Protection against cold in prehospital care: wet clothing removal or addition of a vapor barrier.

OBJECTIVE: The purpose of this study was to evaluate the effect of wet clothing removal or the addition of a vapor barrier in shivering subjects exposed to a cold environment with only limited insulation available. METHODS: Volunteer subjects (n = 8) wearing wet clothing were positioned on a spineboard in a climatic chamber (-18.5°C) and subjected to an initial 20 minutes of cooling followed by 30 minutes of 4 different insulation interventions in a crossover design: 1) 1 woolen blanket; 2) vapor barrier plus 1 woolen blanket; 3) wet clothing removal plus 1 woolen blanket; or 4) 2 woolen blankets. Metabolic rate, core body temperature, skin temperature, and heart rate were continuously monitored, and cold discomfort was evaluated at 5-minute intervals. RESULTS: Wet clothing removal or the addition of a vapor barrier significantly reduced metabolic rate (mean difference ± SE; 14 ± 4.7 W/m(2)) and increased skin temperature rewarming (1.0° ± 0.2°C). Increasing the insulation rendered a similar effect. There were, however, no significant differences in core body temperature or heart rate among any of the conditions. Cold discomfort (median; interquartile range) was significantly lower with the addition of a vapor barrier (4; 2-4.75) and with 2 woolen blankets (3.5; 1.5-4) compared with 1 woolen blanket alone (5; 3.25-6). CONCLUSIONS: In protracted rescue scenarios in cold environments with only limited insulation available, wet clothing removal or the use of a vapor barrier is advocated to limit the need for shivering thermogenesis and improve the patient's condition on admission to the emergency department.

Validity and reliability of the Cold Discomfort Scale: a subjective judgement scale for the assessment of patient thermal state in a cold environment.

Complementary measures for the assessment of patient thermoregulatory state, such as subjective judgement scales, might be of considerable importance in field rescue scenarios where objective measures such as body core temperature, skin temperature, and oxygen consumption are difficult to obtain. The objective of this study was to evaluate, in healthy subjects, the reliability of the Cold Discomfort Scale (CDS), a subjective judgement scale for the assessment of patient thermal state in cold environments, defined as test-retest stability, and criterion validity, defined as the ability to detect a difference in cumulative cold stress over time. Twenty-two healthy subjects performed two consecutive trials (test-retest). Dressed in light clothing, the subjects remained in a climatic chamber set to -20 °C for 60 min. CDS ratings were obtained every 5 min. Reliability was analysed by test-retest stability using weighted kappa coefficient that was 0.84 including all the 5-min interval measurements. When analysed separately at each 5-min interval the weighted kappa coefficients were was 0.48-0.86. Criterion validity was analysed by comparing median CDS ratings of a moving time interval. The comparison revealed that CDS ratings were significantly increased for every interval of 10, 15, and 30 min (p < 0.001) but not for every interval of 5 min. In conclusion, in a prehospital scenario, subjective judgement scales might be a valuable measure for the assessment of patient thermal state. The results of this study indicated that, in concious patients, the CDS may be both reliable and valid for such purpose.

Effect of temperature difference between manikin and wet fabric skin surfaces on clothing evaporative resistance: how much error is there?

Clothing evaporative resistance is one of the inherent factors that impede heat exchange by sweating evaporation. It is widely used as a basic input in physiological heat strain models. Previous studies showed a large variability in clothing evaporative resistance both at intra-laboratory and inter-laboratory testing. The errors in evaporative resistance may cause severe problems in the determination of heat stress level of the wearers. In this paper, the effect of temperature difference between the manikin nude surface and wet textile skin surface on clothing evaporative resistance was investigated by both theoretical analysis and thermal manikin measurements. It was found that the temperature difference between the skin surface and the manikin nude surface could lead to an error of up to 35.9% in evaporative resistance of the boundary air layer. Similarly, this temperature difference could also introduce an error of up to 23.7% in the real clothing total evaporative resistance (R ( et_real ) < 0.1287 kPa m(2)/W). Finally, it is evident that one major error in the calculation of evaporative resistance comes from the use of the manikin surface temperature instead of the wet textile fabric skin temperature.

Deriving the operational procedure for the Universal Thermal Climate Index (UTCI).

The Universal Thermal Climate Index (UTCI) aimed for a one-dimensional quantity adequately reflecting the human physiological reaction to the multi-dimensionally defined actual outdoor thermal environment. The human reaction was simulated by the UTCI-Fiala multi-node model of human thermoregulation, which was integrated with an adaptive clothing model. Following the concept of an equivalent temperature, UTCI for a given combination of wind speed, radiation, humidity and air temperature was defined as the air temperature of the reference environment, which according to the model produces an equivalent dynamic physiological response. Operationalising this concept involved (1) the definition of a reference environment with 50% relative humidity (but vapour pressure capped at 20 hPa), with calm air and radiant temperature equalling air temperature and (2) the development of a one-dimensional representation of the multivariate model output at different exposure times. The latter was achieved by principal component analyses showing that the linear combination of 7 parameters of thermophysiological strain (core, mean and facial skin temperatures, sweat production, skin wettedness, skin blood flow, shivering) after 30 and 120 min exposure time accounted for two-thirds of the total variation in the multi-dimensional dynamic physiological response. The operational procedure was completed by a scale categorising UTCI equivalent temperature values in terms of thermal stress, and by providing simplified routines for fast but sufficiently accurate calculation, which included look-up tables of pre-calculated UTCI values for a grid of all relevant combinations of climate parameters and polynomial regression equations predicting UTCI over the same grid. The analyses of the sensitivity of UTCI to humidity, radiation and wind speed showed plausible reactions in the heat as well as in the cold, and indicate that UTCI may in this regard be universally useable in the major areas of research and application in human biometeorology.

The UTCI-clothing model.

The Universal Thermal Climate Index (UTCI) was conceived as a thermal index covering the whole climate range from heat to cold. This would be impossible without considering clothing as the interface between the person (here, the physiological model of thermoregulation) and the environment. It was decided to develop a clothing model for this application in which the following three factors were considered: (1) typical dressing behaviour in different temperatures, as observed in the field, resulting in a model of the distribution of clothing over the different body segments in relation to the ambient temperature, (2) the changes in clothing insulation and vapour resistance caused by wind and body movement, and (3) the change in wind speed in relation to the height above ground. The outcome was a clothing model that defines in detail the effective clothing insulation and vapour resistance for each of the thermo-physiological model's body segments over a wide range of climatic conditions. This paper details this model's conception and documents its definitions.

Protection against cold in prehospital care: evaporative heat loss reduction by wet clothing removal or the addition of a vapor barrier--a thermal manikin study.

INTRODUCTION: In the prehospital care of a cold and wet person, early application of adequate insulation is of utmost importance to reduce cold stress, limit body core cooling, and prevent deterioration of the patient's condition. Most prehospital guidelines on protection against cold recommend the removal of wet clothing prior to insulation, and some also recommend the use of a waterproof vapor barrier to reduce evaporative heat loss. However, there is little scientific evidence of the effectiveness of these measures. OBJECTIVE: Using a thermal manikin with wet clothing, this study was conducted to determine the effect of wet clothing removal or the addition of a vapor barrier on thermal insulation and evaporative heat loss using different amounts of insulation in both warm and cold ambient conditions. METHODS: A thermal manikin dressed in wet clothing was set up in accordance with the European Standard for assessing requirements of sleeping bags, modified for wet heat loss determination, and the climatic chamber was set to -15 degrees Celsius (°C) for cold conditions and +10°C for warm conditions. Three different insulation ensembles, one, two or seven woollen blankets, were chosen to provide different levels of insulation. Five different test conditions were evaluated for all three levels of insulation ensembles: (1) dry underwear; (2) dry underwear with a vapor barrier; (3) wet underwear; (4) wet underwear with a vapor barrier; and (5) no underwear. Dry and wet heat loss and thermal resistance were determined from continuous monitoring of ambient air temperature, manikin surface temperature, heat flux and evaporative mass loss rate. RESULTS: Independent of insulation thickness or ambient temperature, the removal of wet clothing or the addition of a vapor barrier resulted in a reduction in total heat loss of 19-42%. The absolute heat loss reduction was greater, however, and thus clinically more important in cold environments when little insulation is available. A similar reduction in total heat loss was also achieved by increasing the insulation from one to two blankets or from two to seven blankets. CONCLUSION: Wet clothing removal or the addition of a vapor barrier effectively reduced evaporative heat loss and might thus be of great importance in prehospital rescue scenarios in cold environments with limited insulation available, such as in mass-casualty situations or during protracted evacuations in harsh conditions.

Localised boundary air layer and clothing evaporative resistances for individual body segments.

Evaporative resistance is an important parameter to characterise clothing thermal comfort. However, previous work has focused mainly on either total static or dynamic evaporative resistance. There is a lack of investigation of localised clothing evaporative resistance. The objective of this study was to study localised evaporative resistance using sweating thermal manikins. The individual and interaction effects of air and body movements on localised resultant evaporative resistance were examined in a strict protocol. The boundary air layer's localised evaporative resistance was investigated on nude sweating manikins at three different air velocity levels (0.18, 0.48 and 0.78 m/s) and three different walking speeds (0, 0.96 and 1.17 m/s). Similarly, localised clothing evaporative resistance was measured on sweating manikins at three different air velocities (0.13, 0.48 and 0.70 m/s) and three walking speeds (0, 0.96 and 1.17 m/s). Results showed that the wind speed has distinct effects on local body segments. In contrast, walking speed brought much more effect on the limbs, such as thigh and forearm, than on body torso, such as back and waist. In addition, the combined effect of body and air movement on localised evaporative resistance demonstrated that the walking effect has more influence on the extremities than on the torso. Therefore, localised evaporative resistance values should be provided when reporting test results in order to clearly describe clothing local moisture transfer characteristics. PRACTITIONER SUMMARY: Localised boundary air layer and clothing evaporative resistances are essential data for clothing design and assessment of thermal comfort. A comprehensive understanding of the effects of air and body movement on localised evaporative resistance is also necessary by both textile and apparel researchers and industry.

Parallel and serial methods of calculating thermal insulation in European manikin standards.

Standard No. EN 15831:2004 provides 2 methods of calculating insulation: parallel and serial. The parallel method is similar to the global one defined in Standard No. ISO 9920:2007. Standards No. EN 342:2004, EN 14058:2004 and EN 13537:2002 refer to the methods defined in Standard No. EN ISO 15831:2004 for testing cold protective clothing or equipment. However, it is necessary to consider several issues, e.g., referring to measuring human subjects, when using the serial method. With one zone, there is no serial-parallel issue as the results are the same, while more zones increase the difference in insulation value between the methods. If insulation is evenly distributed, differences between the serial and parallel method are relatively small and proportional. However, with more insulation layers overlapping in heavy cold protective ensembles, the serial method produces higher insulation values than the parallel one and human studies. Therefore, the parallel method is recommended for standard testing.

Determination of clothing evaporative resistance on a sweating thermal manikin in an isothermal condition: heat loss method or mass loss method?

This paper addresses selection between two calculation options, i.e heat loss option and mass loss option, for thermal manikin measurements on clothing evaporative resistance conducted in an isothermal condition (T(manikin) = T(a) = T(r)). Five vocational clothing ensembles with a thermal insulation range of 1.05-2.58 clo were selected and measured on a sweating thermal manikin 'Tore'. The reasons why the isothermal heat loss method generates a higher evaporative resistance than that of the mass loss method were thoroughly investigated. In addition, an indirect approach was applied to determine the amount of evaporative heat energy taken from the environment. It was found that clothing evaporative resistance values by the heat loss option were 11.2-37.1% greater than those based on the mass loss option. The percentage of evaporative heat loss taken from the environment (H(e,env)) for all test scenarios ranged from 10.9 to 23.8%. The real evaporative cooling efficiency ranged from 0.762 to 0.891, respectively. Furthermore, it is evident that the evaporative heat loss difference introduced by those two options was equal to the heat energy taken from the environment. In order to eliminate the combined effects of dry heat transfer, condensation, and heat pipe on clothing evaporative resistance, it is suggested that manikin measurements on the determination of clothing evaporative resistance should be performed in an isothermal condition. Moreover, the mass loss method should be applied to calculate clothing evaporative resistance. The isothermal heat loss method would appear to overestimate heat stress and thus should be corrected before use.

Cooling vests with phase change materials: the effects of melting temperature on heat strain alleviation in an extremely hot environment.

A previous study by the authors using a heated thermal manikin showed that the cooling rates of phase change material (PCM) are dependent on temperature gradient, mass, and covering area. The objective of this study was to investigate if the cooling effects of the temperature gradient observed on a thermal manikin could be validated on human subjects in extreme heat. The subjects wore cooling vests with PCMs at two melting temperatures (24 and 28°C) and fire-fighting clothing and equipment, thus forming three test groups (vest24, vest28 and control group without the vest). They walked on a treadmill at a speed of 5 km/h in a climatic chamber (air temperature = 55°C, relative humidity = 30%, vapour pressure = 4,725 Pa, and air velocity = 0.4 m/s). The results showed that the PCM vest with a lower melting temperature (24°C) has a stronger cooling effect on the torso and mean skin temperatures than that with a higher melting temperature (28°C). Both PCM vests mitigate peak core temperature increase during the resting recovery period. The two PCM vests tested, however, had no significant effect on the alleviation of core temperature increase during exercise in the heat. To study the possibility of effective cooling of core temperature, cooling garments with PCMs at even lower melting temperatures (e.g. 15°C) and a larger covering area should be investigated.

Effects of air velocity and clothing combination on heating efficiency of an electrically heated vest (EHV): a pilot study.

Cold endangers the heat balance of the human body. Protective clothing is the natural and most common equipment against cold stress. However, clothing for cold protection may be bulky and heavy, affecting human performance and increasing the work load. In such cases, a heated garment with built-in heating elements may be helpful. This pilot study presents a method based on a thermal manikin to investigate the effects of air velocity and clothing combination on the heating efficiency of an electrically heated vest (EHV). An infrared thermal camera was used to detect surface temperature distributions of the EHV on the front and back. Results show that the heating efficiency of the EHV decreases with increasing air velocity. Changes in EHV sequence in the three-layer clothing combination also significantly affect the heating efficiency: it increases with the increasing number of layers on top of the EHV. The highest mean temperature on the inner surface of the EHV was 40.2 degrees C, which indicates that it is safe for the wearers. For the EHV to heat the human body effectively, we suggest that it be worn as a middle layer. Finally, the EHV is especially suitable for occupational groups whose metabolic rate is below 1.9 Mets.

Cooling vests with phase change material packs: the effects of temperature gradient, mass and covering area.

Phase change material (PCM) absorbs or releases latent heat when it changes phases, making thermal-regulated clothing possible. The objective of this study was to quantify the relationships between PCM cooling rate and temperature gradient, mass and covering area on a thermal manikin in a climatic chamber. Three melting temperatures (24, 28, 32 degrees C) of the PCMs, different mass, covering areas and two manikin temperatures (34 and 38 degrees C) were used. The results showed that the cooling rate of the PCM vests tested is positively correlated with the temperature gradient between the thermal manikin and the melting temperature of the PCMs. The required temperature gradient is suggested to be greater than 6 degrees C when PCM vests are used in hot climates. With the same temperature gradient, the cooling rate is mainly determined by the covering area. The duration of the cooling effect is dependent on PCM mass and the latent heat. STATEMENT OF RELEVANCE: The study of factors affecting the cooling rate of personal cooling equipment incorporated with PCM helps to understand cooling mechanisms. The results suggest climatic conditions, the required temperature gradient, PCM mass and covering area should be taken into account when choosing personal PCM cooling equipment.

A review of technology of personal heating garments.

Modern technology makes garments smart, which can help a wearer to manage in specific situations by improving the functionality of the garments. The personal heating garment (PHG) widens the operating temperature range of the garment and improves its protection against the cold. This paper describes several kinds of PHGs worldwide; their advantages and disadvantages are also addressed. Some challenges and suggestions are finally addressed with regard to the development of PHGs.

Heat gain from thermal radiation through protective clothing with different insulation, reflectivity and vapour permeability.

The heat transferred through protective clothing under long wave radiation compared to a reference condition without radiant stress was determined in thermal manikin experiments. The influence of clothing insulation and reflectivity, and the interaction with wind and wet underclothing were considered. Garments with different outer materials and colours and additionally an aluminised reflective suit were combined with different number and types of dry and pre-wetted underwear layers. Under radiant stress, whole body heat loss decreased, i.e., heat gain occurred compared to the reference. This heat gain increased with radiation intensity, and decreased with air velocity and clothing insulation. Except for the reflective outer layer that showed only minimal heat gain over the whole range of radiation intensities, the influence of the outer garments' material and colour was small with dry clothing. Wetting the underclothing for simulating sweat accumulation, however, caused differing effects with higher heat gain in less permeable garments.

Testing cold protection according to EN ISO 20344: is there any professional footwear that does not pass?

The present Comité Européen de Normalisation (CEN) and International Organization for Standardization (ISO) standards for safety, protective and occupational footwear EN ISO 20344-20347 classify footwear as cold protective by a pass/fail test where the limits are set for an allowed 10 degrees C temperature drop inside the footwear during 30 min at a temperature gradient of approximately 40 degrees C. It is questionable if a simple pass/fail test of this kind provides approved footwear that really protects the feet from cooling in exposures ranging from temperatures at +18 degrees C to as low as or even lower than -50 degrees C. This study selected for testing some professional footwear that could certainly not be considered as cold protective. Some footwear that could be used in cold was selected with as low insulation as the not cold-intended footwear. Also, a boot intended for cold was selected to be tested according to a modified standard at a temperature gradient of 70 degrees C. The footwear selection was based on insulation measurements with a thermal foot model. All footwear did pass the test. Although it is clear for the user that a sandal, a mesh shoe or a thin textile shoe is not cold protective, it is not as clear that an item of safety footwear, that has as low insulation as those mentioned above, could be classified as cold protective according to the present standards. Because of this, the user might have a deceptive feeling of safety and may be exposed to higher risks. As practically all professional footwear may pass this cold test, then the method/requirements should be radically changed or such a test should be removed from the standards.

Protection against cold in prehospital care-thermal insulation properties of blankets and rescue bags in different wind conditions.

INTRODUCTION: In a cold, wet, or windy environment, cold exposure can be considerable for an injured or ill person. The subsequent autonomous stress response initially will increase circulatory and respiratory demands, and as body core temperature declines, the patient's condition might deteriorate. Therefore, the application of adequate insulation to reduce cold exposure and prevent body core cooling is an important part of prehospital primary care, but recommendations for what should be used in the field mostly depend on tradition and experience, not on scientific evidence. OBJECTIVE: The objective of this study was to evaluate the thermal insulation properties in different wind conditions of 12 different blankets and rescue bags commonly used by prehospital rescue and ambulance services. METHODS: The thermal manikin and the selected insulation ensembles were setup inside a climatic chamber in accordance to the modified European Standard for assessing requirements of sleeping bags. Fans were adjusted to provide low (< 0.5 m/s), moderate (2-3 m/s) and high (8-9 m/s) wind conditions. During steady state thermal transfer, the total resultant insulation value, Itr (m2 C/Wclo; where C = degrees Celcius, and W = watts), was calculated from ambient air temperature (C), manikin surface temperature (C), and heat flux (W/m2). RESULTS: In the low wind condition, thermal insulation of the evaluated ensembles correlated to thickness of the ensembles, ranging from 2.0 to 6.0 clo (1 clo = 0.155 m2 C/W), except for the reflective metallic foil blankets that had higher values than expected. In moderate and high wind conditions, thermal insulation was best preserved for ensembles that were windproof and resistant to the compressive effect of the wind, with insulation reductions down to about 60-80% of the original insulation capacity, whereas wind permeable and/or lighter materials were reduced down to about 30-50% of original insulation capacity. CONCLUSIONS: The evaluated insulation ensembles might all be used for prehospital protection against cold, either as single blankets or in multiple layer combinations, depending on ambient temperatures. However, with extended outdoor, on-scene durations, such as during prolonged extrications or in multiple casualty situations, the results of this study emphasize the importance of using a windproof and compression resistant outer ensemble to maintain adequate insulation capacity.

Apparent latent heat of evaporation from clothing: attenuation and "heat pipe" effects.

Investigating claims that a clothed person's mass loss does not always represent their evaporative heat loss (EVAP), a thermal manikin study was performed measuring heat balance components in more detail than human studies would permit. Using clothing with different levels of vapor permeability and measuring heat losses from skin controlled at 34 degrees C in ambient temperatures of 10, 20, and 34 degrees C with constant vapor pressure (1 kPa), additional heat losses from wet skin compared with dry skin were analyzed. EVAP based on mass loss (E(mass)) measurement and direct measurement of the extra heat loss by the manikin due to wet skin (E(app)) were compared. A clear discrepancy was observed. E(mass) overestimated E(app) in warm environments, and both under and overestimations were observed in cool environments, depending on the clothing vapor permeability. At 34 degrees C, apparent latent heat (lambda(app)) of pure evaporative cooling was lower than the physical value (lambda; 2,430 J/g) and reduced with increasing vapor resistance up to 45%. At lower temperatures, lambda(app) increases due to additional skin heat loss via evaporation of moisture that condenses inside the clothing, analogous to a heat pipe. For impermeable clothing, lambda(app) even exceeds lambda by four times that value at 10 degrees C. These findings demonstrate that the traditional way of calculating evaporative heat loss of a clothed person can lead to substantial errors, especially for clothing with low permeability, which can be positive or negative, depending on the climate and clothing type. The model presented explains human subject data on EVAP that previously seemed contradictive.

Gait muscle activity during walking on an inclined icy surface.

The objective of this study was to explain the contribution of lower extremity muscle activity to gait kinetic and kinematic adaptations for maintaining gait dynamic balance when walking on an inclined icy surface and the biomechanical mechanisms used to counteract slip risk. A two-way factorial experimental design was applied. The two independent variables were the walkway surface (ice and treadmill) and the walkway inclination (0 masculine, 6 masculine, 8 masculine). The dependent variable was the amplitude of the surface EMG of four right lower extremity muscles (tibialis anterior TA, gastrocnemius lateralis GL, rectus femoris RF, and biceps femoris BF). Twelve healthy subjects (7 males and 5 females) participated in the walking trials. A two-way ANOVA analysis showed that on the icy surface in the heel contact phase, EMG amplitudes significantly decreased in TA and RF compared to those for the treadmill surface. In the mid-stance phase, the GL muscle activity significantly decreased on ice compared to treadmill and all four muscle activities increased significantly with the inclination. During the toe off phase, GL and RF activities increased with the inclination. The mechanisms identified may be applied to develop intervention, rehabilitation and training techniques, and to improve performance in human locomotion, such as for winter sports.

Slips and falls in a cold climate: underfoot surface, footwear design and worker preferences for preventive measures.

Slips and falls and associated outdoor injuries are prevalent in cold climates. The objectives of this field investigation were to describe the consequences of slips and falls on ice and snow and the associated injuries, to assess the risks of various icy and snowy surfaces, to identify design needs of footwear, and to ascertain preventive measure preferences of outdoor workers. The organizations investigated were a newspaper delivery service, a military regiment, mining and construction industries. The results showed that fall events occur most frequently on ice covered with snow. This is due to the difficulty of perceiving hidden risks in order to adjust gait strategies. The professional footwear provided does not provide enough protection against slips and falls. Slip resistant properties are ranked as one of the top requirements by the users. Their most preferred preventive measures are footwear with anti-slip properties and the application of anti-slip materials, such as sand or salt.

Dry and wet heat transfer through clothing dependent on the clothing properties under cold conditions.

The purpose of this study was to investigate the effect of moisture on the heat transfer through clothing in relation to the water vapour resistance, type of underwear, location of the moisture and climate. This forms part of the work performed for work package 2 of the European Union THERMPROTECT project. Thermal manikin results of dry and wet heat loss are presented from different laboratories for a range of 2-layer clothing with similar dry insulations but different water vapour permeabilities and absorptive properties. The results obtained from the different manikins are generally consistent with each other. For each climate, total wet heat loss is predominately dependent on the permeability of the outer layer. At 10 degrees C, the apparent evaporative heat loss is markedly higher than expected from evaporation alone (measured at 34 degrees C), which is attributed to condensation within the clothing and to increased conductivity of the wet clothing layers.