Frostbite Slides

William J. Mills, Jr., M.D, a noted expert in frostbite and hypothermia, donated the following slides.

Dr Mills developed the ‘Alaskan Method’ — a system of care now used around the world in the treatment of frostbite and hypothermia. Mills has published more than 100 papers on the subject, established a high-altitude laboratory on Mount McKinley, and directed the Center for High Altitude Health Research at the University of Alaska. The slides were originally published in the January-March 1993 issue of Alaska Medicine, the entire issue was dedicated to the article.

Total Images: 136
121 121. Fig. 29. C-402. Plantar views of feet had demonstrated area of edema, severe bleb formation on heels, with epidermal and dermal gangrenous skin change. Rx supportive care (see x-ray changes). Case C402: Plantar views of feet
122 122. Fig. 30. C-402 Lateral views of feet, three and 1/2 weeks post freezing, snowmobile trip, with injury superimposed on condition of ’alcoholic peripheral neuropathy.’ Unaware" of cold injury till development of mummification of toes. Calcaneal views normal." Case C402: X-Ray Lateral views of feet
123 123. Fig. 31. C-402. Unexpectantly, avascular changes, with collapse of calcaneal structure occured. Asymptomatic due to neuropathy. Generally degenerative changes are not seen as early as four months post freezing.. C402: X-Ray, Avascular changes, with collapse of calcaneal structure
124 124. F/V JOHN N OLAF An eighty foot shrimper from Kodiak, Alaska. Abandoned in severe storm and icing, winds greater than 100 knots. Crew of four left in a raft --all lost --area of Shelikov Straits. January 1974. Photo credit: Taken bv Mr. Nom1 Holm Crn]rt~~v Mr~ Norm Hoh F/V JOHN N OLAF, shrimper, Kodiak, Alaska
125 125. Fig. 1. U.S. Marine. Vietnam. Wann water immersion foot. Demonstrating pale. almost cyanotic feet with creases. wrinkling of toes and soles. Complaint of tingling and bumming. Warm water immersion
126 126. Fig.2. Frame #1: C-826-83. The patient is a 27-year-old psychotic patient lost in the coastal woods of Alaska wearing only long underwear without shoes and stockings. He apparently had been camping in a tent when driven from the tent by a bear. He was without food and water for approximately nine days. The ambient temperatures were near freezing during the day. occasionally below freezing at night. The patient developed signs of compartment pressure injuries in feet, and fasciotomy was performed on the tenth day, the day of hospital arrival and rescue. This frame demonstrates severe necrosis and liquefaction of tissues and area of fasciotomy site performed at the day of rescue. Frame #2: The plantar view of feet on the II day with increasing necrosis. Frame #3: Anterior AP view with medial malleolar needle insertion demonstrates total loss of sensation at that level. Frame #4: On day II, technetium 99 pertechnetate demonstrates loss of capillary perfusion to the level of the malleolus bilaterally. This is a more accurate assessment of blood supply than the Doppler examination previously done that gave a positive pulse at mid-arch level, possibly reflecting pulses transmitted from a higher level. Frame #5: Because of overwhelming necrosis and mixed infection of both feet, a modified guillotine amputation was performed at the level of the malleolus, where eventually adequate vascular supply was found. By the sixth week, tissue granulation was present, enough to allow split thickness skin graft cover. Frame #6: At both procedures (guillotine amputation and then skin grafts to obtain physiologic cover), stump traction was used postoperatively to avoid tissue retraction and loss of length. Eventually, at six weeks, revision amputation at 10 inches from the knee joint was performed with good result. His psychiatric care continues. After review of his history elsewhere, it appeared that he had wet-cold insult, immersion injury, followed by freezing. Case 826-83: Wet, cold and freeze
127 127. Fig. 3. Ten days of wet cold exposure, followed by freezing, thawing and question of refreezing. Path. Specimen from C-826-83. I. Partially degenerated internal elastic membrane. 2. Arterial Lumen 3. Disrupted, fragmented endothelial lining. 4. Early organized thrombus. 5. Tunica media, edematous disruption of elastic fibers Case 826-83: Pathology Specimen
128 128. Fig.4. U.S. Coast Guard minimal estimate of ship loses and lives lost (1981-1991) in Alaska waters. Ship and lives lost in Alaska waters,1981-1991
129 129. Fig. 5. -Hypothermia -Immersion Injury -Frostbite Frame #1: Demonstrates a fishennan, age 23, aboard a crab fishing vessel in the Bering Sea that foundered in a stonn when ice accumulated on the rigging, causing the ship to ’turn-table’. The patient was in a life raft for five days, clad only in sweatshirt, pants and stockings. He was with two companions who had survival suits. The patient was without a suit. He was constantly cold and wet and was warmed by his crew companions who were in survival suits. The patient had constant wet extremities with superficial freezing of the extremities. He was hallucinating, vomiting, dehydrated with evidence of freezing of both feet at the time of helicopter rescue. Rewarming was perfonned in warm water at a rescue site in the Aleutian Islands, and the patient was then transferred to an Anchorage hospital. He was treated for hypothennia, by further tub warming with diagnosis of frostbite superimposed on immersion injury as well as severe dehydration and hypothennia. Frame #2: The feet on admission were cold, mottled with massive edema apparent, and the patient complaining of severe pain and burning in feet. Subfascial tissue pressures indicated values throughout the feet at levels greater than 100 mm Hg. Frame #3: Technetium scan the next morning after arrival demonstrates early loss of distal foot capillary perfusion. Frame #4: On the same day, bilateral fasciotomy was perfonned, revealing only minimal bleeding at the fasciotomy site, pale tissue and evidence of early necrosis of muscle in the anterior tibial compartment. The fasciotomy pennitted muscle and neurovascular structures to be relieved of occlusive pressure. Impending dusky muscle necrosis in the anterior compartment is apparent. Severe compartment pressure is further apparent as the muscle groups exploded outward after the fasia release. Frame #5: Six months after injury, the patient demonstrates adequate split thickness skin graft closure, phalangeal amputation and a functional foot despite the insult of hypothennia, freezing superimposed on immersion injury, compartment pressure syndrome and dehydration and caloric deprivation. Note: Compartment pressure is common in severe cold injury. No treatment, either geneml or vascular or drug therapy or thawing method or sympathectomy, can be effective until the compartment pressure is relieved. Compartment necrosis greater than 37 to 40 mm Hg, especially in the range of 60 mm Hg or greater. are sufficient to occlude the capillary tree and small vessels, and this pressure must be relieved. A further comment is that the burning, severe pain associated with immersion injury, wet-cold injury or trench foot is often relieved in the early stages by epidural blockade that is perfonned with an indwelling catheter for two to three days. This is further relieved by the use of the drug Dibenzyline, an alpha blocker, given at 10 mg a day for two or three days followed by 10 mg twice daily for five to seven days: Hypothermia -Immersion Injury -Frostbite
130 130. Fig. 6: C-II04. 12-14-88. Immediate post rescue. Begining hyperemic stage. Pain, burning, hyperemia, distal cyanosis and anesthesia distally. No evidence of hammer toe deformity. Case 1104: Post rescue - Hyperemic stage.
131 131. Fig 8. C-II0S 12-14-88 Early hyperemic stage. Swelling, ’redness’ edema generalized. Anesthesia of toes. Plantar arch aching, pain. Case 1105: Post Rescue - Early hyperemic stage
132 132. Fig.10. C-1106. 12-18-88. Hyperemia of foot and supra malleolar area, plantar pain upon weight bearing. Hypesthesia to anesthesia from mid foot to toes. No evidence of hammer toe deformity. Case 1106: Post Rescue - Hyperemia of foot
Total Images: 136