An Institutional Protocol for the Treatment of Severe Frostbite Injury-A 6-Year Retrospective Analysis.

The treatment of severe frostbite injury has undergone rapid development in the past 30 years with many different diagnostic and treatment options now available. However, there is currently no consensus on the best method for management of this disease process. At our institution, we have designed a protocol for severe frostbite injury that includes diagnosis, medical treatment, wound cares, therapy, and surgery. This study assess the efficacy of our treatment since its implementation six years ago. During this time, all patients with severe frostbite injury were included in prospective observational trial of the protocol. We found that this protocol results in significant tissue salvage with over 80.7% of previously ischemic tissue becoming viable and not requiring amputation. We also were able to improve our center's efficiency over the course of six years and now our current average time from rapid rewarming to delivery of thrombolytics is under six hours.

CASE SERIES OF HYPERBARIC OXYGEN THERAPY FOR CENTRAL RETINAL ARTERY OCCLUSION.

PURPOSE: To retrospectively report the outcomes of patients presenting to our facility with central retinal artery occlusion and receiving therapy with hyperbaric oxygen (HBO). METHODS: This was a retrospective, chart review at a single hospital center. Patients with diagnosed central retinal artery occlusion were treated with HBO twice daily for 5 days during their inpatient stay for a total of 10 HBO treatments. Main outcome was change from the documented presenting best-corrected visual acuity to discharge best-corrected visual acuity. Thirty-nine patients with central retinal artery occlusion were included in the analysis during a 30-month period. RESULTS: Twenty-eight of 39 patients (72%) had some improvement in acuity. There was a mean of 5.05 lines of improvement using a modified Snellen chart after completing their HBO treatment course. Patients treated within 12 hours of symptom onset showed the greatest improvement in their visual acuity (6.11 mean lines of improvement). Complications of therapy included middle ear barotrauma (10/39) and confinement anxiety (1/39) and did not interfere with the therapy regimen or hospital course. CONCLUSION: This retrospective case series supports the use of emergent HBO therapy as a viable treatment option for patients with central retinal artery occlusion. Hyperbaric oxygen therapy was safely administered and well tolerated.

Microangiography: An Alternative Tool for Assessing Severe Frostbite Injury.

Assessment of frostbite injury typically relies on computed tomography, angiography, or nuclear medicine studies to detect perfusion deficits prior to thrombolytic therapy. The aim of this study was to evaluate the potential of a novel imaging method, microangiography, in the assessment of severe frostbite injury. Patients with severe frostbite were included if they received a post-thrombolytic Technetium 99 (Tc99) bone scan, a Tc99 bone scan without thrombolytic therapy, and/or post-thrombolytic microangiography (MA) study. We included all patients from the years 2006 to 2018 with severe frostbite injury who had received appropriate imaging for diagnosis: Tc99 scan alone (N = 82), microangiography alone (N = 22), and both Tc99 and microangiography (N = 26). The majority of patients received thrombolytic therapy (76.2%), and the average time to thrombolytics was 6.9 hours. Tc99 scans showed strong correlation with amputation level (r = .836, P < .001), and microangiography showed a slightly stronger positive correlation with amputation level (r = .870, P < .001). In the subset who received both Tc99 scan and microangiography (N = 26), we observed significant differences in the mean scores of perfusion deficit (z = 3.20, P < .001). In this subset, a moderate correlation was found between level of perfusion deficit on Tc99 bone scan and amputation level (r = .525, P = .006). A very strong positive correlation was found between the microangiography studies and the amputation level (r = .890, P < .001). These results demonstrate that microangiography is a reliable alternative method of assessing severe frostbite injury and predicting amputation level.

Esophageal Stricture Following Radiation, Concurrent Immunochemotherapy, Treated With Hyperbaric Oxygen and Dilation.

Low-dose palliative radiation may offer symptomatic relief in patients with spinal metastases from primary renal cell cancer and is unlikely to result in radiation injury. Patients with advanced malignancy requiring palliative radiation are often also receiving chemotherapy. Synergistic adverse effects resulting from combined palliative radiation and novel antiprogrammed cell death-1 (anti-PD 1) and/or multityrosine kinase inhibitors are rare. We report about a 60-year-old woman with metastatic clear-cell renal cancer, status post-left nephrectomy, with debilitating mid-back pain from metastatic tumor burden and foraminal nerve compression. Her chemotherapeutic regimen was repeatedly altered because of progression of disease until she was maintained on the anti-PD 1 checkpoint inhibitor, nivolumab. She received palliative radiation to her thoracic spine over a 2-week period, and nivolumab was then switched to cabozantinib midway through a course of palliative radiation. The patient rapidly developed severe esophagitis, progressing to esophageal stricture, and required placement of a percutaneous endoscopic gastrostomy tube. She was successfully treated with serial esophageal dilation and hyperbaric oxygen treatments to diminish inflammation and improve tissue vascularity. Concurrent use of anti-PD 1 and/or multityrosine kinase drugs may accelerate development of radiation injury regardless of radiation dosage. Radiation-induced esophageal stricture was managed successfully in this patient with serial esophageal dilation and adjuvant hyperbaric oxygen.

Hyperbaric oxygen therapy for the prevention of arterial gas embolism in food grade hydrogen peroxide ingestion.

Food grade hydrogen peroxide ingestion is a relatively rare presentation to the emergency department. There are no defined guidelines at this time regarding the treatment of such exposures, and providers may not be familiar with the potential complications associated with high concentration hydrogen peroxide ingestions. In this case series, we describe four patients who consumed 35% hydrogen peroxide, presented to the emergency department, and were treated with hyperbaric oxygen therapy. Two of the four patients were critically ill requiring intubation. All four patients had evidence on CT or ultrasound of venous gas emboli and intubated patients were treated as if they had an arterial gas embolism since an exam could not be followed. After hyperbaric oxygen therapy each patient was discharged from the hospital neurologically intact with no other associated organ injuries related to vascular gas emboli. Hyperbaric oxygen therapy is an effective treatment for patients with vascular gas emboli after high concentration hydrogen peroxide ingestion. It is the treatment of choice for any impending, suspected, or diagnosed arterial gas embolism. Further research is needed to determine which patients with portal venous gas emboli should be treated with hyperbaric oxygen therapy.