Cool Your Jets Bro

History: Twenty-two year old male basic trainee was brought to the ED after collapsing during a routine ruck march. At mile 8/12, soldier was noted to develop an unsteady gate and had witnessed loss of consciousness. A rectal core temperature was obtained and noted to be >107degreeF. Cooling initiated with ice sheets and EMS was activated. On arrival to the ED, patient demonstrated confusion and persistently elevated core temperatures despite ice sheeting, chilled saline and cold water bladder lavage. Cooling measures were discontinued after patient achieved euthermia in the ED;however, his temperatures subsequently spiked>103degreeF. Given rebound hyperthermia, an endovascular cooling (EVC) device was placed in the right femoral vein and patient was transferred to the ICU. Multiple attempts to place EVC device on standby were unsuccessful with subsequent rebound hyperthermia. Prolonged cooling was required. Physical Exam: VS: HR 121, BP 85/68, RR 22 SpO2 100% RA, Temp 102.4degreeF Gen: young adult male, NAD, shivering, A&Ox2 (person and place only) HEENT: Scleral anicteric, conjunctiva non-injected, moist mucus membranes Neck: Supple, no LAD Chest: CTAB, no wheezes/rales/rhonchi CV: tachycardia, regular rhythm, normal S1, S2 without murmurs, rubs, gallops ABD: NABS, soft/non-distended, no guarding or rebound EXT: No LE edema, tenderness SKIN: blisters with broad erythematous bases on bilateral heels Neuro: CN II-XII grossly intact, 5/5 strength in all extremities. Differential Diagnosis: 216. Septic Shock 217. Hypothalamic Stroke 218. Exertional Heat Stroke (EHS) 219. Neuroleptic Malignant Syndrome 220. Thyroid Storm Test Results: CBC: 18.2>14.5/40.6<167 CMP: 128/3.5 88/1831/2.7<104, AST 264, ALT 80, Ca 8.8 Lactate: 7.1 CK: 11 460 Myoglobin: 18 017 TSH: 3.16 CXR: No acute cardiopulmonary process Blood Cx: negative x2 CSF Cx: Negative COVID/Influenza/EBV: Negative Brain MRI: wnl. Final Diagnosis: Exertional Heat Stroke. Discussion(s): No EVC protocols exist for the management of EHS or rebound/refractory hyperthermia. As a result, the protocol used for this patient was adapted from post-cardiac arrest cooling protocols. It is unclear if this adapted protocol contributed to his delayed cooling and rebound hyperthermia as it was not intended for this patient demographic/ pathophysiology. Furthermore, despite initiating empiric antibiotics upon admission, delayed recognition and tailored therapy for his bilateral ankle cellulitis may have contributed to the difficulty in achieving euthermia. In summary, more research needs to be done to evaluate and develop an EVC protocol for EHS. Outcome(s): Euthermia was achieved and maintained after 36 hours of continuous EVC, at which point it was discontinued. His CK, AST/ALT, creatinine and sodium down-trended after discontinuation of EVC. Patient's antibiotics were transitioned to an oral formulation for treatment of ankle cellulitis and he was prepared for discharge. He was discharged with regular follow-up with the Fort Benning Heat Clinic. Follow-Up: After discharge, patient had regularly scheduled visits with the Fort Benning Heat Clinic. His typical lab markers for exertional heat stroke were regularly monitored. He had continued resolution of his Rhabdomyolysis, acute kidney injury and hyponatremia with typical treatment. Soldier returned to duty after 10 weeks of close monitoring and rehabilitation.

Evaluation of the effects of cold and hot environmental temperatures on the spatial distribution of facial skin temperature

In the Covid-19 disaster, fever detection using infrared thermography became widespread. A person with fever is detected based on the facial skin temperature measured in a non-invasive and free-of-restraint method. Recent studies have pointed out that the facial whole skin temperature, when measured immediately after entering a moderately moderate environment from a cold environment, is not practical for detecting persons with fever because it is greatly affected by the environmental temperature. On the other hand, the effect of cold and hot temperatures on the details of the entire face has not been evaluated. In this study, we compared the cold and hot environments and the acclimation to moderate temperatures to The effects of cold and hot environments on the whole face skin temperature distribution was evaluated in detail.The results showed that the periorbital area and side of the nose were least affected in the cold environment, and the side of the the nose was least affected in the hot environment. And, These parts are suggested to be suitable for core temperature estimation considering the environmental temperature. © 2022 IEEE.

Determination of Internal Temperature by Measuring the Temperature of the Body Surface Due to Environmental Physical Factors-First Study of Fever Screening in the COVID Pandemic.

The SARS-CoV-2 virus pandemic has shown that the use of a contact thermometer to verify the elevated body temperature of a suspected person carries a risk of spreading disease. The perfect solution seems to be the use of thermal imaging as a diagnostic method in fever evaluation. The aim of the research is to develop an algorithm for thermovision measurements in fever screening standards in the context of the impact of various weather conditions on the temperature of people entering the public institution. Each examined person had two thermal images of the face-AP and lateral projection. Using a T1020 FLIR thermal camera with a resolution of 1024 × 768 pixels; the mean temperature was measured from the area of the forehead, the maximum forehead, the corners of the eyes, the inside of the mouth and the external auditory canal temperature. On the other hand, using classic contact thermometers, the temperature in the armpit and ear was measured. The obtained preliminary results showed very strong and positive correlations between the temperature in the ear measured with an ear thermometer and the maximum, minimum and average forehead temperature. These correlations oscillate at approximately r = 0.6, but the highest value of Spearman coefficient was obtained for the mean temperature of the forehead. Moreover, high correlations were also obtained between the temperature in the ear, measured with an ear thermometer, and the maximum temperature in the corners of the eyes and in the ear, measured with a thermal imaging camera. These values were, respectively, r = 0.54, r = 0.65. In summarizing, remote body temperature measurement taken with a thermal camera can be useful in the assessment of the body's core temperature.

Evaluation of a Wearable in-Ear Sensor for Temperature and Heart Rate Monitoring: A Pilot Study.

In the context of the COVID-19 pandemic, wearable sensors are important for early detection of critical illness especially in COVID-19 outpatients. We sought to determine in this pilot study whether a wearable in-ear sensor for continuous body temperature and heart rate monitoring (Cosinuss company, Munich) is sufficiently accurate for body temperature and heart rate monitoring. Comparing with several anesthesiologic standard of care monitoring devices (urinary bladder and zero-heat flux thermometer and ECG), we evaluated the in-ear sensor during non-cardiac surgery (German Clinical Trials Register Reg.-No: DRKS00012848). Limits of Agreement (LoA) based on Bland-Altman analysis were used to study the agreement between the in-ear sensor and the reference methods. The estimated LoA of the Cosinuss One and bladder temperature monitoring were [-0.79, 0.49] °C (95% confidence intervals [-1.03, -0.65] (lower LoA) and [0.35, 0.73] (upper LoA)), and [-0.78, 0.34] °C (95% confidence intervals [-1.18, -0.59] (lower LoA) and [0.16, 0.74] (upper LoA)) of the Cosinuss One and zero-heat flux temperature monitoring. 89% and 79% of Cosinuss One temperature monitoring were within ± 0.5 °C limit of bladder and zero-heat flux monitoring, respectively. The estimated LoA of Cosinuss One and ECG heart rate monitoring were [-4.81, 4.27] BPM (95% confidence intervals [-5.09, -4.56] (lower LoA) and [4.01, 4.54] (upper LoA)). The proportion of detection differences within ± 2BPM was 84%. Body temperature and heart rate were reliably measured by the wearable in-ear sensor.

A Novel Non-Invasive Thermometer for Continuous Core Body Temperature: Comparison with Tympanic Temperature in an Acute Stroke Clinical Setting.

There is a growing research interest in wireless non-invasive solutions for core temperature estimation and their application in clinical settings. This study aimed to investigate the use of a novel wireless non-invasive heat flux-based thermometer in acute stroke patients admitted to a stroke unit and compare the measurements with the currently used infrared (IR) tympanic temperature readings. The study encompassed 30 acute ischemic stroke patients who underwent continuous measurement (Tcore) with the novel wearable non-invasive CORE device. Paired measurements of Tcore and tympanic temperature (Ttym) by using a standard IR-device were performed 3-5 times/day, yielding a total of 305 measurements. The predicted core temperatures (Tcore) were significantly correlated with Ttym (r = 0.89, p < 0.001). The comparison of the Tcore and Ttym measurements by Bland-Altman analysis showed a good agreement between them, with a low mean difference of 0.11 ± 0.34 °C, and no proportional bias was observed (B = -0.003, p = 0.923). The Tcore measurements correctly predicted the presence or absence of Ttym hyperthermia or fever in 94.1% and 97.4% of cases, respectively. Temperature monitoring with a novel wireless non-invasive heat flux-based thermometer could be a reliable alternative to the Ttym method for assessing core temperature in acute ischemic stroke patients.

Centralising cardiac arrest care: a single centre retrospective observational study

Introduction: Glan Clwyd Hospital (GCH) has offered a 24/7 Percutaneous Coronary Intervention (PCI) service in North Wales (population approx. 690,000) since 2017 and has been designated one of three Welsh Cardiac Arrest Centres. The aim of the study was to evaluate the impact of this development upon resource requirements and outcomes. Methods: Retrospective review of the ICU Ward Watcher database to identify patients undergoing CPR in the 24 h prior to admission April 2013-April 2021. Patients likely to have sustained Out-of-Hospital Cardiac Arrest (OOHCA) of primary cardiac aetiology (OOHCAC) were identified from primary/secondary diagnoses and free text entry. Data were subsequently analysed using Excel and SPSS. The project was registered as a service evaluation. Results: There were 367 ICU admissions following cardiac arrest;245 were OOHCA, of which 189 were considered OOHCA-C. Annual OOHCA admissions increased through the study period from 12 (2013-2014) to 50 (2019-2020) before decreasing to 29 during COVID-19 pandemic (2020-2021). OOHCA bed days increased from 38 in 2013-2014 to 215 in 2019-2020, falling to 169 in 2020-2021. Proportions of OOHCA-C patients undergoing pre-ICU PCI increased with time (33% in 2013-2014 to 47% in 2020-2021). Hospital mortality following OOHCA was 61.2% and OOHCA-C was 59.7%;temporal trends did not reach statistical significance. Main factors from first 24 h of ICU admission associated with hospital mortality are presented below. On logistic regression, only lactate, central temperature and lack of pre-ICU PCI significantly predicted hospital mortality (p < 0.001) (Table 1). Conclusions: Centralising cardiac arrest care has led to an appreciable rise in ICU bed occupancy. Although overall hospital mortality for OOHCA-C remains high and appreciating potential selection bias, a significant association between PCI and survival to hospital discharge appears to support clinical pathways enabling PCI access following OOHA-C [1]. (Table Presented).

Accuracy of tympanic versus digital infra-red thermometers for measuring core body temperature in critical care department-a quality improvement project during covid-19 redeployment at a district general hospital in Surrey, England

Aim: Accurate determination of core body temperature in critically ill patients is required for initiating diagnosis and management. (1) Ideally, temperature measurement should be non-invasive, hygienic, convenient, and affordable. Infrared thermometers are convenient and noninvasive but sensitive to environmental factors. Alternatively, tympanic thermometers are cost effective but invasive. Various observational studies have concluded that tympanic thermometers have high specificity/ sensitivity compared to infrared thermometers (2,3). We aimed to demonstrate accuracy of tympanic over infrared thermometers. Method: In this observational prospective study, eighty patients (forty each) admitted in intensive care from February 2021 - July 2021 were included. Temperature measurements with were conducted - measuring differences between digital and tympanic thermometers. A Plan Do Study Act cycle was used to facilitate change. Excel and SPSS software were used for data analysis. Results: Our study concluded a statistically significant (p,0.01) difference in readings with mean difference of 1.18°C (highest -6°C, lowest- 0.5°C). Pyrexia was undetected in 4 of 40 patients with digital thermometers. Additionally, two patients undergoing hypothermia correction were not adequately measured. Therefore, infrared thermometers were significantly less sensitive and were replaced with tympanic thermometers. A second cycle conducted again demonstrated significant (p<0.01) difference with mean difference of 1.92°C. (highest -6.5°C, lowest -1°C). Conclusions: Tympanic thermometers have higher accuracy and precision over digital thermometers. We managed to establish change during our audit with concluding evidence showing infrared thermometers procure false observations affecting patient care, hence, unsafe. In conclusion, tympanic thermometers should be encouraged in critical care settings for vigilant care.

Choosing wisely: The use of clinical criteria to guide blood culturing practices

INTRODUCTION: Fever is a common problem in ICU patients. Despite clinical research and guideline recommendations indicating that clinical criteria and not fever alone should be used to order blood cultures (BC), these cultures are frequently obtained as part of a “fever workup” without careful review of the patient's clinical status. Unnecessary BC increase clinical workload and can lead to inappropriate treatments if the culture is contaminated. The purpose of this quality improvement (QI) initiative was to develop clinical criteria that providers were to review when ordering BC, with a goal to reduce the numbers of inappropriate BC. METHODS: This QI project was completed in a 36-bed surgery/trauma/burn ICU. After reviewing pertinent studies and guidelines, clinical criteria for obtaining blood cultures were developed by a subcommittee and approved by the ICU QI committee. These criteria included a core temperature of 38.3°C on at least two separate readings, evidence of sepsis with worsening physiologic parameters in at least one organ system, no apparent non-infectious cause of fever, at least 48 hours after non-emergency surgery, no BC obtained in the past 36 hours unless positive, and no plans for end of life or comfort care. The protocol was implemented in February, 2021. Numbers of BC were tracked for 5 months after implementation, and compared for the same 5-month periods for 2019 and 2020, to capture trends both before and during the COVID pandemic. RESULTS: The average number of BC/month prior to implementation of clinical criteria were 218 in 2019 and 209 in 2020 (CI 212-225). After implementation of clinical criteria, the number was 184 (CI 139-221) in 2021. This represented a 14% decrease in the number of BC, although this decrease did not achieve statistical significance. CONCLUSIONS: The implementation of clinical criteria for when to obtain BC resulted in a reduced cultures. Further investigation is needed to determine if this decrease is sustainable and will reach statistical significance, if the criteria can be further modified to further decrease inappropriate BC, and to ensure that decreasing the number of BC does not result in delayed recognition of bacteremia or other infections. Following clinical criteria to avoid unnecessary BC could be a helpful tool to help clinicians to choose wisely.

Enhanced personal protective equipment can cause acute kidney injury in health care workers during COVID-19 pandemics

Introduction: Enhanced personal protective equipment (PPE) can expose health care workers (HCWs) to high heat stress and dehydration. The objective of this study was to assess the risk of acute kidney injury (AKI) among HCWs during the pandemic. Material and Methods: We recruited 52 HCWs worked on the mobile COVID-19 screening bus in the summer of 2021. We measured the body water content, pulse, core body temperature, blood pressure, creatinine, and urinary analysis before and after the work shift. We obtained the amount of water intake, environmental and personal measurements of temperature, humidity, and heat stress index during the work shift. Physicians interviewed the study subjects to confirm their medical history. Paired sample t-tests were used to test the pre and post-measurements. Results and Conclusions: After excluding 18 subjects who did not wear PPE in the pilot study, 34 HCWs were used in the analyses (male: 11.8%;female: 88.2 %). Most of them were nurses, with a mean age of 30.53 years old (SD 6.82). After a work shift, 14.7% of the subjects had incident AKI (1.5 times reference value or increase≧0.3 mg/dl). Core body temperature increased 0.27 degree (95% confidence interval [CI]: 0.16 to 0.38), creatinine level increased 0.161 mg/dl (95% CI: 0.11 to 0.22, p<0.001). The estimated glomerular filtration rate (eGFR) showed a significant decline in renal function (-16.82 ml/min/1.73m2, 95% CI: -22.47 to -11.17, p<0.001). There was a protective effect of hydration (p= 0.09). In conclusion, wearing enhanced PPE can cause kidney injuries. There is an urgent need to develop regulations to prevent AKI among HCWs.