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Frostbite is a common injury in high altitude medicine. Intravenous vasodilators have a proven efficacy and, recently, have been proposed as a safe outpatient treatment. Nevertheless, the lack of availability and consequently delayed application of this treatment option can result in poor clinical outcomes for patients. We present the case of a 60-year-old Chilean man with severe frostbite injuries suffered while climbing Mount Everest. The patient was initially given field treatment to the extent permitted by conditions and consensus guidelines. Unfortunately, advanced management was delayed, with iloprost administered 75 hours after the initial injury. The patient also underwent 5 days of hyperbaric and analgesic/antibiotic therapies. An early bone scan predicted a poor clinical outcome, and five of the patient's fingers, between both hands, were incompletely amputated. We present this case to exemplify the importance of advanced in-field management of frostbite injuries.

Hypothermia and frostbite occur when there is a significant decrease in central and peripheral body temperature in individuals exposed to cold windy conditions, often at high altitude or in a mountain environment. Portable hyperbaric chambers increase the barometric pressure and thereby the partial pressure of oxygen inside the chamber, and their use is a well-known treatment for altitude illness. This study aims to show that a portable hyperbaric chamber could also be used to treat hypothermia and frostbite in the field, when rescue or descent is impossible or delayed.During a European research program (SOS-MAM, Flow Pulse study) measurements were taken from 27 healthy nonacclimatized voluntary subjects (21 men, 6 women, mean age 41 ± 17) at an altitude of 3800 m (Chamonix Mountain Lab, Aiguille du Midi, France) right before and immediately after spending 1 hour in a portable hyperbaric chamber at 300 mbar. We measured digital cutaneous temperature (Tcut), digital cutaneous blood flow (Fcut), digital tissue oxygenation (TWe observed significant increases in Tchamb: 9.3°C compared with the outside temperature, Tcut: +7.5°C (±6.2°C 71%), Fcut: +58This study shows that a portable hyperbaric chamber can be used to treat frostbite and/or hypothermia in the field at altitude when descent or rescue is impossible or even simply delayed.

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.

We report a retrospective study of the prognostic value of 2-phase technetium 99m bone scanning performed in 92 patients who presented to Chamonix Hospital with severe frostbite of the extremities in the past 12 years. The results of this study show that an initial bone scan (as early as day 3) has excellent specificity in evaluating the severity of frostbite injury. There was a direct correlation between the demarcation zone of uptake in the phalanges and the eventual level of amputation (positive predictive value, 0.84). A second scan on approximately day 7 was even more sensitive and informative. A strong correlation existed between positive uptake and eventual healing (negative predictive value, 0.99). This study showed that (99m)Tc bone scanning in the first few days after frostbite injury indicates the level of amputation in severe frostbite in more than 84% of cases. We propose an algorithm based on the results of this study that can be used to evaluate new medical and surgical management of frostbite injury.

Iloprost With and Without rt-PA: Treatment of 131 Cases of Severe Frostbite Emmanuel Cauchy; Eric Chetaille; Emmanuel Pham; Hugo Nespoulet; Pascal Zellner; Francois Becker; Peter Hackett IFREMMONT (Institut de Formation et de Recherche en Medecine de Montagne), Hopital de Chamonix, Chamonix, France, Institute for Altitude Medicine, Telluride, CO, USA Introduction.—Both rt-PA and iloprost (prostacyclin) are effective treatments for severe frostbite, but it is unclear if using them in combination is more effective. Objective.—To evaluate combined treatment with rt-PA and iloprost in severe frostbite, compared with other therapies. Methods.—Retrospective case review of 131 patients with severe frostbite. Patients without contraindication or severe trauma were managed with rapid rewarming (381C bath water immersion þ aspirin IV [250mg] þ buflomedil IV [400 mg, alphalytic vasodilator] during 1 hour. Then 41 patients received daily treatment of aspirin and buflomedil (TT-A); 58 received aspirin and IV iloprost 2 ng/6 h (prostacyclin) (TT-B); and 20 received aspirin, IV tPA (100 mg, first day only) and iloprost (TT-C). Twelve patients did not receive any treatment (TT-D). The final level of amputation was measured 3 to 8 days later on bone scanning. Results.—For grade 3 frostbite, 100% of the patients required amputation in TT-D (4 of 4 patients), as did 62.5% with TT-A (10 of 16 patients), 4.9% with TT-B (2 of 41 patients) (P o .01), and 27.3% with TT-C (3 of 11 patients) (P o .03). For grade 4, 100% needed amputation in TT-D (3 of 3 patients), 100% in TT-A (4 of 4 patients), 66.7% TT-B (4 of 6 patients) (P o .001) and 44.4% with TT-C (4 of 9 patients) (P o 0.03). Of 407 digits, 183 frozen fingers lead to 22 amputations (TT-A 49%, TT-B 0%, TT-C 2%, TT-D 49%), and 224 frozen toes lead to 25 amputations (TT-A 34%, TT-B 0%; TT-C 4%, TT-D 62%). Analysis showed that tPA was effective up to 12 hours and iloprost up to 48 hours. Conclusion.—The efficacy of iloprost was significantly higher than buflomedil or no treatment. The addition of rt-PA to prostacycline seems to improve the prognosis only of stage 4 frostbite and only when the delay between rewarming and treatment was less than 12 hours.

Objective Previous frostbite classifications were mainly based on retrospective diagnosis and, most of the time, could not be used to predict the final outcome of the lesions and especially the probability of an amputation and its level. The aim of this study was to suggest a new classification at day 0 based mainly on the topography of the lesions and on early bone scan results, which are more convenient and accurate in predicting the final outcome of frostbites. Methods The retrospective study of the clinical histories of 70 patients hospitalized at Chamonix Hospital (Mont-Blanc Massif) from 1985 to 1999 for severe frostbite injuries of the extremities has allowed us to classify the aspects of the initial lesions on day 0 and to compare them with final outcomes. Results A strong correlation was found between the extent of the lesion and the outcome of each finger or toe. When the initial lesion was on the distal phalanx, the probability of bone amputation was around 1% for the digit, 31% for the middle phalanx, 67% for the proximal phalanx, 98% for the metacarpal/metatarsal, and 100% for the carpal/tarsal. Conclusions Based on these clinical results and on the results of bone scans (previously validated), a new classification of frostbite severity at day 0 is proposed. Four degrees of severity are defined: first degree, leading to recovery; second degree, leading to soft tissue amputation; third degree, leading to bone amputation, and fourth degree, leading to large amputation with systemic effects.

To the Editor: Many alternatives have been proposed for the treatment of frostbite: hemodilution, platelet-aggregation inhibitors, low-molecular-weight heparin, alpha-adrenergic vasodilators, calcium-channel inhibitors, nonsteroidal antiinflammatory agents, prostacyclin analogues, fibrinolytic agents, and hyperbaric oxygen. None have been assessed in prospective randomized trials. Small retrospective studies1–3 suggest the efficacy of thrombolysis or prostacyclin analogues against spasm and thrombosis. Between 1996 and 2008, we randomly assigned 47 patients (44 men and 3 women) with severe frostbite to one of three treatment regimens in an open-label study. Severe frostbite was defined as having at least one digit (finger or toe) with frostbite stage 3 . . .