Prehospital management of accidental hypothermia: A nationwide survey among Italian helicopter emergency medical services

Background Accidental hypothermia, defined as a drop in core temperature below 35 degrees C, is a significant concern in prehospital care. Despite Italy's variable climate and demographic vulnerability, limited data exist on how Helicopter Emergency Medical Services (HEMS) manage hypothermic patients nationally. This study aimed to describe operational practices, equipment availability, specialized and critical care interventions for accidental hypothermia across Italian HEMS. Methods A nationwide observational survey was conducted between February 4 and March 7, 2025, targeting all 56 Italian HEMS bases. Operational characteristics, diagnostic and monitoring resources, passive and active warming equipment, specialized and critical care interventions, and training protocols were assessed. Data were analyzed descriptively, with comparisons to international guideline recommendations and evidence-based standards. Results Fifty-five (98.2%) bases responded. Operational models varied considerably, with 46% providing 24-hour service and 21% capable of night-time hoist operations. 70% reported availability of thermometers capable of detecting hypothermia, but among these, nearly one-third still relied on measurement methods not recommended by international guidelines. Passive insulation was universally available but frequently limited to basic reflective foil blankets, lacking comprehensive multilayer systems. Over half of services (54%) had no active external rewarming devices. Mechanical cardiopulmonary resuscitation (CPR) was widely accessible, coordination with Extracorporeal Membrane Oxygenation (ECMO)-capable centers was reported by nearly two-thirds of services, while portable blood gas analyzers remained rarely available. Hypothermia-specific training was absent in 27% of services, and seasonal equipment adaptations occurred in only 34%. Identified needs included enhanced warming devices, improved temperature monitoring, and standardized protocols. Conclusion Substantial variability and important gaps exist in hypothermia management across Italian HEMS, particularly in temperature monitoring accuracy, active rewarming capabilities, structured passive insulation strategies, and specialized training. These findings underline the urgent need for more standardized protocols, targeted equipment improvement, and simulation-based training to optimize prehospital hypothermia care in Italy.