cases of frostbite. We present a 34-year-old black man who was brought to the emergency department at fourth post-injury day with frostbite injury involving both lower extremities after prolonged exposure to subzero temperatures. In our previous experimental study, 99mTc sestamibi scintigraphy has been employed for evaluating frostbite injuries in rabbit hindlegs. In the case presented, 99mTc sestamibi scintigraphy, as a new diagnostic tool, was performed for detection of skeletal muscle perfusion on the fourth post-injury day. The scintigraphic images show diffusely reduced uptake in soft tissues of both calves and feet. It was thought that this hypoperfusion was due to viable but ischemic tissue. Five days after medical therapy, 99mTc sestamibi scan showed prominently increased uptake in both calves and feet and skin necrosis was observed. Debridement of necrotic skin and subcutaneous tissue was performed, and split-thickness skin graft was applied for coverage of the skin defect. Healing was good 15 days after grafting. We think 99mTc sestamibi scan can be used for assessment of soft-tissue perfusion and evaluation of treatment in frostbite injury.

Salvage of avascular bone from frostbite with free tissue transfer

Traditional management of frostbite injury of the hands and fingers has been to allow demarcation to occur between viable and nonviable tissues, corresponding to the level of amputation required. In this case report, phalangeal length in mummified digits was maintained with free tissue transfer followed by evidence of bony revascularization on bone scan. Rather than waiting for tissue demarcation to occur, the authors propose that consideration be given to debridement of soft tissues in the frostbitten fingers followed by free tissue transfer to salvage length and function in the digital bony skeleton.

Frostbite: pathogenesis and treatment

Frostbite, once almost exclusively a military problem, is becoming more prevalent among the general population and should now be considered to be within the scope of the civilian physician's practice. Studies into the epidemiology of civilian frostbite have identified several risk factors that may aid the clinician in the diagnosis and management of cold injuries. Research into the pathophysiology has revealed marked similarities in inflammatory processes to those seen in thermal burns and ischemia/reperfusion injury. Evidence of the role of thromboxanes and prostaglandins has resulted in more active approaches to the medical treatment of frostbite wounds. Although the surgical management of frostbite involves delayed debridement 1 to 3 months after demarcation, recent improvements in radiologic assessment of tissue viability have led to the possibility of earlier surgical intervention. In addition, several adjunctive therapies, including vasodilators, thrombolysis, hyperbaric oxygen, and sympathectomy, are discussed.

Corticotropin-releasing factor inhibits the acute inflammatory response of rat pawskin to cold injury

The anti-inflammatory effects of human/rat corticotropin-releasing factor (CRF), a 41-residue peptide hormone, on an experimental model of cold injury were examined. Male albino rats were anesthetized with sodium pentobarbital 60 mg/kg ip and the paws immersed for 1 or 2 min in a 22% NaCl solution maintained at -20 +/- 0.5 degrees C. Swelling in response to cold was measured by changes in paw volume using the fluid displacement method, and protein leakages from blood vessels were measured using Evans blue and Monastral blue dyes. Thirty minutes after cold exposure the paw volume increased from 1.5 +/- 0.1 to 2.4 +/- 0.1 ml/paw and the Evans blue content increased from 4 +/- 1 to 178 +/- 9 micrograms/pawskin. These responses to cold were inhibited by 40 to 60% after CRF was injected 56 micrograms/kg sc 30 min before or 28 micrograms/kg iv 10 min before or 5 min after cold exposures. Microscopic studies of the skin showed that CRF reduced leakage of Monastral blue pigment from the vascular compartment into the walls of capillaries and venules. The anti-inflammatory effects of CRF were blocked by alpha-helical CRF(9-41), a CRF receptor antagonist, injected 92 micrograms/kg iv 5 min before and 15 min before cold exposure.

Intense bone imaging agent uptake in the soft tissues of the lower legs and feet relating to ischemia and cold exposure

We present a patient with diffuse and intense uptake in the soft tissues of both lower legs and feet seen on 99mTc-HMDP bone scintigraphy. This finding presumably resulted from compromised blood supply to the lower legs plus a cold environment. The extraosseous bone imaging agent localization was presumably related to an existing ischemic condition that was exacerbated by cold. Differential diagnosis of the scan pattern should be differentiated from the artifact of socks contaminated by radioactive urine.