Blount, G

Hermann, G

Holmes, J

Knight, ICS

Martin, J

Paton, B

Starzl, TE

Name not available

Seminar on frostbite

D-Scholarship@Pitt

Seminar on frostbite* Chairman: 3:00 a.m., Monday morning. He was discovered by GILBERT HERMANN, M.D. Attending Surgeon Veterans Administration Hospital Instructor in Surgery University of Colorado School of Medicine Participants (all faculty members except Drs. Knight and Martin) : THOMAS E. STARZL, M.D. Chief, Surgical Service Veterans Administration Hospital Associate Professor of Surgery BRUCE PATON, M.D. Assistant Professor of Surgery and Director of Halsted Laboratory I. C. S. KNIGHT, M.D., F.R.C.S. Visiting Surgeon Edinburgh, Scotland JOSEPH HOLMES, M.D. Professor of Medicine JULIA MARTIN, M.D. Estes Park, Colorado GILBERT BLOUNT, M.D. Professor of Medicine Head of Division of Cardiology DR. HERMANN: This seminar is concerned with frostbite, a constantly recurring health hazard in the Rocky Mountain area. The case for discus- sion is a complex one, but does illustrate many problems encountered in diagnosis, treatment and prophylaxis of frostbite. Dr. Martin, you were the first physician to see the patient. Could the discus- sion be started with a presentation of the patient's history and appearance when you first saw him? DR. MARTIN: The patient, aged 25, went moun- tain climbing on a Saturday in October. During the afternoon, he and his companion parted. Short- ly he became lost in snow and decided to settle for the night. The following morning he attempted to walk out but again became lost. He ate snow but did not have any solid food. He remembers nothing about his actions subsequent to about 'From Colorado General Hospital and the Veterans Admin- istration Hospital, Denver. search parties about 10:OO a.m. on Tuesday morn- ing. When found, he was conscious but not co- herent. His fingers and elbows were stiff, but could be passively extended. His feet and lower legs were mottled. His respirations were 18 per minute; heart rate, 50. His blood pressure was unobtainable, as were his peripheral pulses. Rectal temperature was 25 degrees Centigrade. After emergency care, he was transferred to Colorado General Hospital. DR. HERMANN: Dr. Paton, please tell us about the patient's appearance when you saw him in the emergency room a t  Colorado General Hospital. DR. PATON: The patient was conscious but dis- oriented. Rectal temperature was 29.5 degrees Cen- tigrade, blood pressure unobtainable, and his heart rate was about 65 with auricular fibrillation. The exposed parts of his face were bright red in color, with no areas of impending tissue loss. His hands were scratched and torn, but the color was reason- ably normal. The part of his feet and ankles which had been inside his boots were purple and mottled proximally and dead white distally. There was no evidence of capillary filling. Blood chemistries drawn at this time revealed a blood urea nitrogen of 56 and evidence of severe acidosis with an arterial pH of 7.1. His urinary output initially was good, but in the next few hours decreased. Because his oliguria persisted over the next 72 hours, he was dialyzed. After evaluating his frostbitten legs, it was decided to treat this injury by the technic of rapid rewarming. DR. HERMANN: Dr. Starzl, please discuss the place of rapid rewarming in the treatment of frostbite. DR. STARZL: Despite enormous experience with frostbite, especially during recent wars, the basic physiology of this form of trauma has been poorly understood. Consequently, there has been ambiguity concerning the appropriate methods of therapy, particularly in the acute lesion. Recent work has shown that the one single treatment of proved value is rapid rewarming of frozen members, the technic of which is explicit. The injured extremity should be immersed in water which is kept between 37 and 42 degrees centigrade until no further improvement occurs. When this patient's feet were placed in the warm water, the line of demarcation advanced toward his toes, rapidly at  first, but as it moved distally, the rate of color return became progressively slower. At the time the feet were removed from the warm water, it was apparent that little, if any, tissue loss would occur. Numerous other remedies, including sympa- thectomy, vasodilator drugs, heparin, or the sys- temic infusion of low molecular weight dextran have been recommended for immediate treatment of frostbite. None of these has been proved to be of consistent value. DR. HERMANN: Dr. Starzl, please say a few words about the place of amputation in treatment of frostbite. DR. STARZL: The degree of eventual tissue loss is almost always less than that which would be anticipated from the initial examination. Weeks, or even months, may be required before the true extent of tissue loss is accurately known. There- fore, definitive amputation should be delayed as long as possible. DR. HERMANN: Dr. Paton, one of the in- triguing aspects of this case was the generalized body hypothermia this patient evidenced. Would you enlarge on this subject? DR. PATON: Unfortunately, detailed observa- tions of people with accidental profound hypo- thermia are scant. The facts that we do know have been accumulated with controlled hypothermia. The major change noted with hypothermia is pro- gressive decreases in the oxygen requirement and the oxygen consumption. For example, at 30 de- grees centigrade, somewhat above this patient's temperature when he was first found, the oxygen consumption is only 50 per cent of normal. Coincidental with progressive decrease in the demand for oxygen is lowering of blood pressure and slowing of pulse. There is also an increasing irritability of the myocardium. Spontaneous res- piration usually ceases about 32 to 30 degrees, but in isolated instances as in this patient, respirations may be maintained a t  lower temperatures. There are progressive electroencephalographic changes with decreasing temperature. At about 20 degrees, all electrical activity in the brain ceases. I t  can be seen, therefore, that this patient was extremely lucky in that, although his body tem- perature had fallen to the range where ventricular fibrillation occurs where spontaneous respiration usually ceases, he managed to survive. DR. HERMANN: Dr. Holmes, this patient de- veloped renal shut-down as part of his illness. Was this due to the effect of cold per se on the kidneys, or was it secondary to prolonged hypotension? DR. HOLMES: It is difficult to state whether this patient's renal lesion was a result of prolonged hypotension or of hypothermia itself. We do know that the former condition can lead to lower nephron nephrosis. We also know that, although proteinuria has been associated with exposure to cold, there is little reference in the literature to occurrence of prolonged oliguria or acute tubular necrosis secondary to cold injury. Although in- duced hypothermia causes reductions in glomeru- - - lar filtration rate and renal blood flow, rewarming rapidly restores these values to normal. This patient was dialyzed in keeping with our policy of early and frequent dialyses in all trauma patients with associated oliguria. He was dialyzed on the third hospital day. By this time, his BUN had risen to 180 mg. per cent. The dialysis pro- duced notable clinical improvement and after going through a brief diuretic phase, the BUN dropped to 18 mg. per cent by the fifth post- treatment day. There was no further evidence of renal dysfunction. DR. HERMANN: Thank you, Dr. Holmes. Dr. Blount, as a cardiologist with interest in cardiac surgery and controlled hypothermia, would you comment upon this patient's auricular fibrillation and the relationship of cold to the functioning of the myocardium? DR. BLOUNT: The auricular fibrillation which this patient exhibited when first seen is a well known response of human myocardium to hypo- thermia. In the human, auricular fibrillation is the first abnormal rhythm manifested with de- creasing temperatures. As the temperature drops, this will be followed by ventricular fibrillation and eventually cardiac standstill. Somewhere be- tween 28 to 30 degrees centigrade, most patients will develop auricular fibrillation. With tempera- tures below 28 degrees, ventricular fibrillation supervenes with increasing frequency. In this pa- tient, as has been the case using controlled hypo- thermia, the cardiac rhythm spontaneously as- sumed a normal beat, coincidental wtih rewarm- ing. Because of the possibility of ventricular fibril- lation during hypothermia, a continuous visualized monitoring of a patient's cardiac rhythm is neces- sary. Specialized equipment should be in the im- mediate vicinity for treatment of ventricular fib- rillation, should it occur. DR. HERMANN: Probably the most important aspect of this discussion is prophylaxis or pre- vention of frostbite. Dr. Knight, you have had a wide experience with this problem in Great Bri- tain. Would you outline basic principles for pro- tecting one's self from cold injury? DR. KNIGHT: The most fundamental and pri- mary means of protection, of course, is proper clothing-multiple layers of light woolen material and a windproof outer garment. Still air is a poor heat conductor, so multiple layers of clothing which entrap air in its intersticies act as an ideal insulator. Proper head gear and foot wear are also necessary. Gloves should be worn at all times, particularly when hands must come in contact with metallic objects. Since heat is generated into the body by its basal metabolism and by muscular effort, physical activity will provide warmth for the body to some extent. Violent exercise, on the other hand, is injurious. Although it generates heat, it increases the water and heat loss from the lungs. Large amounts of both heat and water may be lost in this way. In addition, sweating, which is an ac- companiment of violent exercise, will cause a more rapid loss of heat due to increased evapora- tion. Lastly, it has been my experience that the majority of cases of frostbite occur when people become fatigued, with resultant carelessness. When exposure to prolonged cold is inevitable, one must refrain from becoming overtired. An adequate diet is likewise extremely important, both in pre- venting fatigue and in supplying fuel for the metabolism of the body. DR. HERMANN: Thank you, Dr. Knight. Ev- eryone who is exposed to temperatures which may cause frostbite must heed those basic precepts of self-care. Realization that frostbite implies a long term illness with possible economic and physically disastrous consequences must be impressed on all peoples residing in cold regions. ReQrint from February Rocky 1963 Mountain Medical Journal Official Journal of: The Colorado Medical Society . The Montana Medical Association s The Nevada State Medical Association b The New Mexico Medical Society T h e  Utah State Medical Association The Wyoming State Medical Society The Rocky Mountain Medical Conference 0 1963 by The Colorado Medical Society 

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Seminar on frostbite

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