Managing frostbite in a South African patient

Abstract

This report focuses on a 23‐year‐old man of African‐Caribbean origin who presented to a Burns unit with soft‐tissue loss following a road traffic collision (RTC) in an extremely cold weather. Having been involved in the RTC, he walked from the scene to the hospital subsequently sustaining frostbite to both his feet. This case illustrates the management of frostbite and highlights some key principles in the management of this problem.

Introduction

Thermal cold injury can be localised or general. When frostbite occurs, tissues freeze and ice crystals form in between the cells (1). Local cold injury may or may not be associated with hypothermia. Central core temperature is essential to life and as a result of homeostatic response, blood flow may be redistributed from the peripheral extremity to the central core (2, 3, 4). Through cellular injury and vascular impairment, cold‐induced protein changes and membrane damage leading to vasoconstriction and subsequent endothelial injury and thrombo‐embolism contribute to vascular insufficiency and ischemia (3, 4, 5, 6). This in turn may lead to micro‐emboli with necrosis and gangrene as the end result (2, 4, 7, 8).

Case report

A 23‐year‐old soldier was involved in a road traffic collision after a night out. He was intoxicated from alcohol and drove home in icy conditions. He lost control of his vehicle and collided with a nearby tree. Stranded in a field, he walked to the nearest village 8 miles away in sub‐freezing temperatures (−4 ± 2°C) without shoes. He presented the next day to the local hospital and was then subsequently seen at the local burns unit. He sustained degloving injuries to both feet which were initially thought to be secondary to the car accident. Speaking little English, after a detailed history through an interpreter, the alleged events were recounted. He had sustained no other injuries and his core temperature was recorded at 35·2°C initially. Being a soldier he was otherwise fit and well. Blood samples were sent for full blood count, urea and electrolytes, lactate, CRP, sickle screen and toxicology screen. Of note, his sickle cell status was negative, with creatinine kinase level >8000 U (Figure 1).

Figure 1.

A clinical photograph depicting the soft‐tissue loss of the glaborous skin on the soles of both feet in the South African patient. Assessing the depth of the burn can occasionally be challenging in darker skin types (Fitzpatrick V and VI).

On review of his history together with injuries, a diagnosis of frostbite was made. He was managed at the Burns unit with elevation, analgesia, fluids and dressings initially. He remained an in‐patient for 5 days during which time he stabilised and his burns demarcated. Elevation and monitoring for compartment syndrome together with physiotherapy, and occupational therapy together with nutritional therapy were needed to manage his problem holistically to ensure healing of his injuries and their sequelae. After 14 days of pain management, physiotherapy and regular dressing changes, his wounds were debrided and grafted, with amputations of both his second and third toes on both feet (Figure 2).

Figure 2.

A clinical photograph depicting the dorsum of the foot. There is marked oedema with tense soft tissues. Clinicians must remain cognisant of compartment syndrome in the foot.

Discussion

Frostbite is the most common cold injury, with the upper and lower extremities most commonly affected. Typically mountaineers and explorers who deal with extreme weather often at high altitudes are frequently affected. Aside from these individuals, those with peripheral neuropathy secondary to diabetes or vasculitides are also at risk.

Vessels close to the skin begin to constrict at freezing temperatures and blood is shunted away from the extremities via the action of glomus bodies. The same response may also be a result of exposure to high winds. This constriction helps to preserve core body temperature. In extreme cold conditions, or when the body is exposed to cold for long periods, this protective strategy can reduce blood flow in some areas of the body to dangerously low levels. This lack of blood leads to the eventual freezing and death of skin tissue in the affected areas.

With respect to cold injury, a differentiation has to be made between reversible and irreversible changes, frostnip and frostbite. Broadly speaking frostnip refers to superficial cooling of tissues without cellular destruction, whereas frostbite involves tissue destruction (7, 8). Precautions should be taken to protect extremities in cold weather with protective clothing, thermal layers and avoidance of sustained exposure to severe cold in a dry or wet environment (8).