Frostbite

Frostbite - tissue damage caused by local exposure to cold, leading to a long drop in temperature, damage to anatomical structures, down to necrosis of organs.

ICD-10 code

• X31 Excessively low natural temperature.
• Т33.0-9 Surface frostbite.
• Т34.0-9 Frostbite with tissue necrosis.
• Т35.0-7 Frostbite, which engulfs several areas of the body and causes unfrozen frostbite.

Symptoms of frostbite

In the development of pathological changes in the affected areas leading role belongs to spasm of the arteries. With a short action of the cold, only surface vessels react, a frostbite of I-II degree occurs. With more prolonged and intensive cooling, a prolonged spasm of all arterial vessels occurs, resulting in the death of soft tissues and bones.

During frostbite, two periods are identified: latent (pre-reactive) and reactive, before and after warming the patient accordingly. In the first period, the frost-bitten area is pale, cold to the touch, insensitive. The patient complains of a feeling of numbness, "stiffness", "cold feet". Less often disturb the pain in the feet and calf muscles. In a small number of observations, frostbites are not accompanied by any sensations. In the pre-active period, diagnosis is not difficult, but the depth and extent of tissue damage can not be determined.

In the reactive period after the warming of the frosted area, the main complaint of patients becomes pain. It occurs immediately after the patient has warmed up, is quite intense and is typical for all victims. Patients experience a burning sensation, heat, "stiffness" in frost-bitten areas. In favor of the end of the "latent period" is evidence of swelling and discoloration of the skin from white to cyanotic.

In 95% of cases, limbs are subject to frostbite, most often lower; the lesion is limited to the fingers and does not extend beyond the ankle or wrist joints. This localization is caused by the worst blood supply of the peripheral parts of the limbs in comparison with other areas of the body, they are more prone to the effects of cold, they develop hemodynamic disorders more rapidly. In addition, the hands and feet are less protected from exposure to cold. Frosts of other localizations (ears, nose, cheeks) are observed much less often. In the overwhelming number of observations frostbites occur when the frost occurs at an air temperature of -10 ° C or lower. However, with high air humidity and strong wind, frostbites are possible even at a higher temperature approaching 0 ° C. More often frostbites people in unconsciousness are exposed (at strong alcoholic intoxication, a serious trauma, an epilepsy attack). In such situations, as a rule, frostbites of the fourth degree arise.

Atypical forms of frostbite

In contrast to the described "classical" form of frostbite, several of their varieties are distinguished, characterized by a peculiar clinical course and arising in conditions different from those described - feint and "trench stop".

Festering is a pathological condition of the skin that develops as a result of prolonged exposure to low temperature and high air humidity and is characterized by swelling, blueness, painful tenderness and itching. Considered as a chronic frostbite of the first degree, the elimination of repeated cooling contributes to the elimination of fever. Often, the fever occurs in the form of dermatitis or dermatosis. People who, due to the nature of their work, are constantly exposed to the effects of cold with high humidity (fishermen, sailors, rafters of the forest), refusal is considered a professional disease.

Foot trench - frostbite feet as a result of their prolonged moderate cooling; occurs at an air temperature of about 0 ° C and high humidity, mainly in a military setting. This is a form of local cold injury, first described during the First World War in the massive defeat of the feet of soldiers who have long been in trenches filled with water. The disease is characterized by disorders of tactile, temperature and pain sensitivity, the appearance of pain, the appearance of a feeling of "stiffness" of the feet. The edema develops, the skin acquires a pale shade with areas of hyperemia, cold to the touch; then bubbles with hemorrhagic contents are formed. The final is the necrosis of the feet with the development of moist gangrene. With bilateral injury is characterized by extremely severe course of the disease with high fever and severe intoxication.

A peculiar form of a cold trauma is an "immersion stop" ("immersed limb"). This pathology develops with the long-term presence of limbs in cold water and occurs almost exclusively in seamen or in pilots in distress in the seas at a water temperature of 0 to +10 ° C. Two, three, and sometimes four limbs are affected simultaneously, and frostbite occurs 2-3 times faster than on land.

The "high-altitude stop" occurs in the case of pilots flying at high altitudes, with extremely low air temperatures (-40 to -55 ° C) and high speeds, in conditions of a low oxygen content.

Sometimes contact frostbites develop from the contact of bare hands with metal objects cooled to -40 ° C. These frostbites, as a rule, are superficial and are limited in area.

Complications arising from frostbite are subdivided into local and general. The most frequent among the local - lymphangitis, lymphadenitis, thrombophlebitis, erysipelas, phlegmon, abscess, arthritis, osteomyelitis. In later terms, develop neuritis, endarteritis, trophic ulcers, scar deformities and contractures, a persistent increase in cold sensitivity. Of the common complications in the early periods observed intoxication, pneumonia, sepsis, multiple organ failure; in later - myocardial, nephro- and encephalopathy.

[1], [2], [3]

Classification

Frostbite is classified according to the depth of tissue damage to 4 degrees:

• Frostbite I. After warming, the skin of the frostbitten area is cyanotic, often with a crimson hue, a slight edema, marbling of color is possible. Frostbites I degree pass through 5-7 days of conservative treatment, with the edema disappears completely, the skin acquires a normal color. Shortly there is an itch, cyanosis, hypersensibility to a cold.
• Frostbite II. It is accompanied by necrosis of the upper zone of the papillary epithelial layer, the formation of blisters filled with a transparent serous fluid (sometimes a few days after warming). The bottom of the bladder is the papillary layer of the skin, represented by a surface of pink or pale red color, sensitive to mechanical irritation. At this degree, the growth layer of the skin is not damaged, therefore, in a short time (8-14 days), complete epithelization of the wound surfaces is observed under the influence of conservative treatment. Residual manifestations are similar to the first degree.
• Frostbite III. The skin of the affected area is deadly pale or blue-crimson! The edema of tissues is expressed. Bubbles are filled with hemorrhagic fluid, after opening it and removing the epidermis, the non-viable surface of the papillary layer of the skin is exposed, insensitive to mechanical irritation (for example, pricking a needle or touching a ball with alcohol). Necrosis extends to the entire thickness of the skin. Self-epithelization of such wounds is impossible in connection with the death of all epithelial elements of the skin. Healing is possible by the development of granulations and scarring. Lost nails often grow deformed. Extensive wound defects require plastic closure with autologous transplants.
• Frostbite IV. Occurs with the longest action of the cold agent and a prolonged period of tissue hypothermia, accompanied by the necrosis of all tissues, including bones. 8-10 days after the injury, dry gangrene of the fingers or toes and moist gangrene of the proximally located areas develop. The demarcation line appears at the end of the 2nd - the beginning of the 3rd week. The process of spontaneous rejection of necrotic tissue takes several months.

With frostbites of III-IV degree, there are four zones of pathological changes (in the direction from the periphery to the center):

• total necrosis;
• irreversible degenerative changes (where subsequently can occur trophic ulcers and ulcerated scars);
• reversible degenerative processes;
• ascending pathological processes.
• In the last two zones, the development of persistent vascular and neuro-trophic disorders is possible.

[4], [5], [6]

How is frostbite recognized?

The victim indicates a prolonged stay in a low temperature air. Differential diagnosis of frostbite is performed with gangrene of the toes in cases of diabetic angiopathy or obliterating endarteritis.

Indications for consultation of other specialists

Need an angio-surgeon, a therapist.

Example of the formulation of the diagnosis

Frostbite of both feet of III-IV degree.

[7], [8], [9],

Treating frostbites

The main goal of the treatment is warming and restoration of normal blood flow in the affected parts of the body.

Indications for hospitalization

Frostbite of III-IV degree of any area and localization; widespread surface frostbite.

First aid with frostbite

In order to prevent further cooling and recovery of temperature in the affected parts of the body, the victim should be taken to a warm room, changed into dry clothes and shoes. Common activities include giving the affected hot tea, coffee, food, 50-100 ml of vodka. With frostbite of the auricles, cheeks, nose, you can easily rub the frosted areas with a clean hand or a soft cloth until the pink color of the skin appears.

It is necessary to exclude premature warming from the outside, when the victim is already in the room: the heat must go "from within" due to blood circulation. Thus, the tissue warming limit gradually shifts to the periphery, where the circulation is restored earlier than the metabolism, which protects tissues from ischemia. To achieve this effect, a thermal or heat-insulating bandage is applied as soon as possible to the affected area. In it alternate 5-6 layers of gauze and cotton wool (batting, wool, foam rubber, sintepon) with two or three times laying between them compress paper (polyethylene, metal foil). The thickness of this dressing is 5-6 cm. No bandages are manipulated with frosted areas prior to bandaging. Bandages on the affected area are left for at least 6-12 hours, until the sensitivity is restored.

After the hospitalization of the victim, measures are taken to gradually warm the tissues "from the inside out". This is achieved by infusion systemic and regional treatment, whose goal is to eliminate vasospasm, restore microcirculation, prevent thrombosis in small and large diameter vessels.

The use of ultraviolet radiation, UHF therapy, infrared radiation and simply warm air from the fan in the first phase of the wound process during frostbites of III-IV degree promotes the transfer of moist necrosis to dry.

[10],

Medication

To improve blood circulation in the affected limbs, the following drugs are injected intravenously twice a day during the first week after the injury: solutions of dextran (reopolyglucin) 400 ml, glucose 10% - 400 ml, procaine (novocaine) 0.25% - 100 ml, vitamin B : 5% - 2 ml, nicotinic acid 1% - 2 ml, ascorbic acid 5% - 4 ml, drotaverina (no-shpy) 2% - 2 ml, papaverine 2% - 4 ml; heparin sodium (heparin) 10,000 units, pentoxifylline (trental) 5 ml or dipyridamole (curantyl) 0.5% - 2 ml, hydrocortisone 100 mg. Infusions are produced at a speed of 20-25 drops per minute. Therapy should continue in the situation, if within 2-3 days it was not possible to normalize the temperature and trophism of tissues. In this case, it is necessary to reduce the tissue necrosis zone.

Of great importance is the introduction of drugs directly into the regional bloodstream of the frostbitten limb. This is achieved by puncturing the corresponding main artery (radial, ulnar, humerus, femoral). Typically, the following drugs are administered: solutions of procaine (novocaine) 0.5% - 8.0; nicotinic acid 1% - 2.0; heparin sodium (heparin) 10 thousand units; ascorbic acid 5% - 5.0; aminophylline (euphyllin) 2.4% - 5.0; Pentoxifylline (trental) 5.0 [or dipyridamole (quarantil) 0.5% - 2.0]. The first day of infusion is performed 2-3 times, the next 2-3 days and 1-2 times. The duration of the course of vasoactive infusion therapy is at least 7 days.

Novokainovye perineal, vagosympathetic, perineural conductive and simple case blockades performed in the pre-reactive or early reactive periods promote analgesia, vasodilation and a decrease in interstitial edema, thereby creating favorable conditions for normalizing the temperature in the affected tissues.

Patients admitted to the hospital in the late reactive period, with clearly expressed signs of irreversible tissue damage, should perform the entire complex of the above-described therapeutic and prophylactic measures with a view to possible limiting the extent and extent of tissue damage.

Surgical treatment of frostbite

Indications

Deep frostbite of III-IV degree.

Methods of surgical treatment

Local treatment of wounds after frostbite is performed according to the general surgical rules for treatment of purulent wounds. It is necessary to take into account the depth of the lesion and the phase of the wound process.

For frostbites of the 1st degree after the wound toilet, gauze bandages with water-soluble antibacterial creams are applied [chloramphenicol / dioxomethyltetrahydropyrimidine (levomekol), dioxomethyltetrahydropyrimidine / sulfodimethoxin / trimecaine / chloramphenicol (levosin), benzyldimethyl-myristide-propylammonium (miramite ointment), mafenide], chloramphenicol (synthomycin), etc. Complete epithelization occurs in a short time (7-10 days) without any cosmetic or functional defects.

With frostbites of III-IV degree, conservative treatment allows you to prepare the affected areas for surgery. The nature of the medicines used depends on the phase of the wound process. In the first phase (acute inflammation, copious separation, rejection of dead tissue), antiseptic solutions, hypertonic solutions of sodium chloride, antibacterial ointments on a water-soluble basis, as well as drugs with necrolytic action [trypsin, chymotrypsin, terlitin, prosubtilin (prophasim), etc.) are used. . Dressings are done daily, the affected limbs are laid on the tires of Belera.

In the second phase of the wound process (after the subsidence of inflammation, reducing edema and the amount of wound detachable, rejection of nonviable tissues), dressings are less often (2-3 days later) with fat-based ointments [with nitrofural (0.2% fatacilin ointment)].

In the third phase (epithelization and scarring), it is advisable to use plant biogenic stimulants (Kalanchoe and aloe juice) and animal origin (15% propolis ointment). For the same purpose, ointments with dioxomethyl-tetrahydropyrimidine (methyluracil) 10%, actovegin 20%, etc. Are used.

Modern tactics of surgical treatment of deep frostbites pursues the goal of the fastest removal of nonviable tissues, prevention of development of severe complications and maximum preservation of the volume of viable tissues.

As in the treatment of deep burns, necrotic, necrectomy, amputation and dermatome free skin grafts are used.

Possible postoperative complications

Suppuration of postoperative wounds, melting of skin grafts, suppuration of donor wounds.

What is the prognosis of frostbite?

Surface frostbite has a favorable prognosis, patients return to work. Deep frostbite with the defeat of large segments of the limbs leads to persistent disability.