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Gordon L, Ferris J, Pauli H. Rewarming from unwitnessed hypothermic cardiac arrest with good neurological recovery using extracorporeal membrane oxygenation. Perfusion 2023; 38:1734-1737. [PMID: 35980270 DOI: 10.1177/02676591221122274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 26-year-old man, who was training in bad weather for a mountain ultramarathon, became hypothermic after running for 4 h. He deteriorated and was unable to continue. His running partner went for help. The man suffered an unwitnessed hypothermic cardiac arrest. The on-site management and evacuation are described and included the use of intermittent cardiopulmonary resuscitation and a mechanical device during transport. The patient was successfully resuscitated and rewarmed by Extracorporeal Membrane Oxygenation (ECMO) after more than 2 h of cardiopulmonary resuscitation. After 14 h of ECMO support and five days of ventilation, the patient subsequently made a good neurological recovery. At hospital discharge, he had normal cerebral function, and an improving peripheral polyneuropathy affecting distal limbs, with paraesthesia in both feet and reduced coordination and fine motor skills in both hands.
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Affiliation(s)
- Les Gordon
- Department of Anaesthesia, University Hospitals Morecambe Bay Trust, Lancaster, UK
- Langdale Ambleside Mountain Rescue Team, Ambleside, UK
| | - John Ferris
- North Cumbria Integrated Care NHS Trust, West Cumberland Hospital, Whitehaven, UK
- Keswick Mountain Rescue Team, Keswick, UK
| | - Henning Pauli
- Department of Cardiothoracic Anaesthesia and Intensive Care, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
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Zafren K, Hollis S, Weiss EA, Danzl D, Wilburn J, Kimmel N, Imray C, Giesbrecht G, Tipton M. Prevention and Treatment of Nonfreezing Cold Injuries and Warm Water Immersion Tissue Injuries: A Supplement to the Wilderness Medical Society Clinical Practice Guidelines. Wilderness Environ Med 2023; 34:172-181. [PMID: 37130771 DOI: 10.1016/j.wem.2023.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 01/26/2023] [Accepted: 02/15/2023] [Indexed: 05/04/2023]
Abstract
We convened an expert panel to develop evidence-based guidelines for the evaluation, treatment, and prevention of nonfreezing cold injuries (NFCIs; trench foot and immersion foot) and warm water immersion injuries (warm water immersion foot and tropical immersion foot) in prehospital and hospital settings. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according to the criteria published by the American College of Chest Physicians. Treatment is more difficult with NFCIs than with warm water immersion injuries. In contrast to warm water immersion injuries that usually resolve without sequelae, NFCIs may cause prolonged debilitating symptoms, including neuropathic pain and cold sensitivity.
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Affiliation(s)
- Ken Zafren
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK; Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA; International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Zürich, Switzerland.
| | - Sarah Hollis
- Regional Occupational Health Team, Defence Medical Services MOD, Catterick Garrison, UK
| | - Eric A Weiss
- Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA
| | - Daniel Danzl
- Department of Emergency Medicine, University of Louisville School of Medicine, Louisville, KY
| | - Jessie Wilburn
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | | | - Chris Imray
- Coventry National Institute for Health Research, Clinical Research Facility, University Hospital Coventry & Warwickshire, NHS Trust, Coventry, UK
| | - Gordon Giesbrecht
- Faculty of Kinesiology and Recreation Management and Departments of Emergency Medicine and Anesthesia, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mike Tipton
- Extreme Environments Laboratory, School of Sport, Health & Exercise Science, University of Portsmouth, Portsmouth, UK
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3
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Zafren K. Nonfreezing Cold Injury (Trench Foot). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10482. [PMID: 34639782 PMCID: PMC8508462 DOI: 10.3390/ijerph181910482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/23/2021] [Accepted: 09/25/2021] [Indexed: 11/16/2022]
Abstract
Nonfreezing cold injury (NFCI) is a modern term for trench foot or immersion foot. Moisture is required to produce a NFCI. NFCI seldom, if ever, results in loss of tissue unless there is also pressure necrosis or infection. Much of the published material regarding management of NFCIs has been erroneously borrowed from the literature on warm water immersion injuries. NFCI is a clinical diagnosis. Most patients with NFCI have a history of losing feeling for at least 30 min and having pain or abnormal sensation on rewarming. Limbs with NFCI usually pass through four 'stages.' cold exposure, post-exposure (prehyperaemic), hyperaemic, and posthyperaemic. Limbs with NFCI should be cooled gradually and kept cool. Amitriptyline is likely the most effective medication for pain relief. If prolonged exposure to wet, cold conditions cannot be avoided, the most effective measures to prevent NFCI are to stay active, wear adequate clothing, stay well-nourished, and change into dry socks at least daily.
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Affiliation(s)
- Ken Zafren
- Department of Emergency Medicine, Alaska Native Medical Center, 4315 Diplomacy Drive, Anchorage, AK 99508, USA;
- Department of Emergency Medicine, Stanford University Medical Center, 900 Welch Road, Suite 340, Palo Alto, CA 94304, USA
- International Commission for Mountain Emergency Medicine (ICAR MedCom), 8058 Zürich, Switzerland
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Bjertnæs LJ, Hindberg K, Næsheim TO, Suborov EV, Reierth E, Kirov MY, Lebedinskii KM, Tveita T. Rewarming From Hypothermic Cardiac Arrest Applying Extracorporeal Life Support: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:641633. [PMID: 34055829 PMCID: PMC8155640 DOI: 10.3389/fmed.2021.641633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/04/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: This systematic review and meta-analysis aims at comparing outcomes of rewarming after accidental hypothermic cardiac arrest (HCA) with cardiopulmonary bypass (CPB) or/and extracorporeal membrane oxygenation (ECMO). Material and Methods: Literature searches were limited to references with an abstract in English, French or German. Additionally, we searched reference lists of included papers. Primary outcome was survival to hospital discharge. We assessed neurological outcome, differences in relative risks (RR) of surviving, as related to the applied rewarming technique, sex, asphyxia, and witnessed or unwitnessed HCA. We calculated hypothermia outcome prediction probability score after extracorporeal life support (HOPE) in patients in whom we found individual data. P < 0.05 considered significant. Results: Twenty-three case observation studies comprising 464 patients were included in a meta-analysis comparing outcomes of rewarming with CPB or/and ECMO. One-hundred-and-seventy-two patients (37%) survived to hospital discharge, 76 of 245 (31%) after CPB and 96 of 219 (44 %) after ECMO; 87 and 75%, respectively, had good neurological outcomes. Overall chance of surviving was 41% higher (P = 0.005) with ECMO as compared with CPB. A man and a woman had 46% (P = 0.043) and 31% (P = 0.115) higher chance, respectively, of surviving with ECMO as compared with CPB. Avalanche victims had the lowest chance of surviving, followed by drowning and people losing consciousness in cold environments. Assessed by logistic regression, asphyxia, unwitnessed HCA, male sex, high initial body temperature, low pH and high serum potassium (s-K+) levels were associated with reduced chance of surviving. In patients displaying individual data, overall mean predictive surviving probability (HOPE score; n = 134) was 33.9 ± 33.6% with no significant difference between ECMO and CPB-treated patients. We also surveyed 80 case reports with 96 victims of HCA, who underwent resuscitation with CPB or ECMO, without including them in the meta-analysis. Conclusions: The chance of surviving was significantly higher after rewarming with ECMO, as compared to CPB, and in patients with witnessed compared to unwitnessed HCA. Avalanche victims had the lowest probability of surviving. Male sex, high initial body temperature, low pH, and high s-K+ were factors associated with low surviving chances.
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Affiliation(s)
- Lars J. Bjertnæs
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Kristian Hindberg
- K. G. Jebsen Thrombosis Research and Expertise Center, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Torvind O. Næsheim
- Cardiovascular Research Group, Department of Clinical Medicine, Faculty of Health Sciences, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
| | - Evgeny V. Suborov
- The Nikiforov Russian Federation Center of Emergency and Radiation Medicine, St. Petersburg, Russia
| | - Eirik Reierth
- Science and Health Library, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
| | - Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care, Northern State Medical University, Arkhangelsk, Russia
| | - Konstantin M. Lebedinskii
- Department of Anesthesiology and Intensive Care, North-Western State Medical University Named After I. I. Mechnikov, St. Petersburg, Russia
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russia
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, University of Tromsø (UiT), The Arctic University of Norway, Tromsø, Norway
- Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
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Jørum E, Opstad PK. A 4-year follow-up of non-freezing cold injury with cold allodynia and neuropathy in 26 naval soldiers. Scand J Pain 2020; 19:441-451. [PMID: 30939119 DOI: 10.1515/sjpain-2019-0035] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 03/04/2019] [Indexed: 11/15/2022]
Abstract
Background and aims Non-freezing cold injuries (NFCI), which typically may occur in military personnel, may result from exposure to cold, at temperatures around 0 °C or above, and worsened by wind and moisture. The injury is due to cooling but not freezing of tissue like in frostbite. NFCI may result in in chronic neuropathy and cold hypersensitivity. A recent retrospective study of small-and large fibres has suggested that NFCI results in neuropathic pain due to a sensory neuropathy and question a longitudinal study to verify a possible observation of improvement of NFCI over time. The present study is a 4-year follow-up investigation of large - and small-fibre function in 26 naval cadets and officers who were exposed to cold injury during the same military expedition. Methods The 26 soldiers were investigated clinically (with investigation of motor function, reflexes, sensibility), with nerve conduction studies (NCS) of major nerves in upper- and lower extremity, small fibre testing (QST, measurement of thermal thresholds), measurements of subcutaneous fat tissue and maximal O2 uptake. Investigations found place 2 months following the actual military expedition, with follow-up investigations of affected soldiers at 6-12 months and up to 3-4 years. In order to elucidate possible mechanisms (disinhibition of cold pain by myelinated nerve fibres) of cold allodynia, cold pain thresholds were measured following an ischemic block of conduction of large and small myelinated nerve fibres. Results Of 26 soldiers, 19 complained of numbness in feet and a large majority of 16 of cold hypersensitivity 2 months following injury. There were significant alterations of both large- and small-fibre function, indicating a general large- and small-fibre neuropathy. The most prominent finding was a pronounced cold allodynia, inversely correlated with the amount of subcutaneous fat. During the first year, results of NCS and thermal testing gradually normalized in most. Seven soldiers developed chronic symptoms in the form of cold hypersensitivity and with findings of cold allodynia, which was not further enhanced, but abolished following block of conduction of myelinated nerve fibres. Seven soldiers were free of symptoms from that start of the investigation, probably because they had been more eager to keep their legs moving during the exposure to cold. Conclusions Of a total of 26 soldiers, only seven developed chronic symptoms of cold hypersensitivity, corresponding to the finding of cold allodynia by thermal testing. The cold allodynia may not be explained by disinhibition of cold pain by myelinated fibres as in healthy subjects. A large majority recovered from an initial large-and small fibre neuropathy, demonstrating that recovery from NFCI may occur. Implications Although large-and small fibre neuropathy may be restored following cold injury, there is a risk of a permanent and disabling cold hypersensitivity, corresponding to the findings of cold allodynia. It is of uttermost importance to secure military personnel from the risk of cold injuries. It seems important to avoid immobilisation of extremities during exposure to cold.
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Affiliation(s)
- Ellen Jørum
- Section of Clinical Neurophysiology, The Department of Neurology, Oslo University Hospital - Rikshospitalet, Oslo, Norway.,Oslo University Hospital - Rikshospitalet and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Yan LJ, Zhang FR, Ma CS, Zheng Y, Chen JT, Li W. Arteriovenous Graft for Hemodialysis: Effect of Cryotherapy on Postoperative Pain and Edema. Pain Manag Nurs 2019; 20:170-173. [PMID: 30425011 DOI: 10.1016/j.pmn.2018.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 02/14/2018] [Accepted: 07/13/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Arteriovenous grafting offers an alternative for patients whose vessels are unsuitable for arteriovenous fistula. However, as a result of subcutaneous tunnel dissection, postoperative pain and edema of the operated limb present early after surgery. As a traditional therapeutic approach, cryotherapy has the ability to suppress postoperative pain and edema. AIMS The purpose of the study was to investigate the feasibility of cryotherapy after arteriovenous graft surgery to decrease perioperative medication usage. DESIGN This study was a randomized controlled trial. SETTING A large integrated health care facility in South China. PARTICIPANTS/SUBJECTS A total of 85 hemodialysis patients who received arteriovenous graft surgery from March 2011 to February 2017 were enrolled. METHODS The participants were divided into an intervention group and a control group according to the postoperative management. Ice packs were applied covering the operative forearm for 120 minutes after wound closure in the intervention group. General information, pain score, analgesic consumption, wound inflammation, forearm edema, and participant satisfaction were compared between the two groups. RESULTS Cryotherapy-treated patients required less analgesia (26.19% vs. 48.84%, p < .05), reported lower pain score from 30 minutes to 48 hours postoperative (p < .05), less wound inflammation (11.90% vs. 25.58%, p < .05), and higher participant satisfaction (8.92 ± 0.57 vs. 6.52 ± 0.63, p < .05), whereas the incidence of forearm edema was equivalent (p > .05). No adverse events were reported in either group. CONCLUSIONS Cryotherapy is a preferable intervention for patients after arteriovenous graft implantation as a result of its favorable cost, convenience, and fewer side effects.
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Affiliation(s)
- Li-Jun Yan
- Department of Hemodialysis, The First Affiliated Hospital of Shantou University Medical College, Shantou City, Guangdong Province, China
| | - Fei-Ran Zhang
- Department of General Surgery, The First Affiliated Hospital of Shantou University Medical College, Shantou City, Guangdong Province, China
| | - Chan-Shan Ma
- Department of General Surgery, The First Affiliated Hospital of Shantou University Medical College, Shantou City, Guangdong Province, China
| | - Yang Zheng
- Department of General Surgery, The First Affiliated Hospital of Shantou University Medical College, Shantou City, Guangdong Province, China.
| | - Jun-Tian Chen
- Department of General Surgery, The First Affiliated Hospital of Shantou University Medical College, Shantou City, Guangdong Province, China
| | - Wei Li
- Department of General Surgery, The First Affiliated Hospital of Shantou University Medical College, Shantou City, Guangdong Province, China
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Zhang FR, Zheng Y, Yan LJ, Ma CS, Chen JT, Li W. Cryotherapy Relieves Pain and Edema After Inguinal Hernioplasty in Males With End-Stage Renal Disease: A Prospective Randomized Study. J Pain Symptom Manage 2018; 56:501-508. [PMID: 30025940 DOI: 10.1016/j.jpainsymman.2018.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 07/08/2018] [Accepted: 07/09/2018] [Indexed: 02/05/2023]
Abstract
CONTEXT Tension-free hernioplasty under local anesthetic infiltration is a reasonable choice for end-stage renal disease patients with hernia. OBJECTIVES The purpose of the study was to investigate the feasibility of cryotherapy after hernioplasty surgery to relieve pain and scrotal edema. METHODS This was a prospective, randomized, and controlled trial held in a large integrated health care facility in South China. One hundred sixty-nine male patients on hemodialysis and scheduled for hernioplasty were enrolled between March 2013 and February 2017. The participants were divided into an intervention group and a control group. In the intervention group, ice packs were applied after surgery. Demographic information, vital signs, pain score, opioid consumption, wound inflammation, scrotal edema, and patient satisfaction were compared between the two groups. The primary outcome was pain score. RESULTS Cryotherapy-treated patients required less opioid consumption (5.95 vs. 15.29 mg; P < 0.05), reported lower pain scores from 30 minutes to 48 hours after operation (P < 0.05), less wound inflammation (11.90 vs. 32.94%; P < 0.05), lower incidence of scrotal edema in the first and second days (P < 0.05), and higher patient satisfaction (8.95 vs. 6.50 cm; P < 0.05), with stable vital signs throughout the monitoring period (P > 0.05). CONCLUSION Owing to its favorable cost, convenience, and low frequency of adverse effects, cryotherapy is useful for end-stage renal disease populations after hernioplasty to relieve pain and scrotal edema.
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Affiliation(s)
- Fei-Ran Zhang
- Department of General Surgery, The First Affiliated Hospital of Shantou University Medical College, Jinping District, Shantou City, Guangdong Province, China
| | - Yang Zheng
- Department of General Surgery, The First Affiliated Hospital of Shantou University Medical College, Jinping District, Shantou City, Guangdong Province, China.
| | - Li-Jun Yan
- Department of Hemodialysis, The First Affiliated Hospital of Shantou University Medical College, Jinping District, Shantou City, Guangdong Province, China
| | - Chan-Shan Ma
- Department of General Surgery, The First Affiliated Hospital of Shantou University Medical College, Jinping District, Shantou City, Guangdong Province, China
| | - Jun-Tian Chen
- Department of General Surgery, The First Affiliated Hospital of Shantou University Medical College, Jinping District, Shantou City, Guangdong Province, China
| | - Wei Li
- Department of General Surgery, The First Affiliated Hospital of Shantou University Medical College, Jinping District, Shantou City, Guangdong Province, China
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Dietrichs ES, Håheim B, Kondratiev T, Traasdahl E, Tveita T. Effects of hypothermia and rewarming on cardiovascular autonomic control in vivo. J Appl Physiol (1985) 2017; 124:850-859. [PMID: 29357499 DOI: 10.1152/japplphysiol.00317.2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Rewarming from accidental hypothermia is associated with cardiovascular dysfunction that complicates rewarming and contributes to a high mortality rate. We investigated autonomic cardiovascular control, as well as the separate effects of cooling, hypothermia, and rewarming on hemodynamic function, aiming to provide knowledge of the pathophysiology causing such complications in these patients. A rat model designed for circulatory studies during cooling, hypothermia (15°C), and rewarming was used. Spectral analysis of diastolic arterial pressure and heart rate allowed assessment of the autonomic nervous system. Hemodynamic variables were monitored using a conductance catheter in the left ventricle and a pressure transducer connected to the left femoral artery. Sympathetic cardiovascular control was reduced after rewarming. Stroke volume increased during cooling but decreased during stable hypothermia and did not normalize during rewarming. Despite autonomic dysfunction, total peripheral resistance increased during cooling and did not normalize after rewarming. The present data show that sympathetic cardiovascular control is reduced by hypothermia and rewarming. A simultaneous systolic dysfunction is seen in rewarmed animals, caused by reduced filling of the left ventricle and impaired contractile function, in the presence of normal diastolic function. These findings show that dysfunction of the efferent sympathetic nervous system could be instrumental in development of rewarming shock. NEW & NOTEWORTHY The present study shows impaired autonomic control of cardiovascular function after rewarming from severe hypothermia. In victims of accidental hypothermia, rewarming shock is a much feared and lethal complication. The pathophysiology causing such cardiovascular collapse appears complex. Our findings indicate that dysfunction of the autonomic nervous system is an important part of the pathophysiology. Thus the present study gives novel information, important for further development of treatment strategies in this patient group.
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Affiliation(s)
- Erik Sveberg Dietrichs
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway , Tromsø , Norway.,Department of Research and Education, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Clinical Pharmacology, Division of Diagnostic Services, University Hospital of North Norway , Tromsø , Norway
| | - Brage Håheim
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway , Tromsø , Norway
| | - Timofei Kondratiev
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway , Tromsø , Norway
| | - Erik Traasdahl
- PET Imaging Center, Division of Diagnostic Services, University Hospital of North Norway , Tromsø , Norway
| | - Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT, The Arctic University of Norway , Tromsø , Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway , Tromsø , Norway
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Anand P, Privitera R, Yiangou Y, Donatien P, Birch R, Misra P. Trench Foot or Non-Freezing Cold Injury As a Painful Vaso-Neuropathy: Clinical and Skin Biopsy Assessments. Front Neurol 2017; 8:514. [PMID: 28993756 PMCID: PMC5626869 DOI: 10.3389/fneur.2017.00514] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/13/2017] [Indexed: 01/05/2023] Open
Abstract
Background Trench foot, or non-freezing cold injury (NFCI), results from cold exposure of sufficient severity and duration above freezing point, with consequent sensory and vascular abnormalities which may persist for years. Based on observations of Trench foot in World War II, the condition was described as a vaso-neuropathy. While some reports have documented nerve damage after extreme cold exposure, sensory nerve fibres and vasculature have not been assessed with recent techniques in NFCI. Objective To assess patients with chronic sensory symptoms following cold exposure, in order to diagnose any underlying small fibre neuropathy, and provide insight into mechanisms of the persistent pain and cold hypersensitivity. Methods Thirty soldiers with cold exposure and persistent sensory symptoms (>4 months) were assessed with quantitative sensory testing, nerve conduction studies, and skin biopsies. Immunohistochemistry was used to assess intraepidermal (IENF) and subepidermal (SENF) nerve fibres with a range of markers, including the pan-neuronal marker protein gene product 9.5 (PGP 9.5), regenerating fibres with growth-associated protein 43 (GAP43), and nociceptor fibres with transient receptor potential cation channel subfamily V member 1 (TRPV1), sensory neuron-specific receptor (SNSR), and calcitonin gene-related peptide (CGRP). von Willebrand factor (vWF), endothelial nitric oxide synthase (eNOS), and vascular endothelial growth factor (VEGF) were used for assessing blood vessels, and transient receptor potential cation channel, subfamily A member 1 (TRPA1) and P2X purinoceptor 7 (P2X7) for keratinocytes, which regulate nociceptors via release of nerve growth factor. Results Clinical examination showed pinprick sensation was abnormal in the feet of 20 patients (67%), and between 67 and 83% had abnormalities of thermal thresholds to the different modalities. 7 patients (23%) showed reduced sensory action potential amplitude of plantar nerves. 27 patients (90%) had decreased calf skin PGP 9.5 IENF (p < 0.0001), the remaining 3 patients had decreased nerve markers in subepidermis or foot skin. There were marked increases of all vascular markers (for vWF in calf skin, p < 0.0001), and increased sensory or regenerating SENF (for calf skin, GAP43, p = 0.002). TRPA1 (p = 0.0012) and P2X7 (p < 0.0001) were increased in basal keratinocytes. Conclusion A range of skin biopsy markers and plantar nerve conduction studies are useful objective assessments for the diagnosis of peripheral neuropathy in NFCI. Our results suggest that an increase in blood vessels following tissue ischaemia/hypoxia could be associated with disproportionate and abnormal nerve fibres (irritable nociceptors), and may lead to NFCI as a “painful vaso-neuropathy.”
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Affiliation(s)
- Praveen Anand
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Rosario Privitera
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Yiangos Yiangou
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Philippe Donatien
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Rolfe Birch
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Peter Misra
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
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Hilmo J, Naesheim T, Gilbert M. “Nobody is dead until warm and dead”: Prolonged resuscitation is warranted in arrested hypothermic victims also in remote areas – A retrospective study from northern Norway. Resuscitation 2014; 85:1204-11. [DOI: 10.1016/j.resuscitation.2014.04.029] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 03/04/2014] [Accepted: 04/01/2014] [Indexed: 10/25/2022]
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11
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Cui ZJ, Deng JX, Zhao KB, Yu DM, Hu S, Shi SQ, Deng JB. Effects of chronic cold exposure on murine central nervous system. J Neurosci Res 2014; 92:496-505. [DOI: 10.1002/jnr.23333] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/24/2013] [Accepted: 10/25/2013] [Indexed: 01/29/2023]
Affiliation(s)
- Zhan-Jun Cui
- Institute of Neurobiology of Henan University; Kaifeng People's Republic of China
- Medical College of Henan University; Kaifeng People's Republic of China
| | - Jie-Xin Deng
- Institute of Neurobiology of Henan University; Kaifeng People's Republic of China
| | - Kai-Bing Zhao
- Medical College of Kaifeng University; Kaifeng People's Republic of China
| | - Dong-Ming Yu
- Institute of Neurobiology of Henan University; Kaifeng People's Republic of China
| | - Sang Hu
- Institute of Neurobiology of Henan University; Kaifeng People's Republic of China
| | - Shu-Qin Shi
- Institute of Neurobiology of Henan University; Kaifeng People's Republic of China
| | - Jin-Bo Deng
- Institute of Neurobiology of Henan University; Kaifeng People's Republic of China
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