A previously healthy 16-year-old male presented by ambulance from a referring institution for evaluation of cold exposure/frostbite to both hands. By report the patient had been found by police wandering in the middle of the road with his coat open, his head uncovered, and his hands ungloved. The patient's feet were protected with insulated snow boots. Heavy moisture and snow to the anterior surface of the patient's clothing raised concern that he had been unconscious and lain in the snow for a period of time. The police described him as "significantly intoxicated," and he purportedly admitted to alcohol and marijuana use on the evening of injury. The ambient air temperature on the night of admission ranged between -10.5 to -12.8 degrees Celsius with wind chill factors of -14 to -19 degrees Celsius.
The patient was transported home by the police and released into the custody of his parents. Upon arriving home his father described the patient's hands as "cold and red" and re-warming of the hands by soaking them in warmed water was attempted. The temperature of the water used in home therapy and the duration of warm water immersion was not reported. After home warming, the patient's fingers were noted to swell significantly, with associated darkening of the skin.
At this point the patient was transported by private vehicle to an emergency department (ED) for evaluation. While at the referring facility he had a peripheral intravenous line inserted, and he was given an intravenous dose of cefazolin and divided doses of morphine sulfate and hydromorphone for analgesia. Laboratory studies revealed an ethanol level of 0.19 g/dL, white blood cell count of 27.5 k/mm3, hematocrit 50.3%, international normalized ratio (INR) 1.0, and a random glucose level of 113 mg/dL. After brief evaluation and initial treatment, the patient was transferred by ambulance to tertiary care for plastic surgery evaluation. The time of ground transport was 2 hours.
The patient arrived to the tertiary center ED 4 hours after being found by police. Initial exam revealed a well-nourished, well-developed, 77-kilogram teenage boy who was lethargic but easily aroused and oriented x3. Vital signs included blood pressure 93/54 mm/Hg, respiratory rate 18 per minute, pulse 105 beats per minute, temperature 36.6 degrees Celsius, and pulse oximetry 97% on room air. Primary and secondary surveys of this patient were non-contributory except for the examination of his extremities.
Bilaterally, his hands and fingers demonstrated dorsal abrasions, discoloration, and hemorrhagic blisters. The right hand demonstrated mottling and discoloration of the ring and small fingers distal to the proximal interphalangeal (PIP) joint and of the long finger tip. The ring finger had small hemorrhagic blisters on the dorsal surface. The right long finger had small dorsal abrasions. The right index finger and thumb demonstrated no significant abnormalities on examination.
The left hand was more seriously injured, with all digits affected. The left index, long, ring, and small fingers were mottled and cool, with evidence of hemorrhagic blisters along the dorsal surface. The tip of the left thumb was similarly affected (Figure 1). Doppler pulses to the left index and long finger were not present distal to the PIP joint.
Abrasions and pain were noted to the patient's knees bilaterally. Examination of both lower extremities demonstrated no neurovascular compromise and full range of motion. Plain films of the patient's bilateral knees and hands did not reveal fractures or acute injury. A Breathalyzer test taken 1 hour after arrival was 0.083.
A 1 L bolus of normal saline was infused, and both hands were placed in 40 degrees Celsius warm water baths for 20 minutes. Tetanus prophylaxis was provided, an additional dose of cefazolin was infused, and morphine in divided doses was provided for analgesia. Computerized tomography of the head/cervical spine was performed to identify occult traumatic injury or intracranial hemorrhage. These studies were negative for intracranial hemorrhage, skull fracture, or cervical spine injury. No other interventions were performed in the ED, and the patient was taken emergently to interventional radiology for bilateral upper extremity angiography and evaluation for intra-arterial infusion of thrombolytic therapy.
After informed consent and provision of conscious sedation, bilateral femoral artery sheaths were placed. Initial arteriography revealed standard anatomy of the aortic arch and patency of the bilateral subclavian, axillary, and brachial arteries. Selective angiography of the forearm and hand vessels bilaterally was performed. The radial, anterior interosseus, and posterior interosseus arteries were patent bilaterally. The right ulnar artery was also patent. Hand and finger arteriography demonstrated several areas of impaired arterial microcirculation.
On the right hand initial arteriography revealed impaired distal microcirculation to the thumb, a focal radial digital artery occlusion to the index finger, with diminished tip circulation, diminished tip circulation to the long finger, distal occlusion of both digital arteries of the ring finger with absent tip microcirculation, and near total occlusion of arterial blood supply to the small finger.
Initial arteriography of the left hand demonstrated ulnar artery spasm and occlusion of the ulnar artery, severe spasm of both digital arteries to the thumb with diminished micro-circulation, occlusion of the digital artery with minimal circulation to the index finger, no microcirculation to the long finger, and occlusion of the ulnar digital arteries with diminished microcirculation to the ring and small finger (Figure 2).
After initial angiographic exam, 3000 units of heparin were infused into the femoral sheaths, followed by intra-arterial infusion of 50 mcg of nitroglycerine bilaterally via catheters placed in the brachial arteries. Continuous infusions of tissue plasminogen activator (tPA) 0.25 mg and 500 units of heparin per hour were provided to each brachial catheter and femoral sheath, respectively. tPA infusion was begun within 8 hours of the patient being found by police. The patient subsequently was admitted to the intensive care unit for continued wound care and evaluation.
Approximately 8 hours after initiation of tPA therapy, a repeat angiography was performed through the existing arterial catheters that revealed improved circulation in the right hand but continued impairment to the distal micro-circulation of the left hand. The right-sided brachial catheter was removed, but the left remained in place for continued tPA therapy. Twelve hours later a third angiographic exam of the left hand demonstrated improved distal circulation in all digits except for the ring finger. Left-sided tPA infusion was discontinued after this study, and the left brachial catheter and both femoral sheaths were removed. Once hemostasis was obtained at the femoral puncture sites, heparin infusion was re-initiated and continued for an additional 72 hours.
Wound care consisted of daily cleansing and topical silver sulfadiazine dressings to the open areas of both hands. Nutritional support and occupational/physical therapy were also started on hospital day 1. Once the patient was able to perform physical therapy exercises and dressing changes independently, he was discharged home on hospital day 6. Before discharge social workers also completed a brief intervention to address his alcohol and illicit drug use. Outpatient support for substance abuse counseling was offered to the patient and family at this time.
The patient was monitored with weekly outpatient clinic visits to assess wound healing and bilateral hand function. The patient eventually required split thickness skin grafts to the left ring and small finger (total graft size 12.5 cm3). After skin grafts the patient healed without complication and has retained full function and sensation to both hands.
Perfusion images before and after tPA administration are demonstrated in Figure 2. A pictorial progress of the patient's wounds is provided in Figure 3.