Therapy

• Microthrombotic injury is a rewarming phenomenon
• Typically if extremity appears warm and well perfused w/ capillary refill probably does not need thrombolytic therapy
• But clinical exam of perfusion is not great – if any concern for severe injury e.g. duskiness, impaired cap refill, need perfusion imaging (bone scan) to evaluate for poor perfusion
• If clearly deeply injured e.g. waxy, dusky and there’s going to be delay to perfusion consider empiric TPA in consultation w/ burn surgeon
• 12 hr cutoff for thrombolytic therapy but loses ~ 20% efficacy w/ every hour of rewarming so w/in 4 hrs is best
• Most important to rewarm once and definitively – repeat freeze-thaw cycle extremely damaging
• If need to transfer for TPA, might be best to just transport cold
• Be sure to run TPA contraindications prior to administration
• Anticoagulation w/ heparin/LMWH after TPA