Prolonged critical avalanche burial for nearly 23 hours with severe hypothermia and severe frostbite with good recovery: A case report

Abstract Background Accidental hypothermia with severe frostbite is a rare combination of injuries with a high risk for long-term sequelae. There are widely accepted recommendations for the management of avalanche victims and for frostbite treatment, but no recommendation exists for the treatment of frostbite in severe hypothermic patients, specifically for the management of hypothermic avalanche victims presenting with frostbite. Case Presentation We present a case of a previously healthy, 53-year-old male skier who was critically buried by an avalanche at 2300 m of altitude at an ambient temperature of -8°C for nearly 23 hours. The victim was found with the right hand out of the snow and an air connection to outside. He was spontaneously breathing, somnolent with Glasgow Coma Scale 11 (Eye 4, Verbal 2, Motor 5), in a severely hypothermic state with an initial core temperature of 23.1°C and signs of cold injuries in all four extremities. After rescue and active external forced air rewarming in the intensive care unit, the clinical signs of first-degree frostbite on both feet and the left hand vanished, while third- to fourth-degree frostbite injuries became apparent on all fingers of the right hand. After reaching a core body temperature of approximately 36°C, aggressive frostbite treatment was started with peripheral arterial catheter-directed thrombolysis with alteplase, intravenous iloprost, ibuprofen, dexamethasone and regional sympathicolysis with a right-sided continuous axillary block. After ten months, the patient had no tissue loss but needed neuropathic pain treatment with pregabalin. Conclusion The combination of severe accidental hypothermia and severe frostbite is rare and challenging, as drug metabolism is unpredictable in a hypothermic patient and no recommendations for combined treatment exist. There is general agreement to give hypothermia treatment the priority and to begin frostbite treatment after full rewarming of the patient. This strategy is not based on evidence and may be questioned. More evidence is needed to identify the optimal dosage and time point to initiate treatment of frostbite in severely hypothermic patients.