Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update.

The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.

Battlefield Analgesia in Tactical Combat Casualty Care.

At the start of the Afghanistan conflict, battlefield analgesia for US military casualties was achieved primarily through the use of intramuscular (IM) morphine. This is a suboptimal choice, since IM morphine is slow-acting, leading to delays in effective pain relief and the risk of overdose and death when dosing is repeated in order to hasten the onset of analgesia. Advances in battlefield analgesia, pioneered initially by Tactical Combat Casualty Care (TCCC), and the Army's 75th Ranger Regiment, have now been incorporated into the Triple-Option Analgesia approach. This novel strategy has gained wide acceptance in the US military. It calls for battlefield analgesia to be achieved using 1 or more of 3 options depending on the casualty's status: 1) the meloxicam and acetaminophen in the combat wound medication pack (CWMP) for casualties with relatively minor pain that are still able to function effectively as combatants if their sensorium is not altered by analgesic medications; 2) oral transmucosal fentanyl citrate (OTFC) for casualties who have moderate to severe pain, but who are not in hemorrhagic shock or respiratory distress, and are not at significant risk for developing either condition; or 3) ketamine for casualties who have moderate to severe pain, but who are in hemorrhagic shock or respiratory distress or are at significant risk for developing either condition. Ketamine may also be used to increase analgesic effect for casualties who have previously been given opioid medication. The present paper outlines the evolution and evidence base for battlefield analgesia as currently recommended by TCCC. It is not intended to be a comprehensive review of all prehospital analgesic options.

Jet lag modification.

Athletes often are required to travel for sports participation, both for practice and competition. A number of those crossing multiple time zones will develop jet lag disorder with possible negative consequences on their performance. This review will discuss the etiology of jet lag disorder and the techniques that are available to shorten or minimize its effects. This includes both pharmacological and nonpharmacological approaches.

Pain control in austere settings.

Sporting events, particularly "extreme" sports, are becoming increasingly more austere and thus further from readily available fixed facility medical care. The provider caring for acute injuries in these more remote locations will be faced with the need to treat pain in the injured athlete. This review provides a stepwise approach to safe and effective pain control in the austere environment.

Wound care in the wilderness: is there evidence for honey?

Honey is one of the most ancient remedies for wound care. Current research has shown promising results for its use in wound care. This review is intended to inform readers of the physiological properties of honey and the evidence that exists to support its clinical use. When compared with evidence for current wound treatment, honey has proven to be a safe, effective, and sometimes superior treatment for various wounds. There are currently US Food and Drug Administration-approved medical-grade honey products available in the United States. Although there have been no clinical trials exploring the use of honey in wilderness environments, it may be a safe, improvisational wound treatment. More robust studies are needed for definitive conclusions of its efficacy and safety.

Wilderness Medical Society practice guidelines for basic wound management in the austere environment.

In an effort to produce best-practice guidelines for wound management in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for the management of wounds sustained in an austere (dangerous or compromised) environment. Recommendations are made about several parameters related to wound management. These recommendations are graded based on the quality of supporting evidence and the balance between the benefits and risks or burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians.

Wilderness Medical Society practice guidelines for basic wound management in the austere environment: 2014 update.

In an effort to produce best-practice guidelines for wound management in the austere environment, the Wilderness Medical Society convened an expert panel charged with the development of evidence-based guidelines for the management of wounds sustained in an austere (dangerous or compromised) environment. Recommendations are made about several parameters related to wound management. These recommendations are graded based on the quality of supporting evidence and the balance between the benefits and risks or burdens for each parameter according to the methodology stipulated by the American College of Chest Physicians. This is an updated version of the original guidelines published in Wilderness & Environmental Medicine 2014;25(3):295-310.

Wilderness Medical Society practice guidelines for the treatment of acute pain in remote environments.

The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians.

Wilderness Medical Society practice guidelines for the treatment of acute pain in remote environments: 2014 update.

The Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded on the basis of the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an updated version of the original WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments published in Wilderness & Environmental Medicine 2014;25(1):41-49.

A blinded, randomized, palatability study comparing variations of 2 popular field water disinfection tablets.

OBJECTIVE: Halogen-based water disinfection tablets may render an unpleasant taste to treated water. Proposed safe additives such as ascorbic acid may reduce this objectionable taste. We compared the palatability of 2 field water disinfectants: iodine-based tetraglycine hydroperiodide (TGHP) and chlorine-based chlorine dioxide (CD) both with and without the concomitant use of an ascorbic acid taste neutralizer. METHODS: Blinded participants randomly sampled 5 different distilled water samples containing combinations of disinfectant tablets and ascorbic acid: 1) water; 2) water with TGHP; 3) water with CD; 4) water with TGHP plus ascorbic acid; and 5) water with CD plus ascorbic acid. Participants rated beverage taste via a 100 mm visual analogue scale (VAS) and ranked the samples from "most pleasant" to "least pleasant." RESULTS: Sixty participants evaluated the samples. On the VAS, water with TGHP tasted worst and water with CD tasted second worst. Water with TGHP plus ascorbic acid, water alone, and water with CD plus ascorbic acid measured similarly as significantly best tasting. Water with TGHP was ranked by 58% as "least pleasant" tasting, while water with TGHP and ascorbic acid was ranked by 40% as "most pleasant" tasting. CONCLUSIONS: Participants found halogen-based disinfected water significantly less palatable prior to the addition of ascorbic acid. Addition of ascorbic acid to treated water created a beverage of similar preference to distilled water. These results may increase compliance with the use of disinfecting tablets by increasing the palatability of drinking water made potable via addition of ascorbic acid to halogen-based chemical disinfection.

10% Povidone-iodine may be a practical field water disinfectant.

OBJECTIVE: A paucity of data exists regarding the use of iodophores such as povidone-iodine (PVI) to disinfect water. We sought to determine a practical minimal disinfecting concentration of 10% PVI over different contact times and temperatures when added to water inoculated with E. coli. METHODS: 1:100, 1:1,000, and 1:10,000 dilutions of 10% PVI were created. Escherichia coli was exposed to these dilutions for 5, 15, and 30 minutes at 10, 20, and 30°C. Bactericidal activity was neutralized with 0.5% sodium thiosulfate. Mean viable colony forming units (CFUs) was determined after triplicate plating on Luria-bertani agar and 24 hours of incubation at 37°C. Effective bactericidal activity was defined as a 5-log reduction. RESULTS: Of the 200,000 E. coli plated, no CFUs were observed after exposure to the 1:100 dilution. After 5 minutes of contact time with the 1:1,000 dilution, at 10°C CFUs were too numerous to count (TNTC), at 20°C the mean CFU count was 92 (standard error ±11), and at 30°C the mean CFU count was 25 (standard error ±8). No CFUs were observed after 15 minutes of exposure to the 1:1,000 dilution across experimental temperatures. The 1:10,000 dilution always yielded CFU growth that was TNTC. CONCLUSIONS: The lowest disinfecting concentration of 10% PVI was the 1:1,000 dilution at 15 minutes of contact time. This supports the use of PVI for water disinfection against E. coli, the organism most commonly responsible for traveler's diarrhea. Further studies may assess its effectiveness against more virulent water borne pathogens.

Expeditionary Resuscitation Surgical Team: The US Army's Initiative to Provide Damage Control Resuscitation and Surgery to Forces in Austere Settings.

Improvements in surgical care on the battlefield have contributed to reduced morbidity and mortality in wounded Servicemembers. 1 Point-of-injury care and early surgical intervention, along with improved personal protective equipment, have produced the lowest casualty statistics in modern warfare, resulting in improved force strength, morale, and social acceptance of conflict. It is undeniable that point-of-care injury, followed by early resuscitation and damage control surgery, saves lives on the battlefield. The US Army's Expeditionary Resuscitation Surgical Team (ERST) is a highly mobile, interprofessional medical team that can perform damage control resuscitation and surgery in austere locations. Its configuration and capabilities vary; however, in general, a typical surgical element can perform one major surgery and one minor surgery without resupply. The critical care element can provide prolonged holding in garrison, but this diminishes in the austere setting with complex and acutely injured patients.

Pain management in the wilderness and operational setting.

The wilderness and operational setting places unique constraints on one's ability to treat pain. In this article we will discuss methods for treating pain both in the wilderness and operational setting. By operational we mean the austere deployed military setting, to include both noncombat and combat operations. The authors combined experience with wartime trauma pain management consists of experience in Operation "Just Cause" (Panama Invasion), Operation "Desert Storm" (Persian Gulf War), Operation "Uphold Democracy" (Haiti liberation), Operation "Enduring Freedom" (Afghanistan conflict), and Operation "Iraqi Freedom" (Iraq conflict).

Emergency department evaluation and management of foot and ankle pain.

Foot and ankle injuries are a frequent cause for a visit to the Emergency Department. A thorough evaluation and treatment of these injuries needs to be an area of in-depth familiarity for the Emergency Medicine physician. The key to proper evaluation is first a history and physical examination that focuses on determining what, if any, imaging is required. Subsequently, a focused history, physical examination, and imaging will then determine if an injury is stable or unstable, requiring operative intervention.

Event medicine: injury and illness during an expedition-length adventure race.

To describe the incidence and type of injury and illness occurring during an expedition-length adventure race and identify those resulting in withdrawal from the event, a prospective cohort study was conducted of the injuries and illness treated during the Subaru Primal Quest Expedition Adventure Race trade mark held in Colorado July 7-16, 2002. All racers, support crewmembers, and race staff were eligible to participate in the study. When a member of the study group received medical care due to an injury or illness, the encounter was recorded on a Medical Encounter Form. If an injury or illness resulted in withdrawal from the race, this was also recorded. Information from the Medical Encounter Forms was used to generate the Medical Log. There were 671 individuals eligible to participate in the study. A total of 243 medical encounters and 302 distinct injuries and illnesses were recorded. There were 179 (59%) injuries and 123 (41%) illnesses. Skin and soft tissue injuries and illness were the most frequent (48%), with blisters on the feet representing the single most common (32.8%). Second was respiratory illness (18.2%), including upper respiratory infection, bronchitis and reactive airway disease-asthma. Respiratory illness was the most common medical reason for withdrawal from the event. Injuries accounted for almost 60% of all injury and illness yet they contributed to less than 15% of the medical withdrawals from the race. Blisters accounted for almost one-third of all conditions treated. Providers of medical support for expedition-length adventure races should be prepared to treat a wide variety of injury and illness.

Ocular problems in military free fall parachutists.

Military free fall parachutists may be unaware of the risk of corneal freezing and desiccation keratitis should their goggles come off during free fall in subfreezing temperatures. We determine the incidence of ocular difficulties in military free fall parachutists and the role freezing temperatures may play in causing these problems. We found that 79% of those who responded to the survey had lost their goggles at least once during free fall and 69% experienced ocular symptoms after goggle loss. Analysis shows a 30-fold increase in the duration of symptoms in subfreezing vs. above-freezing temperatures, with the odds of the ground mission being affected at 7.3 per 100 jumps in the subfreezing group. The rate of goggles coming off per jump is 3.3 times less with >75 jumps. Contact lenses are not protective and photorefractive keratectomy was not detrimental.

Intubating laryngeal mask airway versus laryngoscopy and endotracheal intubation in the nuclear, biological, and chemical environment.

OBJECTIVE: Intubation is a difficult skill under normal circumstances and more so with a limited visual field such as wearing a protective mask in a chemical or biological incident. This study sought to determine whether successful intubation using the intubating laryngeal mask airway (ILMA) under protective mask conditions was equivalent to standard endotracheal intubation. METHODS: A pilot study was conducted using emergency medicine personnel. Participant's attempted intubation of a manikin while wearing a standard U.S. Army M-40 protective mask. Two attempts were performed with each method. RESULTS: One hundred percent of the ILMA placements were successful with only 78% success with endotracheal intubation (p = 0.1). Time to successful intubation and ventilation was significantly less for the ILMA versus endotracheal intubation (p = 0.005). CONCLUSION: This study suggests that under simulated chemical and biological conditions using an M-40 protective mask, intubation is accomplished faster and with more success with the ILMA.

Evaluation of NuStatr, a Novel Nonimpregnated Hemostatic Dressing, Compared With Combat Gauze in Severe Traumatic Porcine Hemorrhage Model.

BACKGROUND: Uncontrolled hemorrhage remains one of the most challenging problems facing emergency medical professionals and a leading cause of traumatic death in both battlefield and civilian environments. Survival is determined by the ability to rapidly control hemorrhage. Several commercially available topical adjunct agents have been shown to be effective in controlling hemorrhage, and one, Combat Gauze (CG), is used regularly on the battlefield and for civilian applications. However, recent literature reviews have concluded that no ideal topical agent exists for all injuries and scenarios. The authors compared a novel nonimpregnated dressing composed of cellulose and silica, NuStat (NS), to CG in a lethal hemorrhagic groin injury. These dressings were selected for their commercial availability and design intended for control of massive hemorrhage. METHODS: A complex penetrating femoral artery groin injury was made using a 5.5mm vascular punch followed by 45 seconds of uncontrolled hemorrhage in 15 swine. The hemostatic dressings were randomized using a random sequence generator and then assigned to the animals. Three minutes of manual pressure was applied with each agent after the free bleed. Hextend bolus (500 mL) was subsequently rapidly infused using a standard pressure bag along with the addition of maintenance fluids to maintain blood pressure. Hemodynamic parameters were recorded every 10 minutes and additionally at critical time points defined in the protocol. Primary end points included immediate hemostasis upon release of manual pressure (T0), hemostasis at 60 minutes, and rebleeding during the 60-minute observation period. RESULTS: NS was statistically superior to CG in a 5.5 mm traumatic hemorrhage model at T0 for immediate hemostasis (p=.0475), duration of application time (p=.0093), use of resuscitative fluids (p=.0042) and additional blood loss after application (p=.0385). NS and CG were statistically equivalent for hemostasis at 60 minutes, rebleeding during the study, and the additional secondary metrics, although the trend indicated that in a larger sample size, NS could prove statistical superiority in selected categories. CONCLUSIONS: In this porcine model of uncontrolled hemorrhage, NS improved immediate hemorrhage control, stability, and use of fluid in a 60-minute severe porcine hemorrhage model. In this study, NS demonstrated equivalence to CG at achieving long-term hemostasis and the prevention of rebleed after application. NS was shown to be an efficacious choice for hemorrhage control in combat and civilian emergency medical service environments.