Que enfermedad sufre este paciente

A 36 year old unemployed man with a history of depression and heavy alcohol consumption presented to the local accident and emergency department with injuries to both feet. The previous night he had been drinking heavily. He had attempted to return home but did not make it and had spent the entire night sleeping outside in a snow drift.

He was otherwise fit and well with no allergies, and the only drug that he took regularly was citalopram for his depression.

On arrival, he was systemically well with a normal core temperature. Bilateral foot injuries were noted (figure). The more severely affected right foot had a dusky ischaemic appearance, with a clear temperature change at the level of the ankle joint and absent distal pulses. The toes of the left foot were also dusky and cool, with blistering over their dorsal aspect. The distal pulses were weakly palpable in this foot. The patient had no other injuries and all other systems examinations were normal.

Questions

1 On the basis of the history and examination findings, what is the likely diagnosis?
2 What are the predisposing risk factors for this condition?
3 What investigations might you consider to confirm your diagnosis?
4 How is this condition treated?
5 What is the role of surgery in this condition?

Answers

1 On the basis of the history and examination findings, what is the likely diagnosis?

Short answer

The likely diagnosis is frostbite. This occurs when the temperature of the skin drops to about ˆ’0.5 °C and tissue freezes, resulting in the formation of intracellular ice crystals and microvascular occlusion.

2 What are the predisposing risk factors for this condition?

Short answer

Risk factors include environmental factors; substance misuse, especially alcohol; psychiatric illness; peripheral vascular disease; drugs (prescribed and illicit); and trauma. It is most commonly seen in adult men.

Risk factors for frostbite

Environmental factors

  • Temperature
  • Duration exposure
  • Wind chill
  • High altitude

Behavioural factors

  • Military activities
  • Winter sports
  • Homelessness
  • Being stranded in cold weather
  • Working in cold environment
  • Inadequate clothing
  • Smoking
  • Substance misuse (alcohol, illicit drugs)

Other (medical or physiological) risk factors

  • Psychiatric illness
  • Previous cold injury
  • Immobilisation (trauma)
  • Adult male
  • Dehydration
  • Malnutrition
  • Systemic disease (peripheral vascular disease, diabetes, sepsis, Raynaud €™s disease, stroke)
  • Drugs (sedatives)

3 What investigations might you consider to confirm your diagnosis?

Short answer

Diagnosis is essentially clinical, being based on history and examination. However, scintigraphy using pertechnetate labelled with technetium-99 and magnetic resonance angiography can help assess tissue viability.

4 How is this condition treated?

Short answer

Prioritise any other life threatening conditions. Discuss all cases with a specialist unit that routinely performs peripheral thrombolysis. Immediate treatment includes rapid rewarming, analgesia, ibuprofen (used for its selective antiprostaglandin activity), oral antibiotics, and tetanus prophylaxis. Debride blisters containing clear fluid and apply topical aloe vera to the wound. Prohibit smoking and raise the limb. Consider adjuvant therapy.

5 What is the role of surgery in this condition?

Short answer

Surgery is not usually indicated in the acute phase and should be delayed until the frostbitten area is thoroughly demarcated. However fasciotomy may be indicated in cases of compartment syndrome and early amputation in cases of sepsis.

Patient outcome

The patient was treated with oral ibuprofen 600 mg two to three times daily and intravenous opioid analgesia. His blisters were debrided and 1% silver sulfadiazine cream was applied to the affected areas. He was given tetanus prophylaxis and started on oral antibiotics. He was also given oral pentoxifylline 400 mg three times daily and an epidural lower limb sympathetic block. Computed tomography angiography showed absent flow in both the right posterior tibial and anterior tibial arteries below the level of the ankle joint, but the most distal vessels in the left lower limb were patent. After initial conservative management he became systemically unwell at seven days after injury and developed a fever and raised inflammatory markers. A below the knee guillotine amputation was carried out on the right leg and the amputation stump left open. A week later, once his condition had stabilised, the stump was closed in the operating theatre. He made a swift recovery and was discharged one week later. Follow-up arrangements were made with the prosthetic limb fitting and psychiatric services. One month after discharge, planned delayed distal amputation of the left big toe and second toe was carried out.

[Link to free BMJ article PDF for full-text, images, and long answers]

© 2011 BMJ Publishing Group Ltd

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