Treatment of Frostbite with Iloprost
Date First Published:
July 4, 2017
Last Updated:
August 6, 2017
Report by:
Margo Kaller, Medical student (Oregon Health & Science University, USA)
Search checked by:
Anna Russell, Oregon Health & Science University, USA
Three-Part Question:
In [adult patients with frostbite], does Emergency Department treatment with [iloprost] lead to [improved clinical outcomes]?
Clinical Scenario:
A 56 yo homeless man with a history of alcoholism and stroke is brought to the ED after he was seen sleeping on a park bench in the snow without shoes. He is rousable but 34 F [not sure about this - reads more like Celsius] and is clearly intoxicated with a blood EtOH of 0.22 mg/dL. After giving the patient initial re-warming treatment with warmed blankets, you notice his toes appear severely frostbitten. You know tPA therapy is absolutely contraindicated in this man, but wonder if something else will decrease the likelihood of this man’s toes being amputated.
Search Strategy:
A short cut literature review was carried out to determine whether administration of Iloprost infusion improved the clinical outcomes of patients with frostbite presenting to the Emergency Department.
Search Details:
PubMed, Ovid, and BestBETs databases were searched using the terms [iloprost OR prostacycline OR epoprostenol OR treprostinil] AND [frostbite] LIMIT to human AND English Language
Outcome:
PubMed identified 13 articles, 3 of which were clinical trials relevant to the question. OVID identified 8 articles, 3 of which were the same clinical trials relevant to the question. Browsing the articles’ references and BestBETs browsing did not yield any further articles relevant to this topic.
All relevant papers are summarized in the table.
All relevant papers are summarized in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| A controlled trial of a prostacyclin and rt-PA in the treatment of severe frostbite Cauchy E, Cheguillaume B, Chetaille E 2011 France | 47 patients with severe frostbite presenting to ED directly after mountain rescue Follow-up in 3 months |
Randomized controlled trial | Number of frostbitten digits amputated | aspirin + buflomedil: 106 digits with frostbite, 42 amputated aspirin + iloprost: 142 digits with frostbite, 0 amputated aspirin + iloprost + tPA: 159 digits with frostbite, 5 amputated | Only ~15 patients per study group No tPA given without iloprost Stage 4 frostbite more prevalent in tPA + iloprost group |
| Treatment of severe frostbite with iloprost in northern Canada Poole A, Gauthier J 2016 Canada | 2 patients with grade 3 frostbite presenting to the ED after an arctic race Follow-up in 6 months |
Case report | Number of frostbitten digits amputated | Case 1 patient: 6 digits, right foot, and nose with frostbite, 0 amputations Case 2 patient: 2 digits with frostbite, 0 amputations | Case 2 patient missed one of the doses of iloprost infusion No controls, small study population |
| Treatment of Frostbite with Iloprost E Groechenig 1994 Austria | 5 patients with grade 2 and 3 frostbite presenting to the ED after exposure to cold Follow-up in at least 2 weeks |
Case reports | Number of patients receiving amputation after frostbite diagnosis | None of the 5 patients required any amputation at follow-ups between 14 and 42 days | Uncertain localization of frostbite, unknown follow-up duration 1 patient treated with heparinization No controls, small and medically complex study population |
Author Commentary:
These promising findings necessitate follow-up with large randomized controlled trial to ensure broad reproducibility. Additionally, the long term effects of iloprostol therapy as well as its application in paediatric frostbite should be investigated.
Bottom Line:
Although clinical outcomes associated with iloprostol therapy in frostbite have only been examined in 2 case study series and 1 small randomized controlled trial, this petite body of evidence demonstrates a uniformly favorable effect of iloprostol on patient outcomes. Iloprostol treatment for frostbite of any severity grade may significantly decrease the risk of requiring amputation for the frostbitten area.
References:
- Cauchy E, Cheguillaume B, Chetaille E. A controlled trial of a prostacyclin and rt-PA in the treatment of severe frostbite
- Poole A, Gauthier J. Treatment of severe frostbite with iloprost in northern Canada
- E Groechenig. Treatment of Frostbite with Iloprost