Three weeks ago a 45-year-old man was admitted to the hospital because of frostbite of both feet. He was treated by rapid rewarming and protective care of the feet. All the toes on the right foot have turned black. He has become slightly febrile and progressively more confused during the past few days. Examination discloses cellulitis in the midfoot. Which of the
following is the most appropriate treatment?
(A) Amputation
(B) Application of topical collagenase
© Debridement of necrotic skin over the toes
(D) Hyperbaric oxygen
(E) Whirlpool therapy
In patients at high risk for life-altering amputation (eg, multiple digits, proximal amputation), without contraindications to the use of tPA, who present within 24 hours of injury, we suggest treatment with intra-arterial tPA plus intra-arterial heparin. In facilities not capable of using intra-arterial tPA, we suggest using intravenous tPA, and intravenous heparin.