# Stability of emergency medications during extreme cold: a controlled environmental study

## TL;DR

This study shows that emergency medications remain stable in extreme cold when stored properly, supporting their use in mountain rescue operations.

## Contribution

The study experimentally confirms the stability of eight emergency drugs under simulated extreme cold rescue conditions.

## Key findings

- All eight medications retained at least 90% of their labeled concentrations after repeated cold exposure.
- No physical changes were observed in drug ampoules during the experiment.
- Stable storage is feasible in insulated packaging during simulated alpine rescue scenarios.

## Abstract

Conditions of extreme cold, encountered during mountain and glacial rescue operations, pose challenges for the storage of emergency medications. Understanding how repeated exposure to extreme cold and ambient temperatures affects drug stability is essential for safe prehospital care.

A controlled environmental study was conducted at the terraXcube, a high-fidelity climate simulation facility at Eurac Research in Bolzano, Italy. The study drugs included Acetazolamide, Amiodarone, Dexamethasone, Epinephrine, Ketamine, Naloxone, Norepinephrine and Rocuronium. Drug ampoules were stored within an insulated storage bag, placed inside a regular mountain rescue backpack. This backpack was then used in a high-fidelity training scenario under conditions of extreme cold. The ampoules remained sealed throughout the experiment. The drugs underwent six cycles of exposure, consisting of 45 min at -15 °C followed by 15 min at + 18 °C, simulating temperature fluctuations during repeated alpine rescue operations. Stability was assessed through visual inspection for physical changes (e.g., crystallization, phase separation) and chemical analysis using mass spectrometry, with results expressed as a percentage of the reference concentration.

Visual inspections revealed no overt physical alterations. Mean ± standard deviation (SD) of remaining concentrations ranged from 92.1 ± 1.3% (acetazolamide) to 101.8 ± 7.1% (dexamethasone), with all eight medications retaining ≥ 90% of their labeled concentrations.

Emergency medications can remain chemically stable under extreme cold conditions when stored in sealed, insulated packaging. While our study simulated prehospital conditions without direct environmental exposure, these findings support the feasibility of extended storage and transport of emergency medications in challenging field settings. Further research should assess the impact of direct environmental exposure and evaluate additional stability parameters to optimize storage protocols in real-world scenarios.

Not applicable.

The online version contains supplementary material available at 10.1186/s13049-025-01509-w.