Gelures graves: Plus tôt la thrombolyse

Time Matters in Severe Frostbite: Assessment of Limb/Digit Salvage on the Individual Patient Level.

 

Nygaard RM et Al. J Burn Care Res. 2017 Jan/Feb;38(1):53-59.

 

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Un article très intéressant car il utilise d'une part le score d'hennepin et d'autre part a recours à une imagerie TDM très précoce pour documenter des déficits de vascularisation après réchauffement et dès lors indiquer la thrombolyse.

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Severe frostbite is associated with high levels of morbidity through loss of digits or limbs. The aim of this study was to examine the salvage rate following severe frostbite injury. Frostbite patients from 2006 to 2014 were identified in the prospectively maintained database at a single urban burn and trauma center. Patients with imaging demonstrating a lack of blood flow in limbs/digits were included in the analysis (N = 73). The Hennepin Frostbite Score was used to quantify frostbite injury and salvage. This score provides a single value to assess each individual patient's salvage rate. The majority of patients with perfusion deficits were male (80%) with an average age of 42 years (range 11-83 years). Patients requiring amputation tended to be older (P = .002), have more tissue impacted by frostbite (P < .001), and experienced a longer time from rewarming to thrombolytic therapy (P = .001). A majority of patients (62%) received thrombolytic treatment. The percentage of patients requiring amputation was lower and the salvage rate was higher in patients treated with thrombolytics; however, the differences failed to reach statistical significance (P = .092 and P = .061, respectively). The rate of salvage decreases as the time from rewarming to thrombolytic therapy increases. Regression analysis demonstrates an additional 26.8% salvage loss with each hour of delayed treatment (P = .006). When the amount of tissue at risk for amputation is included in the model, each hour delay in thrombolytic treatment results in a 28.1% decrease in salvage (P = .011). This study demonstrates a significant decrease in limb/digit salvage with each hour of delayed administration of thrombolytics in patients with severe frostbite

OHB des gelures: Etudes des pratiques européennes ?

Place de l'oxygenotherapie hyperbare dans le traitement des gelures : Evaluations des pratiques europeennes

Thèse de médecine Kolakowska E.

À l’heure actuelle, l’oxygénothérapie hyperbare (OHB) ne fait pas partie des recommandations pour le traitement des gelures et pourtant elle est proposée par plusieurs spécialistes. La gelure est une lésion tissulaire survenant lors d’une exposition prolongée et directe à une température inférieure à 0 °C. L’OHB pourrait être utile par le biais de l’amélioration de l’oxygénation locale, la limitation de l’oedème, la lutte contre l’infection et la stimulation des processus de cicatrisation. L’équipe du centre hyperbare de l’Hôpital de Sainte-Marguerite à Marseille avait traité les victimes de gelures avec des résultats très encourageants, ce qui nous a motivé à évaluer les pratiques concernant l’utilisation de l’OHB dans la prise en charge des gelures dans différents centres hyperbares Européens et vérifier, s’il avait existé un bénéfice thérapeutique. Il s’agit d’une étude réalisée à l’aide d’un questionnaire auprès des médecins exerçant aux caissons hyperbares en Europe. Sur 134 messages envoyés, 21 médecins avaient rempli le questionnaire. 86 % des spécialistes estimaient que théoriquement l’OHB pourrait être indiquée dans la prise en charge de gelures. Parmi les 25 patients inclus, 84 % avaient été atteints de gelures profondes et seulement 44% avaient bénéficié d’une prise en charge dans les premières 72 heures. Malgré la gravité des lésions et le délai de la prise en charge, nous avons constaté, qu’à 3 mois d’évolution, 88 % des patients avaient présenté une amélioration sur le plan cutané par rapport à l’état initial. Bien que notre étude ne soit pas d’une grande valeur statistique, elle permet toutefois de s’apercevoir du bénéfice thérapeutique que l’OHB pourrait apporter dans cette pathologie, y compris tardivement. En effet, des études prospectives larges seront nécessaires et justifiées.

Rappel: Schéma physiopathologique de la gelure 

Gelures

Cold Exposure Injuries to the Extremities

Golant A. et AL. J Am Acad Orthop Surg 2008;16:704- 715

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Un document un peu ancien, mais bien fait notamment une physiopathologie clairement présentée.

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Cold exposure injuries comprise nonfreezing injuries that include chilblain (aka pernio) and trench, or immersion, foot, as well as freezing injuries that affect core body tissues resulting in hypothermia of peripheral tissues, causing frostnip or frostbite. Frostbite, the most serious peripheral injury, results in tissue necrosis from direct cellular damage and indirect damage secondary to vasospasm and arterial thromboses. The risk of frostbite is influenced by host factors, particularly alcohol use and smoking, and environmental factors, including ambient temperature, duration of exposure, altitude, and wind speed. Rewarming for frostbite should not begin until definitive medical care can be provided to avoid repeated freeze-thaw cycles, as these cause additional tissue necrosis. Rewarming should be rapid and for an affected limb should be performed by submersion in warm water at 104° to 107.6°F (40° to 42°C) for 15 to 30 minutes. Débridement of necrotic tissues is generally delayed until there is a clear demarcation from viable tissues, a process that usually takes from 1 to 3 months from the time of initial exposure. Immediate escharotomy and/or fasciotomy is necessary when circulation is compromised. In addition to the acute injury, frostbite is associated with late sequelae that include altered vasomotor function, neuropathies, joint articular cartilage changes, and, in children, growth defects caused by epiphyseal plate damage.

Lesions dues au froid: Pas que les gelures

 

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Gelures: L'expérience indienne

Management of Cold Injuries 

Hota PK et Al. Surgical Research Updates, 2013, 1, 20-25

Un article produit par une équipe ayant une grande connaissance de cette pathologie. La place de l'oxygénothérapie hyperbare y est mise en avant.

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Cold injuries are very common among the troops deployed in high altitude regions. Now days, it is also seen  among the civilian populations like mountaineers and winter sportspersons. There is no definitive treatment protocol  available for this entity. In this study, 234 patients of various degrees of cold injuries were treated with a standard  protocol of multidrug therapy with a view to combat the effects of cold injury at various steps of pathogenesis. Deep frost  bite cases were subjected to Hyperbaric Oxygen therapy (HBOT). An encouraging result was found in our study with this  protocol. There was less morbidity. Healing time, hospital stay and loss of digits were less. Multidrug therapy with  Pentoxyphylline, Ibuprofen and soluble aspirin was a better treatment modality than single drug used in the treatment of  cold injuries. HBOT was found to reduce morbidity to a great extent along with saving a number of digits from  amputation. 

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Gelures: Une vision actualisée 2014

Frostbite: a practical approach to hospital management

Handford et al. Extreme Physiology & Medicine 2014, 3:7

 

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La prise en charge des gelures évolue notamment par l'apport de la perfusion d'iloprost dans les formes les plus graves et du positionnement en cours de la thrombolyse. Ce document fait une synthèse des données actuelles.

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Frostbite presentation to hospital is relatively infrequent, and the optimal management of the more severely injured patient requires a multidisciplinary integration of specialist care. Clinicians with an interest in wilderness medicine/ freezing cold injury have the awareness of specific potential interventions but may lack the skill or experience to implement the knowledge. The on-call specialist clinician (vascular, general surgery, orthopaedic, plastic surgeon or interventional radiologist), who is likely to receive these patients, may have the skill and knowledge to administer potentially limb-saving intervention but may be unaware of the available treatment options for frostbite. Over the last 10 years, frostbite management has improved with clear guidelines and management protocols available for both the medically trained and winter sports enthusiasts. Many specialist surgeons are unaware that patients with severe frostbite injuries presenting within 24 h of the injury may be good candidates for treatment with either TPA or iloprost.

In this review, we aim to give a brief overview of field frostbite care and a practical guide to the hospital management of frostbite with a stepwise approach to thrombolysis and prostacyclin administration for clinicians

Gelures: Le guidelines de la WMS

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Les gelures

 

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