Donma Yaralanmaları
Özet
Donuk, soğuk maruziyetine bağlı olarak dokularda meydana gelen termal hasarlar ve yaralanmalardır. Tarihsel süreçte daha çok askeri operasyonlarda karşımıza çıkan bu klinik tablo, günümüzde kış sporlarıyla uğraşanlarda, evsizlerde, yasadışı göçmenlerde ve nöropati hastalarında sıklıkla gözlenmektedir. Erkeklerde kadınlara oranla on kat daha fazla görülen donuk vakalarının yaklaşık yüzde doksanı el ve ayak gibi uç ekstremitelerde yoğunlaşmaktadır. Yaralanma süreci sırasıyla donma öncesi, donma-ısıtma, vasküler staz ve geç iskemi olmak üzere birbirini takip eden dört patolojik evrede ilerler. Klinik değerlendirmede hasarın derinliğine göre dokular birinci dereceden dördüncü dereceye kadar ya da daha basit bir yaklaşımla yüzeyel ve derin olarak sınıflandırılır. Tedavi yönetiminde birincil öncelik koruyucu önlemlerin alınmasıdır; ancak hasar gerçekleştikten sonra temel ilk adım 37-39°C sıcaklıktaki su banyolarında aktif ısıtmanın uygulanmasıdır. Isıtma sonrasında aloe vera ve ibuprofen gibi ajanlar standart bakımda kullanılırken, derin donuk vakalarında ampütasyon riskini azaltmak amacıyla tPA ve iloprost tedavileri uygulanır. Sepsis gelişmediği sürece ampütasyon cerrahisi için acele edilmemeli, demarkasyon hattının netleşmesi için bir ila üç ay beklenmeli ve ekstremite uzunluğu azami ölçüde korunmalıdır.
Frostbite refers to thermal tissue injuries caused by exposure to extreme cold. While historically encountered during military campaigns, it is now frequently observed in winter sports enthusiasts, the homeless, undocumented migrants, and patients with neuropathy. Exhibiting a tenfold higher incidence in men than women, approximately ninety percent of frostbite cases affect the extremities, primarily the hands and feet. The injury progresses through four overlapping pathological phases: pre-thaw, thaw-warming, vascular stasis, and late ischemia. Clinically, tissue damage is classified from first to fourth degree based on depth, or simplified into superficial and deep injuries. Prevention is the primary tenet of management; however, once injury occurs, the critical first step is active rewarming in a water bath maintained at 37-39°C. Post-thaw protocols incorporate aloe vera and ibuprofen for standard care, whereas deep frostbite cases require tPA and iloprost therapies to mitigate amputation risks. Unless signs of sepsis emerge, surgical amputation must not be rushed, allowing one to three months for the line of demarcation to become clear while maximizing limb length preservation.
Referanslar
Zafren K. Frostbite: prevention and initial management. High Alt Med Biol. Mar 2013;14(1):9-12. doi:10.1089/ham.2012.1114
Song DH, Neligan PC. Plastic Surgery: Volume 4: Trunk and Lower Extremity. 4 ed. vol 4. 2017:560.
Shenaq DS, Gottlieb LJ. Cold Injuries. Hand Clinics. 2017/05/01/ 2017;33(2):257-267. doi:https://doi.org/10.1016/j.hcl.2016.12.003
Sokolov V, Biryukov A, Chmyrev I, Tarasenko M, Kabanov P. Burns and frostbite in the Red Army during World War II. Military Medical Research. 2017/02/08 2017;4(1):5. doi:10.1186/s40779-017-0114-9
Swan RH. So-called "Frost-bite.". Proc R Soc Med. 1915;8(Clin Sect):41-46.
Uygur F, Sever C, Noyan N. Frostbite burns caused by liquid oxygen. J Burn Care Res. Mar-Apr 2009;30(2):358-61. doi:10.1097/BCR.0b013e318198a769
Soyuncu S, Yigit O, Eken C. Frostbite injury related to chlorethane application. Wilderness Environ Med. Spring 2009;20(1):103-4. doi:10.1580/08-weme-le-211.1
Choong WL, Wohlgemut HS, Hallam MJ. Frostbite following cryolipolysis treatment in a beauty salon: a case study. J Wound Care. Apr 2 2017;26(4):188-190. doi:10.12968/jowc.2017.26.4.188
Valnicek SM, Chasmar LR, Clapson JB. Frostbite in the prairies: a 12-year review. Plast Reconstr Surg. Sep 1993;92(4):633-41. doi:10.1097/00006534-199309001-00012
Murphy JV, Banwell PE, Roberts AH, McGrouther DA. Frostbite: pathogenesis and treatment. J Trauma. Jan 2000;48(1):171-8. doi:10.1097/00005373-200001000-00036
McIntosh SE, Freer L, Grissom CK, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2019 Update. Wilderness Environ Med. Dec 2019;30(4s):S19-s32. doi:10.1016/j.wem.2019.05.002
Rathjen NA, Shahbodaghi SD, Brown JA. Hypothermia and cold weather injuries. American family physician. 2019;100(11):680-686.
Lacey AM, Fey RM, Gayken JR, et al. Microangiography: An Alternative Tool for Assessing Severe Frostbite Injury. J Burn Care Res. Aug 14 2019;40(5):566-569. doi:10.1093/jbcr/irz112
Manganaro MS, Millet JD, Brown RK, Viglianti BL, Wale DJ, Wong KK. The utility of bone scintigraphy with SPECT/CT in the evaluation and management of frostbite injuries. Br J Radiol. Feb 2019;92(1094):20180545. doi:10.1259/bjr.20180545
Handford C, Thomas O, Imray CHE. Frostbite. Emergency Medicine Clinics of North America. 2017/05/01/ 2017;35(2):281-299. doi:https://doi.org/10.1016/j.emc.2016.12.006
Twomey JA, Peltier GL, Zera RT. An Open-Label Study to Evaluate the Safety and Efficacy of Tissue Plasminogen Activator in Treatment of Severe Frostbite. Journal of Trauma and Acute Care Surgery. 2005;59(6):1350-1355. doi:10.1097/01.ta.0000195517.50778.2e
Johnson AR, Jensen HL, Peltier G, DelaCruz E. Efficacy of Intravenous Tissue Plasminogen Activator in Frostbite Patients and Presentation of a Treatment Protocol for Frostbite Patients. Foot & Ankle Specialist. 2011;4(6):344-348. doi:10.1177/1938640011422596
Lorentzen AK, Davis C, Penninga L. Interventions for frostbite injuries. Cochrane Database of Systematic Reviews. 2020;(12)doi:10.1002/14651858.CD012980.pub2
Folio LR, Arkin K, Butler WP. Frostbite in a Mountain Climber Treated with Hyperbaric Oxygen: Case Report. Military Medicine. 2007;172(5):560-563. doi:10.7205/milmed.172.5.560
Cauchy E, Marsigny B, Allamel G, Verhellen R, Chetaille E. The value of technetium 99 scintigraphy in the prognosis of amputation in severe frostbite injuries of the extremities: A retrospective study of 92 severe frostbite injuries. The Journal of Hand Surgery. 2000/09/01/ 2000;25(5):969-978. doi:https://doi.org/10.1053/jhsu.2000.16357
Barker JR, Haws MJ, Brown RE, Kucan JO, Moore WD. Magnetic Resonance Imaging of Severe Frostbite Injuries. Annals of Plastic Surgery. 1997;38(3):275-279.
Hutchison RL. Frostbite of the Hand. The Journal of Hand Surgery. 2014/09/01/ 2014;39(9):1863-1868. doi:https://doi.org/10.1016/j.jhsa.2014.01.035
