Current Status of Cold Injuries in the South Korean Military Over the Past 5 Years: Analysis and Assessment Based on the 2023-2024 Surveillance System

INTRODUCTION

This study aimed to examine the prevalence of cold injuries and review the cold injury monitoring system in the South Korean military.

MATERIALS AND METHODS

This study conducted a retrospective and cross-sectional analysis using data from the Defense Medical Statistic Information System (DMSIS) on cold injuries among military personnel from 2018 to 2023. It incorporated findings from the Korean Armed Forces Medical Command's cold injury surveillance system and analyzed cases from the Armed Forces Capital Hospital, covering all branches of the military by status and rank.

RESULTS

An analysis of cold injury in the South Korean military over the past 5 years revealed varying numbers of cases treated, from 799 in 2018-2019 to 467 in 2022-2023. According to the surveillance system in 2023-2024, the Army experienced the majority of these cases, with 94.5% of the total. The incidence per 1,000 personnel was the highest in the Army at 0.98 compared to the Air Force and Navy/Marine Corps. Rank-based analysis indicated the most affected were private first-class soldiers. Frostbite was the most frequent condition, alongside chilblains, hypothermia, and immersion injuries, with no marked difference in the type of illness across branches.

CONCLUSIONS

The study underscores the need for focused prevention and treatment, particularly in the Army. By analyzing data from a newly implemented surveillance system, it revealed a higher incidence of frostbite and chilblains among lower ranks. The findings highlight the importance of targeted educational measures and enhanced response strategies to protect personnel against cold injuries.

Emergent Management of Severe Hypothermia, Acidemia, and Coagulopathy in Operative Penetrating Ballistic Cranial Trauma

Hypothermia in a trauma patient has been associated with increased morbidity and mortality and is more frequently seen in those sustaining traumatic brain injuries (TBIs). Acidosis is an important consequence of hypothermia that leads to derangements across the spectrum of the coagulation cascade. Here, we present a case of a 31-year-old male presented after suffering a right parietal penetrating ballistic injury with an associated subdural hematoma and 7 mm midline shift requiring decompressive craniectomy and external ventricular drain (EVD) placement in the setting of severe hypothermia (28°C) and acidosis (pH 7.12). With aggressive rewarming intraoperatively, the use of full-body forced-air warming, warmed IV fluids, and increasing the ambient room temperature, the patient's acidosis and hypothermia improved to pH 7.20 and 34°C. Despite these aggressive attempts to rewarm the patient, he developed coagulopathy in the setting of concurrent hypothermia and acidosis. This case highlights the importance of prompt reversal of hypothermia due to its potentially fatal effects, particularly in the setting of severe TBIs. We discuss the critical aspects of surgical management of the injury and anesthetic management of hypothermia, acidosis, and coagulopathy perioperatively.

The ubiquitin codes in cellular stress responses

Ubiquitination/ubiquitylation, one of the most fundamental post-translational modifications, regulates almost every critical cellular process in eukaryotes. Emerging evidence has shown that essential components of numerous biological processes undergo ubiquitination in mammalian cells upon exposure to diverse stresses, from exogenous factors to cellular reactions, causing a dazzling variety of functional consequences. Various forms of ubiquitin signals generated by ubiquitylation events in specific milieus, known as ubiquitin codes, constitute an intrinsic part of myriad cellular stress responses. These ubiquitination events, leading to proteolytic turnover of the substrates or just switch in functionality, initiate, regulate, or supervise multiple cellular stress-associated responses, supporting adaptation, homeostasis recovery, and survival of the stressed cells. In this review, we attempted to summarize the crucial roles of ubiquitination in response to different environmental and intracellular stresses, while discussing how stresses modulate the ubiquitin system. This review also updates the most recent advances in understanding ubiquitination machinery as well as different stress responses and discusses some important questions that may warrant future investigation.

Hypothermia: Beyond the Narrative Review-The Point of View of Emergency Physicians and Medico-Legal Considerations

Hypothermia is a widespread condition all over the world, with a high risk of mortality in pre-hospital and in-hospital settings when it is not promptly and adequately treated. In this review, we aim to describe the main specificities of the diagnosis and treatment of hypothermia through consideration of the physiological changes that occur in hypothermic patients. Hypothermia can occur due to unfavorable environmental conditions as well as internal causes, such as pathological states that result in reduced heat production, increased heat loss or ineffectiveness of the thermal regulation system. The consequences of hypothermia affect several systems in the body-the cardiovascular system, the central and peripheral nervous systems, the respiratory system, the endocrine system and the gastrointestinal system-but also kidney function, electrolyte balance and coagulation. Once hypothermia is recognized, prompt treatment, focused on restoring body temperature and supporting vital functions, is fundamental in order to avert preventable death. It is important to also denote the fact that CPR has specificities related to the unique profile of hypothermic patients.

Temperature management in the intensive care unit: a practical survey from China

Introduction: Temperature management is an important aspect of the treatment of critically ill patients, but there are differences in the measurement and management of temperature in different Intensive Care Units (ICUs). The objective of this study was to understand the current situation of temperature measurement and management in ICUs in China, and to provide a basis for standardized temperature management in ICUs.Methods: A 20-question survey was used to gather information on temperature management strategies from ICUs across China. Data such as method and frequency of temperature measurement, management goals, cooling measures, and temperature management recommendations were collected.Results: A total of 425 questionnaires from unique ICUs were included in the study, with responses collected from all provinces and autonomous regions in China. Mercury thermometers were the most widely used measurement tool (82.39%) and the axilla was the most common measurement site (96.47%). There was considerable variability in the frequency of temperature measurement, the temperature at which intervention should begin, intervention duration, and temperature management goals. While there was no clearly preferred drug-based cooling method, the most widely used equipment-based cooling method was the ice blanket machine (93.18%). The most frequent recommendations for promoting temperature management were continuous monitoring and targeted management.Conclusion: Our investigation revealed a high level of variability in the methods of temperature measurement and management among ICUs in China. Since fever is a common clinical symptom in critically ill patients and can lead to prolonged ICU stays, we propose that standardized guidelines are urgently needed for the management of body temperature (BT) in these patients.

Prevalence of hypothermia and critical hand temperatures during military cold water immersion training

Cold-weather military operations can quickly undermine warfighter readiness and performance. Specifically, accidental cold-water immersion (CWI) contributes to rapid body heat loss and impaired motor function. This study evaluated the prevalence of hypothermia and critical hand temperatures during CWI. One-hundred seventeen (N = 117) military personnel (mean ± SD age: 27 ± 6 yr, height: 176 ± 8 cm, weight: 81.5 ± 11.6 kg) completed CWI and rewarming during cold-weather training, which included a 10-min outdoor CWI (1.3 ± 1.4°C) combined with cold air (-4.2 ± 8.5°C) exposure. Following CWI, students removed wet clothing, donned dry clothing, and entered sleeping systems. Core (T_c) and hand (T_hand) temperatures were recorded continuously during the training exercise. T_c for 96 students (mean ± SD lowest T_c = 35.6 ± 0.9°C) revealed that 24 students (25%) experienced T_c below 35.0°C. All of 110 students (100%) experienced T_hand below 15.0°C, with 71 students (65%) experiencing T_hand at or below 8.0°C. Loss of hand function and hypothermia should be anticipated in warfighters who experience CWI in field settings. Given the high prevalence of low T_hand, focus should be directed on quickly rewarming hands to recover function.

20(R)-ginsenoside Rg3-loaded polyurethane/marine polysaccharide based nanofiber dressings improved burn wound healing potentials

The management of deep burn injuries is extremely challenging, ascribed to their delayed wound healing rate, susceptibility for bacterial infections, pain, and increased risk of hypertrophic scarring. In our current investigation, a series of composite nanofiber dressings (NFDs) based on polyurethane (PU) and marine polysaccharides (i.e., hydroxypropyl trimethyl ammonium chloride chitosan, HACC and sodium alginate, SA) were accomplished by electrospinning and freeze-drying protocols. The 20(R)-ginsenoside Rg3 (Rg3) was further loaded into these NFDs to inhibit the formation of excessive wound scars. The PU/HACC/SA/Rg3 dressings showed a sandwich-like structure. The Rg3 was encapsulated in the middle layers of these NFDs and slowly released over 30 days. The PU/HACC/SA and PU/HACC/SA/Rg3 composite dressings demonstrated superior wound healing potentials over other NFDs. These dressings also displayed favorable cytocompatibility with keratinocytes and fibroblasts and could dramatically accelerate epidermal wound closure rate following 21 days of the treatment of a deep burn wound animal model. Interestingly, the PU/HACC/SA/Rg3 obviously reduced the excessive scar formation, with a collagen type I/III ratio closer to the normal skin. Overall, this study represented PU/HACC/SA/Rg3 as a promising multifunctional wound dressing, which promoted the regeneration of burn skins and attenuated scar formation.

The Effects of Recombinant Human Granulocyte-Macrophage Colony-Stimulating Factor Gel on Third-Degree Frostbite Wounds in Northeastern China: A Randomized Controlled Trial

The aim of the study was to investigate the effects of the rhGM-CSF gel on third-degree frostbite wounds. Sixty-two patients who had suffered third-degree frostbite on their hand or foot (91 wounds in total) were selected using a convenience sampling method and randomly allocated to two groups: the rhGM-CSF group(31patients,45 frostbite wounds) received the rhGM-CSF gel when wound dressing change daily; however, the control group (31patients, 46 frostbite wounds) received aloe glue. The wound healing time, the score of inflammation about the wound and the positive bacterial culture of wound secretions were used to measure outcomes, respectively. Data were analyzed using SPSS (25.0), Student's t test or Mann-Whitney U test and chi-square test or Fisher exact test were selected, as appropriate. The healing time of the rhGM-CSF group was (12.2 ± 5.0) days, which was significantly shorter than that of the control group (15.5 ± 4.7) days (P < .0001). The rhGM-CSF group's wound inflammation scores on the 7th and 14th day of treatment were (0.96 ± 0.21) and (1.88 ± 0.29), respectively, which were better than those of the control group (1.12 ± 0.24) and (1.38 ± 0.15) (both P < .0001). The positive bacterial culture of wound secretions in the rhGM-CSF group was also better than that in the control group on the 3rd, 7th, and 14th day after treatment (P = .027, .004, .030, respectively). According to the results, using rhGM-CSF gel considerably increases the speed of frostbite wounds healing, and have an effect on protecting third-degree frostbite wounds regarding the positive effects. Trial Registration: This trial was registered in the Chinese Clinical Trial Register, ChiCTR1900021299.

Effects of Seawater Immersion on Lethal Triad and Organ Function in Healthy and Hemorrhagic Shock Rats

INTRODUCTION

Marine casualties are increasing, and mortality from trauma associated with immersion in seawater is high. However, the associated pathophysiological characteristics remain unclear, limiting research into the early emergency treatment strategy.

METHODS

Healthy and 50% hemorrhagic shock rats were soaked in 15°C and 21°C seawater for 2 h, 4 h and 6 h, respectively, and the effects on vital signs, internal environment, tissue metabolism, lethal triad, vital organ functions and survival were observed.

RESULTS

Immersion in seawater can cause death in healthy rats. Rats with hemorrhagic shock in 15°C seawater showed a lower survival rate than the corresponding groups in 21°C seawater. Moreover, compared with 21°C seawater, 15°C seawater played a more remarkable role in decreasing mean arterial pressure, heart rate, and respiration rate, increasing water content and decreasing Na⁺/K⁺-ATPase activity in the brain and lung; increase in plasma osmolality, Na⁺, K⁺, Cl^-, and the occurrence of the lethal triad manifested by a decrease in core body temperature, pH, lactate, and an increase in coagulation parameters, as well as damage to cardiac, intestinal, hepatic, and renal functions in rats with hemorrhagic shock.

CONCLUSIONS

Immersion in seawater at low temperatures could be lethal to healthy rats, causing the occurrence of a lethal triad and damage to vital organs. Furthermore, 15°C-seawater had a more significant effect than 21°C-seawater on aggravating the imbalance of internal environment and tissue metabolism, resulting in a higher incidence of the lethal triad and thus aggravating the dysfunctions of vital organs, which eventually resulted in higher mortality in rats with hemorrhagic shock.

Bioprotective role of platelet-derived microvesicles in hypothermia: Insight into the differential characteristics of peripheral and splenic platelets

BACKGROUND

Most platelets are present in peripheral blood, but some are stored in the spleen. Because the tissue environments of peripheral blood vessels and the spleen are quite distinct, the properties of platelets present in each may also differ. However, no studies have addressed this difference. We previously reported that hypothermia activates splenic platelets, but not peripheral blood platelets, whose biological significance remains unknown. In this study, we focused on platelet-derived microvesicles (PDMVs) and analyzed their biological significance connected to intrasplenic platelet activation during hypothermia.

METHODS

C57Bl/6 mice were placed in an environment of -20 °C, and their rectal temperature was decreased to 15 °C to model hypothermia. Platelets and skeletal muscle tissue were collected and analyzed for their interactions.

RESULTS

Transcriptomic changes between splenic and peripheral platelets were greater in hypothermic mice than in normal mice. Electron microscopy and real-time RT-PCR analysis revealed that platelets activated in the spleen by hypothermia internalized transcripts, encoding tissue repairing proteins, into PDMVs and released them into the plasma. Plasma microvesicles from hypothermic mice promoted wound healing in the mouse myoblast cell line C2C12. Skeletal muscles in hypothermic mice were damaged but recovered within 24 h after rewarming. However, splenectomy delayed recovery from skeletal muscle injury after the mice were rewarmed.

CONCLUSIONS

These results indicate that PDMVs released from activated platelets in the spleen play an important role in the repair of skeletal muscle damaged by hypothermia.

Water Rewarming After Seawater Hypothermia Mitigates IL-1β in Both Intestinal Tissue and Blood

In this study, the rat models of severe hypothermia induced by seawater immersion were established in artificial seawater immersion at 15°C for 5 hours. With the rewarming measurement of 37°C water bath, the rewarming effects were evaluated by monitoring basic vital signs and dynamically detecting intestinal inflammation cytokines. Fifty Sprague-Dawley rats were randomly divided into five groups including the control group (group C), hypothermia group (group H), 2-hour rewarming group (group R2), 6-hour rewarming group (group R6), and 12-hour rewarming group (group R12), with 10 in each group. The basic vital signs of rats (i.e., core temperature, respiration, heart rate, and muscle tremor) were constantly recorded. The inflammatory factors were detected in the intestinal tissue via a protein chip GSR-CAA-67 of Innopsys, and the verification by reverse transcription-quantitative polymerase chain reaction. The levels of cytokines (interleukin IL-1β, IL-6, and IL-10) were detected from blood samples collected at the end of the observation period via enzyme-linked immunosorbent assay. The expression landscape of IL-1β in the intestinal tissue was validated by immunohistochemistry. Five hours of immersion in artificial seawater at 15°C successfully induced severe hypothermia of rats. After 2 hours of constant water bath rewarming at 37°C, the basic vital signs recovered to the normal level and maintained stably as well as the acute inflammatory reaction alleviated effectively, which indicated that 37°C of water immersion rewarming had the potential to be a suitable method for early treatment of water immersion hypothermia. After the process of hypothermia, several inflammatory cytokines of rats in rewarming groups changed distinctly with IL-1β, showing the most significant variations compared with group C, which confirmed IL-1β as a potential monitoring biomarker referring to the therapeutic effect of rewarming for severe hypothermia caused by seawater immersion.

Biomarkers for warfighter safety and performance in hot and cold environments

Exposure to extreme environmental heat or cold during military activities can impose severe thermal strain, leading to impairments in task performance and increasing the risk of exertional heat (including heat stroke) and cold injuries that can be life-threatening. Substantial individual variability in physiological tolerance to thermal stress necessitates an individualized approach to mitigate the deleterious effects of thermal stress, such as physiological monitoring of individual thermal strain. During heat exposure, measurements of deep-body (T_c) and skin temperatures and heart rate can provide some indication of thermal strain. Combining these physiological variables with biomechanical markers of gait (in)stability may provide further insight on central nervous system dysfunction - the key criterion of exertional heat stroke (EHS). Thermal strain in cold environments can be monitored with skin temperature (peripheral and proximal), shivering thermogenesis and T_c. Non-invasive methods for real-time estimation of T_c have been developed and some appear to be promising but require further validation. Decision-support tools provide useful information for planning activities and biomarkers can be used to improve their predictions, thus maximizing safety and performance during hot- and cold-weather operations. With better understanding on the etiology and pathophysiology of EHS, the microbiome and markers of the inflammatory responses have been identified as novel biomarkers of heat intolerance. This review aims to (i) discuss selected physiological and biomechanical markers of heat or cold strain, (ii) how biomarkers may be used to ensure operational readiness in hot and cold environments, and (iii) present novel molecular biomarkers (e.g., microbiome, inflammatory cytokines) for preventing EHS.

Accidental hypothermia: pathophysiology, investigations and management

Accidental hypothermia, defined as an unintentional decrease in core body temperature to below 35°C, adversely affects several body systems, including the cardiovascular, central nervous and renal systems. It is classified according to core body temperature from a maximum of 35°C in mild hypothermia to below 24°C in profound hypothermia. Patients with severe hypothermia (28°C-24°C) are at risk of cardiac arrythmias and cardiac arrest. In patients presenting with hypothermia, it is vital to prevent any further heat loss and quickly start rewarming them. Nurses working in the emergency department have a crucial role in supporting the optimal recovery of hypothermic patients. This article explains the pathophysiology of hypothermia, describes the investigations conducted in patients with accidental hypothermia and discusses management and nursing care.

Hypothermia and cold injuries in children and young people

Although hypothermia and cold injuries are rare in children and young people in the UK, the risk is persistent and requires urgent medical management when it does occur. This article outlines some considerations for professionals who may be caring for hypothermic patients or those at risk of becoming hypothermic.

A Tibetan adolescent girl suffered frostbite on the journey of pilgrimage: A case report

Frostbite in Southwestern China has been overlooked due to its low incidence, relatively mild temperature and lack of literature published before. However, it needs to be further studied for religious diversity and distinct geomorphology. In this article, we reported an 18-year-old Tibetan girl who suffered from blizzard attack during pilgrimage. Her feet and several fingers showed mummified gangrene upon physical examination with poor movement. She was diagnosed with 3rd to 4th degree of frostbite. The girl was given oral ibuprofen, debridement and other regular treatment daily, but she was eventually amputated due to insufficient thrombolytic management in primary hospital, delayed informing consent in the referral hospital and ethnic conflict between religion and guidelines. This case enriched the experience of managing complex frostbite in Tibetan population and alarms that efforts should be integrated to protect pilgrims and mountaineers in the Tibetan region.

Paroxysmal Hypothermia With Prominent Parkinsonian Features After Suprachiasmatic Tumor Resection

Paroxysmal hypothermia (PH) is a rare syndrome of stereotyped episodes of hypothermia, bradycardia, and altered mental status occurring in patients with hypothalamic lesions. Prior cases have mentioned bradykinesia, ataxia, and dysarthria, but parkinsonism has not been described as a specific feature of PH. We report two patients, an adult and a child, who developed PH after suprachiasmatic tumor resection, both with clinical presentations notable for prominent parkinsonian features despite no evidence of parkinsonism during the intervening months and years. We propose a diagnostic algorithm and scoring tool to aid in the clinical diagnosis of PH presenting as parkinsonism.

Core Temperature Measurement-Principles of Correct Measurement, Problems, and Complications

Core temperature reflects the temperature of the internal organs. Proper temperature measurement is essential to diagnose and treat temperature impairment in patients. However, an accurate approach has yet to be established. Depending on the method used, the obtained values may vary and differ from the actual core temperature. There is an ongoing debate regarding the most appropriate anatomical site for core temperature measurement. Although the measurement of body core temperature through a pulmonary artery catheter is commonly cited as the gold standard, the esophageal temperature measurement appears to be a reasonable and functional alternative in the clinical setting. This article provides an integrative review of invasive and noninvasive body temperature measurements and their relations to core temperature.

Hypothermia in Trauma

Hypothermia in trauma patients is a common condition. It is aggravated by traumatic hemorrhage, which leads to hypovolemic shock. This hypovolemic shock results in a lethal triad of hypothermia, coagulopathy, and acidosis, leading to ongoing bleeding. Additionally, hypothermia in trauma patients can deepen through environmental exposure on the scene or during transport and medical procedures such as infusions and airway management. This vicious circle has a detrimental effect on the outcome of major trauma patients. This narrative review describes the main factors to consider in the co-existing condition of trauma and hypothermia from a prehospital and emergency medical perspective. Early prehospital recognition and staging of hypothermia are crucial to triage to proper care to improve survival. Treatment of hypothermia should start in an early stage, especially the prevention of further cooling in the prehospital setting and during the primary assessment. On the one hand, active rewarming is the treatment of choice of hypothermia-induced coagulation disorder in trauma patients; on the other hand, accidental or clinically induced hypothermia might improve outcomes by protecting against the effects of hypoperfusion and hypoxic injury in selected cases such as patients suffering from traumatic brain injury (TBI) or traumatic cardiac arrest.

Hypothermia causes platelet activation in the human spleen

BACKGROUND

Accidental hypothermia results in various dysfunctions in the human body. Additionally, coagulation disorder can lead to a life-threatening condition. We previously demonstrated that platelets stored in the spleen were activated and thus triggered coagulation disorder in a mouse model of hypothermia. In the present study, we wanted to investigate if this phenomenon in mice also occurs in humans as a reaction to hypothermia.

METHODS

We analyzed splenic tissue collected from 22 deceased subjects who have died from hypothermia. These samples were compared with 22 control cases not exposed to cold environment. We performed immunohistochemical staining for CD61 (a marker of all platelets) and CD62P (a marker of activated platelets). We also evaluated the morphology of platelets in the spleen with scanning electron microscopy.

RESULTS

Immunohistochemical analysis revealed no significant changes in the amounts of CD61-positive platelets between the hypothermia and control cases. However, the hypothermia cases contained abundant CD62P-positive platelets compared with those of the control cases. Immunohistochemical analysis also revealed that the activated platelets formed aggregates and adhered to splenic sinusoidal endothelial cells in the hypothermia cases. However, we observed no significant fibrin formation around the activated platelets.

CONCLUSIONS

Hypothermia resulted in splenic platelet activation, which may be used as a postmortem marker of hypothermia. The release of activated platelets from the spleen into to circulation upon rewarming may promote coagulation disturbances.

Accidental Hypothermia and Transcranial Doppler Sonography: Case Report

We present a patient who was diagnosed with hypothermia in the emergency department and the changes in bedside transcranial Doppler (TCD) measurements during and immediately after the diagnoses were recorded. To the best of our knowledge, this is the first case report in the literature in which TCD data were shared in an accidental hypothermia patient in the emergency department. A 78-year-old male patient was brought to the emergency department with the complaint of speech impairment. The respiratory rate was 24 bpm, pulse rate 40 bpm, body temperature 25.6°C, blood pressure 80/50 mmHg, and glasgow coma scale 11. On electrocardiography, sinus bradycardia (40 bpm) and a small deflection (J wave) at the end of the QRS complex were observed. Immediately after the patient's admission, right middle cerebral artery end diastolic velocity (EDV) was 13.42 cm/s, peak systolic velocity (PSV) was 40.25 cm/s, and pulsatile index (PI) was 1.26 cm/s. After 1 hour, her body temperature was 34.5°C. Measurements with TCD were repeated 1 hour later at the same point and EDV was found to be 26.12 cm/s, PSV 84.02 cm/s, and PI 1.33. At the fourth hour, the patient's body temperature was 36.4°C, he was normothermic, and his mental status completely normalized. The patient was hospitalized for follow-up and treatment. This case supports that it can be used in the evaluation of cerebral perfusion and improvement during treatment in patients with accidental hypothermia in their admission to the emergency department.

A Longitudinal Study of T2 Mapping Combined With Diffusion Tensor Imaging to Quantitatively Evaluate Tissue Repair of Rat Skeletal Muscle After Frostbite

Purpose: T2 mapping and diffusion tensor imaging (DTI) enable the detection of changes in the skeletal muscle microenvironment. We assessed T2 relaxation times, DTI metrics, performed histological characterization of frostbite-induced skeletal muscle injury and repair, and provided diagnostic imaging biomarkers.

Design and Methods: Thirty-six Sprague Dawley rats (200 ± 10 g) were obtained. Thirty rats were used for establishing a skeletal muscle frostbite model, and six were untreated controls. Functional MR sequences were performed on rats on days 0, 3, 5, 10, and 14 (n = 6 per time point). Rats were then sacrificed to obtain the quadriceps muscles. Tensor eigenvalues (λ1, λ2, and λ3), mean diffusivity (MD), fractional anisotropy (FA), and T2 values were compared between the frostbite model and control rats. ImageJ was used to measure the extracellular area fraction (EAF), muscle fiber cross-sectional area (fCSA), and skeletal muscle tumor necrosis factor α (TNF-α), and Myod1 expression. The correlation between the histological and imaging parameters of the frostbitten skeletal muscle was evaluated. Kolmogorov–Smirnoff test, Leven’s test, one-way ANOVA, and Spearman coefficient were used for analysis.

Results: T2 relaxation time of frostbitten skeletal muscle was higher at all time points (p < 0.01). T2 relaxation time correlated with EAF, and TNF-α and Myod1 expression (r = 0.42, p < 0.05; r = 0.86, p < 0.01; r = 0.84, p < 0.01). The average tensor metrics (MD, λ1, λ2, and λ3) of skeletal muscle at 3 and 5 days of frostbite increased (p < 0.05), and fCSA correlated with λ1, λ2, and λ3, and MD (r = 0.65, p < 0.01; r = 0.48, p < 0.01; r = 0.52, p < 0.01; r = 0.62, p < 0.01).

Conclusion: T2 mapping and DTI imaging detect frostbite-induced skeletal muscle injury early. This combined approach can quantitatively assess skeletal muscle repair and regeneration within 2 weeks of frostbite. Imaging biomarkers for the diagnosis of frostbite were suggested.

Maternal hypothermia from environmental exposure in the third trimester

A primigravida at 32 weeks gestation developed hypothermia after prolonged exposure to the elements at -30.0°C. Her core temperature dropped to 29.8°C with associated foetal bradycardia. Passive rewarming was undertaken with forced warm air blankets and warmed IV fluids. The foetal heart rate normalised once normothermia was achieved. Serial foetal assessments showed appropriate growth and normal Doppler studies. She went to on deliver a healthy term infant. This case highlights conservative management and prioritising of maternal well-being with a good maternal and foetal outcome.

Rewarming from accidental hypothermia enhances whole blood clotting properties in a murine model

BACKGROUND

Hypothermia triggers coagulation, which can lead to the development of a life-threatening condition. We previously reported that hypothermia induces platelet activation in the spleen, resulting in microthrombosis after rewarming. However, the changes in whole blood clotting properties that occur remain unclear. Using thromboelastography, we investigated blood clotting activity and the effects of rewarming in a murine model of hypothermia.

METHODS

C57Bl/6 mice were exposed to an ambient temperature of -20 °C under general anesthesia until their rectal temperature decreased to 15 °C. One group of mice was kept at 4 °C for 2 h and then euthanized. Another group was rewarmed, kept in normal conditions for 24 h, and then euthanized. Tissue and citrated whole blood samples were obtained from the mice for histopathological analysis, flow cytometry, and thromboelastography.

RESULTS

Hypothermia induced the activation of platelets in the spleen; however, rewarming significantly reduced the number of activated platelets in the spleen while their numbers significantly increased in peripheral blood. In hypothermic mice not subjected to rewarming, no increase in activated platelets was observed in peripheral blood. Thromboelastography analysis showed that whole blood samples from the rewarmed mice displayed an enhanced clotting strength.

CONCLUSIONS

Rewarming from hypothermia enhances whole blood coagulation activity accompanied by an increase in the number of active platelets in peripheral blood. This phenomenon may lead to formation of microthrombi and thrombotic disorders.

Severe hypothermia, bradycardia and cardiac arrest in association with risperidone

Antipsychotic medications, including risperidone, are widely used in the treatment of psychiatric disorders, including schizophrenia. While hyperthermia is an establish adverse effect of these medications, less is known about the rare occurrence of hypothermia. We present two patients who developed hypothermia, bradycardia and cardiac arrest in association with risperidone. We briefly review previously similarly reported cases.

Factors associated with severity of accidental hypothermia: A cohort retrospective multi-institutional study

Background

Frequently it is difficult to determine illness severity in hypothermic patients. Our goal was to determine if there are factors associated with illness severity of hypothermic emergency department (ED) patients.

Methods

Multi-hospital retrospective cohort. Consecutive patients in 24 EDs (1-1-2012 to 4-30–2015). Hypothermic patients (≤35 °C) were identified using ICD codes. We used hospital admission as marker of illness severity. Student's t-test was used for differences between mean age and temperature for admitted and discharged patients. We calculated the percent of patients admitted by factor, the difference from overall admission rate and 95% confidence interval (CI) of difference.

Results

There were 2094 visits with hypothermia ICD code. Of these, 132 patients had initial rectal temperatures ≤35 °C. Females comprised 42%; the mean age was 55 ± 23 years, and overall admission rate was 62%. The percent of patients with alcohol, trauma and found indoors were 39%, 27% and 27%, respectively. For admitted and discharged patients the mean ages were 60 and 48 years, respectively (p = 0.01), and initial mean temperature 32.3 °C vs. 33 °C, respectively (p = 0.07). Found indoors was associated with an 86% admission rate, a 22% increase (95% CI, 3%–34%) compared to overall admission rate. There was no statistically significant difference in admission rates from overall admission rate based on gender, alcohol or trauma.

Conclusions

For hypothermic ED patients increased severity of illness was associated with older age and found indoors but not associated with initial temperature, gender, alcohol or trauma. These findings may assist physicians in treatment and disposition decisions.

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Accidental hypothermia is defined as a decrease in core body temperature to less than 35°C (95°F).

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Secondary hypothermia can occur in healthy and ill persons, even in warm environments, as a result of predisposing factors.

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Maintenance of a normal core temperature is achieved from a balance between heat production and heat loss.

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Factors associated with increased severity of illness for hypothermic ED patients were older age and found indoors.

Thermostability of Lactate Dehydrogenase in Rat Brain under Conditions of Short-Term Moderate Hypothermia

Thermostability of rat brain lactate dehydrogenase (LDH) was studied in intact animals and animals subjected to moderate short-term hypothermia. Two exponential stages, rapid and slow, were distinguished in the thermodenaturation kinetics. The contribution of the rapid phase to the lactate dehydrogenase denaturation kinetics was more significant: the energy of activation for this phase was 2.33 times lower than that for the slow phase. Moderate shortterm hypothermia led to a significant decrease of lactate dehydrogenase thermostability: thermodenaturation rate constants for the rapid (k₁) and slow (k₂) phases increased. Significant changes in parameters a and b reflecting the initial proportion of the two native forms of the enzyme developed only at 40°C. As hypothermia caused no appreciable changes in the energy of activation of lactate dehydrogenase denaturation, a significant contribution of the entropic factor to the decrease of free energy of enzyme denaturation was hypothesized. The data indicated significant labilization of lactate dehydrogenase structure under conditions of moderate hypothermia.

Beneficial effect of fluid warming in elderly patients with bladder cancer undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy

OBJECTIVES

The enhanced recovery after surgery (ERAS) protocol recommends prevention of intraoperative hypothermia. However, the beneficial effect of maintaining normothermia after radical cystectomy has not been evaluated. This study aimed to investigate the efficacy of fluid warming nursing in elderly patients undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy.

METHODS

A total of 108 patients with bladder cancer scheduled to undergo DaVinci robotic-assisted laparoscopic radical cystectomy were recruited and randomly divided into the control group (n=55), which received a warming blanket (43°C) during the intraoperative period and the warming group (n=53), in which all intraoperative fluids were administered via a fluid warmer (41°C). The surgical data, body temperature, coagulation function indexes, and postoperative complications were compared between the two groups.

RESULTS

Compared to the control group, the warming group had significantly less intraoperative transfusion (p=0.028) and shorter hospitalization days (p<0.05). During the entire intraoperative period (from 1 to 6h), body temperature was significantly higher in the warming group than in the control group. There were significant differences in preoperative fibrinogen level, white blood cell count, total bilirubin level, intraoperative lactose level, postoperative thrombin time (TT), and platelet count between the control and warming groups. Multivariate linear regression analysis demonstrated that TT was the only significant factor, suggesting that the warming group had a lower TT than the control group.

CONCLUSION

Fluid warming nursing can effectively reduce transfusion requirement and hospitalization days, maintain intraoperative normothermia, and promote postoperative coagulation function in elderly patients undergoing Da Vinci robotic-assisted laparoscopic radical cystectomy.

Hypothermia-induced activation of the splenic platelet pool as a risk factor for thrombotic disease in a mouse model

BACKGROUND

Hypothermia, either therapeutically induced or accidental (ie, an involuntary decrease in core body temperature to <35°C), results in hemostatic disorders. However, it remains unclear whether hypothermia enhances or inhibits coagulation, especially in severe hypothermia. The present study evaluated the thrombocytic and hemostatic changes in hypothermic mice.

METHODS

C57Bl/6 mice were placed at an ambient temperature of -20°C under general anesthesia. When the rectal temperature decreased to 15°C, 10 mice were immediately euthanized, while another 10 mice were rewarmed, kept in normal conditions for 24 hours, and then euthanized. These treatments were also performed in 20 splenectomized mice.

RESULTS

The hypothermic mice had adhesion of CD62P-positive platelets with high expression of von Willebrand factor (vWF) in their spleens, while the status of the peripheral platelets was unchanged. Furthermore, the plasma levels of platelet factor 4 (PF4) and pro-platelet basic protein (PPBP), which are biomarkers for platelet degranulation, were significantly higher in hypothermic mice than in control mice, indicating that hypothermia activated the platelets in the splenic pool. Thus, we analyzed these biomarkers in asplenic mice. There was no increase in either PF4 or PPBP in splenectomized hypothermic mice. Additionally, the plasma D-dimer elevation and microthrombosis were caused in rewarmed mice, but not in asplenic rewarmed mice.

CONCLUSIONS

Our results indicate that hypothermia leads to platelet activation in the spleen via the upregulation of vWF, and this activation causes hypercoagulability after rewarming.

Effects of a Portable Peritoneal Lavage Device on Dogs with Seawater-Immersed Open Abdominal Injury

Background

Seawater-immersed open abdominal injury is a special injury during marine activities. Effective warmed peritoneal lavage in the field early after injury is the key to treatment. This pilot study aimed at exploring the treatment effects of a self-developed portable peritoneal lavage device compared with conventional treatment model.

Material and Methods

Beagle dogs were used to develop models of seawater-immersed open abdominal injury. A conventional lavage method or a novel peritoneal lavage device was used for lavage and rewarming. The vital signs, electrolyte, serum inflammatory cytokine expression levels, histological changes of mucosa, and microstructure variety of different groups were observed and compared before and after immersion and 2 h, 1 d, 3 d, and 5 d after lavage.

Results

The levels of TNF-α, IL-1β, IL-8, IFN-γ, VEGF, and TGF-β in the blood and the damage of tissues and cells in three groups were increased after immersion and decreased at the later points of time after lavage. The concentration of Na⁺, K⁺, Cl⁻, lactate, and lactate dehydrogenase in the plasma was significantly higher than that before immersion (P < 0.05), and the concentration of Ca²⁺ and HCO₃⁻ and plasma pH decreased slightly (P < 0.05). The degree of tissue inflammation and mucosal injury in the delayed control group and device group was lower than the control group.

Conclusions

Timely lavage and rewarming using a portable peritoneal lavage device reduced the inflammatory response of seawater-immersed open abdominal injury dogs and reduced the damage of multiple organs. The dogs recovered better and faster than the conventional treatment group.

The utility of bone scintigraphy with SPECT/CT in the evaluation and management of frostbite injuries

OBJECTIVE:

Frostbite is a localized cold-thermal injury resulting from prolonged exposure of flesh to freezing and near freezing temperatures. The depth and extent of frostbite injuries are not easily assessed, from a clinical standpoint, at the time of injury making it challenging to plan appropriate management and treatment.

METHODS:

A review of the literature of management of cold-related injuries and retrospective case review of the imaging and clinical course of frostbite injury.

RESULTS:

Bone scintigraphy with single photon emission computed tomography (SPECT)/CT was performed in the acute and subacute course of frostbite injuries, subsequently leading to earlier definitive management and shorter hospital stay.

CONCLUSION:

Multiphase technetium-99m-methylenediphosphonate (⁹⁹mTc-MDP) bone scintigraphy with SPECT/CT can expedite clinical management of frostbite injuries by determining the extent of injury and can accurately predict the level of amputation if needed.

ADVANCES IN KNOWLEDGE:

 SPECT/CT is underutilized at many facilities but can have a profound and immediate impact on clinical management of patients with frostbite when used in combination with physiological bone scan imaging.

The prehospital management of hypothermia - An up-to-date overview

BACKGROUND

Accidental hypothermia concerns a body core temperature of less than 35°C without a primary defect in the thermoregulatory system. It is a serious threat to prehospital patients and especially injured patients, since it can induce a vicious cycle of the synergistic effects of hypothermia, acidosis and coagulopathy; referred to as the trauma triad of death. To prevent or manage deterioration of a cold patient, treatment of hypothermia should ideally begin prehospital. Little effort has been made to integrate existent literature about prehospital temperature management. The aim of this study is to provide an up-to-date systematic overview of the currently available treatment modalities and their effectiveness for prehospital hypothermia management.

DATA SOURCES

Databases PubMed, EMbase and MEDLINE were searched using the terms: "hypothermia", "accidental hypothermia", "Emergency Medical Services" and "prehospital". Articles with publications dates up to October 2017 were included and selected by the authors based on relevance.

RESULTS

The literature search produced 903 articles, out of which 51 focused on passive insulation and/or active heating. The most effective insulation systems combined insulation with a vapor barrier. Active external rewarming interventions include chemical, electrical and charcoal-burning heat packs; chemical or electrical heated blankets; and forced air warming. Mildly hypothermic patients, with significant endogenous heat production from shivering, will likely be able to rewarm themselves with only insulation and a vapor barrier, although active warming will still provide comfort and an energy-saving benefit. For colder, non-shivering patients, the addition of active warming is indicated as a non-shivering patient will not rewarm spontaneously. All intravenous fluids must be reliably warmed before infusion.

CONCLUSION

Although it is now accepted that prehospital warming is safe and advantageous, especially for a non-shivering hypothermic patient, this review reveals that no insulation/heating combinations stand significantly above all the others. However, modern designs of hypothermia wraps have shown promise and battery-powered inline fluid warmers are practical devices to warm intravenous fluids prior to infusion. Future research in this field is necessary to assess the effectiveness expressed in patient outcomes.

Management of Cold Water-induced Hypothermia: A Simulation Scenario for Layperson Training Delivered via a Mobile Tele-simulation Unit

Newfoundland and Labrador (NL) has one of the highest provincial drowning rates in Canada, largely due to the many rural communities located near bodies of water. Factor in the province's cold climate (average NL's freshwater temperature is below 5.4°C)and the prevalence of winter recreational activities among the population, there exists an inherent risk of ice-related injuries and subsequent hypothermia. Oftentimes, these injuries occur in remote/rural settings where immediate support from Emergency Medical Services (EMS) may not be available. During this critical period, it frequently falls on individuals without formal healthcare training to provide lifesaving measures until help arrives. Training individuals in rural communities plays an important role in ensuring public safety. In recent years, simulation-based education has become an essential tool in medical, marine and first aid training. It provides learners with a safe environment to hone their skills and has been shown to be superior to traditional clinical teaching methods. The following case aims to train laypeople from rural settings in the immediate management of an individual who becomes hypothermic following immersion into cold water. However, reaching these individuals to provide training can be a challenge in a province with such a vast geography. To assist with overcoming this, the development of a simulation center that is portable between communities (or Mobile Tele-Simulation Unit) has occurred. By utilizing modern technology, this paper also proposes an innovative method of connecting with learners in more difficult to reach regions.

The Triaging and Treatment of Cold-Induced Injuries

BACKGROUND

In Central Europe, cold-induced injuries are much less common than burns. In a burn center in western Germany, the mean ratio of these two types of injury over the past 10 years was 1 to 35. Because cold-induced injuries are so rare, physicians often do not know how to deal with them.

METHODS

This article is based on a review of publications (up to December 2014) retrieved by a selective search in PubMed using the terms "freezing," "frostbite injury," "non-freezing cold injury," and "frostbite review," as well as on the authors' clinical experience.

RESULTS

Freezing and cold-induced trauma are part of the treatment spectrum in burn centers. The treatment of cold-induced injuries is not standardized and is based largely on case reports and observations of use. distinction is drawn between non-freezing injuries, in which there is a slow temperature drop in tissue without freezing, and freezing injuries in which ice crystals form in tissue. In all cases of cold-induced injury, the patient should be slowly warmed to 22°-27°C to prevent reperfusion injury. Freezing injuries are treated with warming of the body's core temperature and with the bathing of the affected body parts in warm water with added antiseptic agents. Any large or open vesicles that are already apparent should be debrided. To inhibit prostaglandin-mediated thrombosis, ibuprofen is given (12 mg/kg body weight b.i.d.).

CONCLUSION

The treatment of cold-induced injuries is based on their type, severity, and timing. The recommendations above are grade C recommendations. The current approach to reperfusion has yielded promising initial results and should be further investigated in prospective studies.

Frostbite: Spectrum of Imaging Findings and Guidelines for Management

Frostbite is a localized cold thermal injury that results from tissue freezing. Frostbite injuries can have a substantial effect on long-term limb function and mobility if not promptly evaluated and treated. Imaging plays a critical role in initial evaluation of frostbite injuries and in monitoring response to treatment. A multimodality approach involving radiography, digital subtraction angiography (DSA), and/or multiphase bone scintigraphy with hybrid single photon emission computed tomography (SPECT)/computed tomography (CT) is often necessary for optimal guidance of frostbite care. Radiographs serve as an initial survey of the affected limb and may demonstrate characteristic findings, depending on the time course and severity of injury. DSA is used to evaluate perfusion of affected soft tissues and identify potential targets for therapeutic intervention. Angiography-directed thrombolysis plays an essential role in tissue preservation and salvage in deep frostbite injuries. Multiphase bone scintigraphy with technetium 99m-labeled diphosphonate provides valuable information regarding the status of tissue viability after initial treatment. The addition of SPECT/CT to multiphase bone scintigraphy enables precise anatomic localization of the level and depth of tissue necrosis before its appearance at physical examination and can help uncover subtle findings that may remain occult at scintigraphy alone. Multiphase bone scintigraphy with SPECT/CT is the modality of choice for prognostication and planning of definitive surgical care of affected limbs. Appropriate use of imaging to direct frostbite care can help limit the effects that these injuries have on limb function and mobility. ©RSNA, 2016.

Management of Severe Frostbite in a Grey-Headed Parrot (Poicephalus fuscicollis suahelicus)

An approximately 5-year-old female grey-headed parrot (Poicephalus fuscicollis suahelicus) was evaluated after exposure to outdoor temperatures below -20°C (-4°F) for approximately 22 hours. Severe frostbite affecting multiple digits, as well as dehydration and a depressed attitude, were diagnosed. Treatment included oral antibiotics, antifungals, nonsteroidal anti-inflammatories (NSAIDs), pentoxifylline, and topical aloe vera. Surgical amputation of the affected toes was not performed. Mild to moderate pododermatitis over the intertarsal joints developed because of a shift in weight bearing after the loss of most digits. Within 5 months after initial presentation, all frost-damaged toes had self-amputated, and the bird was able to function independently with no limitations in mobility.

A Survey of Accidental Hypothermia Knowledge among Navy Members in China and the Implications for Training

OBJECTIVES

Accidental hypothermia (AH) is a potentially life-threatening condition that can lead to significant morbidity and life-long effects. Navy personnel are always at a greater risk of AH due to frequent outdoor work, wilderness exposure, prolonged immobility and exhaustion. The purpose of the survey was to assess Chinese Navy members' awareness of AH and to make recommendations with regard to better measures for improving it.

METHODS

111 Navy members completed a written questionnaire that was subsequently analyzed.

RESULTS

30.6% of the respondents have experienced AH and 64.9% rated their knowledge of AH as "low" or "none". Over half of them identified the initial symptom of AH as obvious shivering (69.4%) and apathy (45.0%). As for the aggravate symptoms, 60.9% chose the wrong answer of more obvious shivering instead of the right one-absence of shivering (5.4%). In the case of the treatment of mild AH, more than half of the respondents chose the wrong answers.

CONCLUSIONS

This study suggests that the basic skills of recognition and treatment of AH are inadequate in the Chinese Navy. Further work is required to develop a systematical, comprehensive and corresponding education method that would promote correct actions during AH.

Body temperature regulation in diabetes

The effects of type 1 and type 2 diabetes on the body's physiological response to thermal stress is a relatively new topic in research. Diabetes tends to place individuals at greater risk for heat-related illness during heat waves and physical activity due to an impaired capacity to dissipate heat. Specifically, individuals with diabetes have been reported to have lower skin blood flow and sweating responses during heat exposure and this can have important consequences on cardiovascular regulation and glycemic control. Those who are particularly vulnerable include individuals with poor glycemic control and who are affected by diabetes-related complications. On the other hand, good glycemic control and maintenance of aerobic fitness can often delay the diabetes-related complications and possibly the impairments in heat loss. Despite this, it is alarming to note the lack of information regarding diabetes and heat stress given the vulnerability of this population. In contrast, few studies have examined the effects of cold exposure on individuals with diabetes with the exception of its therapeutic potential, particularly for type 2 diabetes. This review summarizes the current state of knowledge regarding the impact of diabetes on heat and cold exposure with respect to the core temperature regulation, cardiovascular adjustments and glycemic control while also considering the beneficial effects of maintaining aerobic fitness.

An uncommon case of severe accidental hypothermia in an urban setting

Accidental hypothermia is an uncommon presentation in urban settings. Here we present a patient admitted with a core temperature of 26.6°C (80°F) and a serum potassium of 8.5 mmol/l who subsequently went into cardiac arrest. After > 90 min of active cardiopulmonary resuscitation and peak serum potassium of >12 mmol/l, the patient had a spontaneous return of circulation. The patient's hospital course was complicated by compartment syndrome of his forearm; however, he was discharged home without any lasting neurological damage.

Practicability of avoiding hypothermia in resuscitation room phase in severely injured patients

Hypothermia in severely injured patients is a high demanding situation resulting from an effect of injury severity, surrounding temperature at trauma site and admittance. This article reviews the possible options to combat hypothermia in the resuscitation room with respect to practicability. This review summarizes available passive and active re-warming techniques and trys to offer a practicable chronology to restore normothermia. Resources should be applied depending on the availability of each institution and manifestation of hypothermia, but there is a strong demand for improvements with respect to practicability, convenience and safety for the patient.