frostbitefreezingrewarmingtPAamputation
Frostbite
כוויית קור
📖 מבוא
Frostbite — נזק רקמתי מקיפאון (tissue freezing, <0°C). Ice crystals intracellular + microvascular thrombosis. Severity: superficial (skin only) vs deep (subcutaneous, muscle, bone). גפיים distales, אוזניים, אף. Bologna Ch 129.
📝 אנמנזה
חשיפה לקור — משך, טמפרטורה? אזורים מושפעים? נימול, כאב, אובדן תחושה? ⚠️ שימוש באלכוהול/סמים (impaired judgment)? מחלת כלי דם? Raynaud? סוכרת (נוירופתיה)? Rewarming כבר בוצע?
🔍 בדיקה
Degree classification: 1st — erythema, edema, no blisters. 2nd — clear/serous blisters (superficial, better prognosis). 3rd — hemorrhagic blisters (deep, worse prognosis). 4th — full-thickness necrosis, muscle/bone involvement. ⚠️ Do NOT assess severity until after rewarming (tissue may look worse initially). Distribution: fingers, toes, ears, nose, cheeks.
📋 סיכום
כוויית קור. Rapid rewarming + טיפול תומך.
💊 המלצות
📋 מידע כללי
-DDx: Chilblains/pernio (no freezing, milder, recurrent), Trench foot/immersion foot (prolonged wet-cold, no freezing), Raynaud (vasospasm, reversible), Cryoglobulinemia (purpura, arthralgia, complement low).
🔬 בירור
-Rapid rewarming (GOLD STANDARD): Immerse in warm water 37-39°C for 15-30 minutes (until tissue is pliable and erythematous). ⚠️ Do NOT rewarm if risk of refreezing (worse damage!). Pain management: opioids often needed (rewarming is very painful). IV ibuprofen/ketorolac. Remove wet clothing, insulate. Do NOT rub or massage frozen tissue.
💊 טיפול
-טיפול: Ibuprofen 400 מ"ג x3/d (inhibits thromboxane, reduces tissue loss). Topical aloe vera to affected areas. Clear blisters — aspirate/debride (thromboxane-containing fluid). Hemorrhagic blisters — leave intact (deep, protect underlying tissue). ⚠️ tPA (tissue plasminogen activator) — within 24h for severe frostbite (angiography showing no flow), reduces amputation rate 50-80% (specialized centers only). Iloprost (prostacyclin) — alternative to tPA.
-Surgical: ⚠️ "Freeze in January, amputate in July" — wait for full demarcation (6-12 weeks) before amputation. Tc-99m bone scan or MRA — assess tissue viability early. Fasciotomy — if compartment syndrome. Hyperbaric oxygen — adjunctive (limited evidence). Sequelae: cold sensitivity (chronic), neuropathy, early-onset osteoarthritis, growth plate damage (children).
📅 מעקב
-הפניה לכירורגיה/מרכז טראומה אם deep frostbite. ביקורת שבועית.
⚗ מרשם
-PO IBUPROFEN 400 mg x3/d (anti-thromboxane) - 1OP
-Topical ALOE VERA gel to rewarmed areas q6h - OTC
-PO OXYCODONE 5 mg q4-6h PRN (rewarming analgesia) - 1OP