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 (38°C bath water immersion + aspirin IV [250mg] + 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 < .01), and 27.3% with TT-C (3 of 11 patients) (P < .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 < .001) and 44.4% with TT-C (4 of 9 patients) (P < 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.