Optimizing Emergent Surgical Cricothyrotomy for use in Austere Environments

Long-Term Outcomes of Cricothyroidotomy Versus Endotracheal Intubation in Military Personnel: A Retrospective Comparative Analysis Cohort Study

INTRODUCTION

Emergency airway management is critical in trauma care. Cricothyroidotomy (CRIC) is a salvage procedure commonly used in failed endotracheal intubation (ETI) or difficult airway cases. However, more data is needed regarding the short and long-term complications associated with CRIC. This study aimed to evaluate the Israel Defense Forces experience with CRIC over the past 2 decades and compare the short-term and long-term sequelae of prehospital CRIC and ETI.

METHODS

Data on patients undergoing either CRIC or ETI in the prehospital setting between 1997 and 2021 were extracted from the Israel Defense Forces trauma registry. Patient data was then cross-referenced with the Israel national trauma registry, documenting in-hospital care, and the Israel Ministry of Defense rehabilitation department registry, containing long-term disability files of military personnel.

RESULTS

Of the 122 patients with short-term follow-up through initial hospitalization, 81% underwent prehospital ETI, while 19% underwent CRIC. There was a higher prevalence of military-related and explosion injuries among the CRIC patients (96% versus 65%, P = 0.02). Patients who underwent CRIC more frequently exhibited oxygen saturations below 90% (52% versus 29%, P = 0.002). Injury Severity Score was comparable between groups.No significant difference was found in intensive care unit length of stay and need for tracheostomy. Regarding long-term complications, with a median follow-up time of 15 y, CRIC patients had more upper airway impairment, with most suffering from hoarseness alone. One patient in the CRIC group suffered from esophageal stricture.

CONCLUSIONS

This retrospective comparative analysis did not reveal significant short or long-term sequelae among military personnel who underwent prehospital CRIC. The long-term follow-up did not indicate severe aerodigestive impairments, thus suggesting that this technique is safe. Along with the high success rates attributed to this procedure, we recommend that CRIC remains in the armamentarium of trauma care providers. The findings of this study could provide valuable insights into managing difficult airway in trauma care and inform clinical decision-making in emergency settings.

Retention of En Route Cricothyroidotomy Skills in Novice Providers Following a Simulation-Based Mastery Learning Curriculum

INTRODUCTION

Surgical cricothyroidotomy (SC) is a vital skill that combat first responders must master as airway obstruction is the third most preventable cause of death on the battlefield. Degradation of skills over time is a known problem, and there is inadequate knowledge regarding the rate of SC skill retention. Our prior study showed that simulation-based mastery learning was effective in training 89 novices how to reliably perform an en route SC to mastery performance standards. This study aims to assess the durability of this skill by bringing participants back in 3 separate cohorts at 6, 12, or 24 months following the initial training to perform SC in the same test environment.

MATERIALS AND METHODS

This was a randomized prospective trial. Random cohorts of equal subjects who previously underwent SC simulation-based mastery learning training were selected to return at 6, 12, and 24 months to retest in the same en route medical evacuation (MEDEVAC) helicopter scenario. A total of 22, 14, and 10 subjects returned at 6, 12, and 24 months, respectively, due to Coronavirus-19 impacts and travel limitations. Participants in the 24-month cohort received a refresher training prior to retesting. All attempts were recorded and blindly graded using the same 10 item standardized SC checklist used in initial training. Our previous work found that mastery criteria for performing a SC were ≤40 seconds and completion of 9/10 items on the checklist. Outcome measures in this study were time to complete the procedure and percent of subjects who completed at least 9/10 items on the SC checklist.

RESULTS

There was an increase in time required to complete the procedure compared to initial training in all three retesting cohorts (initial: median 27.50, interquartile range 25.38-31.07 seconds; 6 months: median 36.33, interquartile range 31.59-55.22 seconds; 12 months: median 49.50, interquartile range 41.75-60.75 seconds; 24 months: median 38.79, interquartile range 30.20-53.08 seconds; P < .0001, P < .0001, P = .0039). There was a decline in median value checklist scores compared to initial training in the 6- and 12-month retesting cohorts (initial: median 10.00/10, interquartile range 9.50-10.00; 6 months: median 8.00/10, interquartile range 6.75-9.00; 12 months: median 8.00/10, interquartile range 6.75-9.25; P < .0001, P < .001). There was no difference in median checklist scores between the initial and 24-month retesting scenario (initial: median 10.00/10, interquartile range 9.50-10.00; 24 months: 10.00/10, interquartile range 9.00-10.00; P= .125). There was a decrease in retention of skills as only 31.82% of subjects at 6 months and 14.29% at 12 months met the defined passing criteria of time to completion of ≤40 seconds and checklist score of ≥9/10. A brief refresher course several months prior to the 24-month cohort retesting greatly increased the retention of SC procedural skills, with 60% of subjects meeting the time and checklist criteria.

CONCLUSIONS

This study showed that the skill required to perform a SC after initial mastery training does decay significantly. A brief refresher course can help increase retention of skills. Based on our findings SC skills should be refreshed at a minimum of every 6 months to assure optimal proficiency.

Development of a novel scoring tool to predict the need for early cricothyroidotomy in trauma patients

Background

The lack of a widely-used tool for predicting early cricothyroidotomy in trauma patients prompted us to develop the Cricothyroidotomy After Trauma (CAT) score. We aimed to predict the need for cricothyroidotomy within one hour of trauma patient arrival.

Methods

Derivation and validation datasets were obtained from the Trauma Quality Improvement Program (TQIP) database. Logistic modeling identified predictors, and weighted averages were used to create the CAT score. The score's performance was assessed using AUROC.

Results

Among 1,373,823 derivation patients, <1 % (n = 339) underwent cricothyroidotomy within one hour. The CAT score, comprising nine predictors, achieved an AUROC of 0.88. Severe neck injury and gunshot wound were the strongest predictors. Cricothyroidotomy rates increased from 0.4 % to 9.3 % at scores of 5 and 8, respectively. In the validation set, the CAT tool yielded an AUROC of 0.9.

Conclusion

The CAT score is a validated tool for predicting the need for early cricothyroidotomy in trauma patients. Further research is necessary to enhance its utility and assess its value in trauma care.

Prehospital Emergency Cricothyrotomy in Dogs Part 1: Experiences With Commercial Cricothyrotomy Kits

The surgical cricothyrotomy (CTT) has been recommended for emergency front of neck airway access (eFONA) during a cannot intubate, cannot oxygenate scenario for military working dogs (MWD) and civilian law enforcement working dogs (operational K9s). In prehospital and austere environments, combat medics and emergency medical service providers are expected to administer emergency medical care to working dogs and may only have emergency airway kits designed for humans at their disposal. The objective of this article is to provide a detailed description of the application of such devices in cadaver dogs and highlight potential alterations to manufacturer guidelines required for successful tube placement. The kits evaluated included the Portex® PCK, Melker universal cricothyrotomy kit and H&H® emergency cricothyrotomy kit. A novel technique for awake cricothyrotomy in the dog is also described, which can also be considered for in-hospital use, together with the open surgical method described for the H&H® kit. To the authors' knowledge, this is the first publication documenting and providing instruction on the application of commercial cricothyrotomy kits in dogs.

Impact of Succinct Training on Open Cricothyrotomy Performance: A Randomized, Prospective, Observational Study of U.S. Army First Responders

INTRODUCTION

Primary airway failure has become the second most common cause of potentially survivable battlefield fatality. Cricothyrotomy is taught to all U.S. military providers as a means of securing an airway in extremis. However, retrospective studies show that cricothyrotomy failure rates for U.S. military first responders performing the procedure in combat is 33%. Our hypothesis was that these rates could be improved.

MATERIALS AND METHODS

We conducted a randomized, prospective, observational study to evaluate the effects of inexpensive, succinct training on open cricothyrotomy performance by studying two unique U.S. Army First Responder participant groups. One participant group consisted of regular U.S. Army Medics (68 Ws). The second group was Special Operations Combat Medics. We evaluated both groups' baseline ability to correctly perform a cricothyrotomy and then randomly assigned individuals within each group to either a training or practice group.

RESULTS

The training group had a higher proportion of success and performed the cricothyrotomy faster than the practice group with 68 Ws group appearing to benefit most from training: their procedural success rates increased by an average of 23%, and their average time-to-correct-placement decreased by 21 seconds-a 33% improvement over baseline.

CONCLUSION

With one manikin, a qualified trainer, and $35 worth of expendable supplies, 10 medics could be trained in the procedure in just 2-3 hours. Our study suggests that this simple intervention has the potential to significantly improve U.S. Army First Responders' ability to correctly perform an open cricothyrotomy and drastically decrease the time needed to perform this lifesaving procedure correctly, possibly saving one in four potentially survivable combat casualties suffering from airway compromise.

Developing Cricothyroidotomy Skills Using a Biomaterial-Covered Model

INTRODUCTION

Cricothyroidotomy is an advanced and life-saving technique, but it is also a rare and a difficult procedure. The purpose of the present study was to produce a low-cost simulation model with realistic anatomic features to investigate its effectiveness in developing cricothyroidotomy skills.

METHODS

This study was performed at a university simulation center with 57 second-year student paramedics and a cricothyroidotomy simulation model. Total scores were assessed using a checklist. This consisted of 13 steps and was scored as misapplication/omission=0, correct performance and timing with hesitation=1, and correct performance and timing without hesitation=2. One of these steps, local anesthesia of the area if time is available, was not performed owing to time limitations. The highest possible score was 24. Data are presented as mean±SD with range, as appropriate. Normal distribution was evaluated using the Kolmogorov-Smirnov test, Student t test, and Mann-Whitney U test, and correlation analysis was used for statistical analysis.

RESULTS

Students completed the cricothyroidotomy procedure steps in 116±46 (55-238) s. At performance assessment, the score achieved was 12±5 (2-24). The highest total score of 24 was achieved by 3 students (5%). Total scores exhibited negative and significant correlation with procedure time (r=-0.403, P=0.002).

CONCLUSIONS

The model developed in this study is an inexpensive and effective method that can be used in cricothyroidotomy training for student paramedics. We think that repeating the cricothyroidotomy procedure on the model will increase success levels.

Comparison of surgical cricothyroidotomy training: a randomized controlled trial of a swine model versus an animated robotic manikin model

Background

Airway obstruction remains a preventable cause of death on the battlefield. Surgical cricothyroidotomy is an essential skill for immediate airway management in trauma. Training for surgical cricothyroidotomy has been undertaken using simulators, cadavers or animal models. The ideal approach to training for this low volume and high-risk procedure is unknown. We hypothesized that current simulation technology provides an equal or better education for surgical cricothyroidotomy when compared with animal tissue training.

Methods

We performed a prospective randomized controlled study comparing training for surgical cricothyroidotomy using hands-on training on swine versus inanimate manikin. We enrolled medical students who had never performed or had formal instruction on surgical cricothyroidotomy. We randomized their instruction to use either a swine model or the inanimate version of the Operative Experience Inc. advanced surgical manikin. Participants' skills were then evaluated on human cadavers and on an advanced robotic manikin. Tests were scored using checklists modified from Objective Structured Assessment of Technical Skills and Tactical Combat Casualty Care. We compared scores between the groups using Wilcoxon rank sum tests and generalized linear models.

Results

Forty-eight participants were enrolled and trained; 30 participants completed the first testing session; 25 completed the second testing session. The mean time to establish an airway from the incision until the cuff was blown up was 95±52 s. There were no significant differences in any of the outcome measures between the two training groups.

Discussion

Measured performance was not different between subjects trained to perform surgical cricothyroidotomy on an animal model or a high fidelity manikin. The use of an advanced simulator has the potential to replace live tissue for this procedure mitigating concerns over animal rights.

Levels of evidence

I.

Prehospital trauma experience of the Israel defense forces on the Syrian border 2013-2017

BACKGROUND

The Israeli Defense Force Medical Corps (IDF-MC) is routinely collecting prehospital data to establish a prehospital registry. Since February 2013, Israel has been providing medical care to Syrian refugees. This unique humanitarian aid begins in prehospital settings and typically culminates in Israeli civilian hospitals. This report describes the accumulated experience of the IDF-MC to provide Syrian refugees with prehospital treatment.

METHODS

Care provided by IDF-MC medical teams, including prehospital casualty care, is regularly documented and after-action reports are conducted. Records of casualties arriving at the Israeli-Syrian border from February 16, 2013, to December 31, 2017, were prospectively extracted from the IDF Trauma Registry. Patients who did not have a casualty card were excluded. The database included demographic information, injury signature and treatment given.

RESULTS

During the study period, 2,785 Syrian casualties were treated, of whom 2,339 were trauma victims. The most common mechanism of injury was penetrating (60.4%). Prehospital lifesaving interventions included 127 endotracheal intubations, 30 cricothyroidotomies, 55 chest decompressions, and 58 tourniquets for extremity hemorrhage control. Remote Damage Control Resuscitation included reconstituted freeze-dried plasma (n = 75) and tranexamic acid (n = 222 casualties) with no adverse effects.

CONCLUSION

The experience of the IDF-MC teams in caring for civilian casualties along a hostile international border is unique. In this capacity, the IDF-MC has demonstrated effectiveness in providing lifesaving and resuscitative interventions including tranexamic acid and freeze-dried plasma. In this experience, tourniquets have been effective in controlling hemorrhage when applied early and endotracheal intubation and cricothyroidotomy have provided effective airway options in select patients. Prehospital combat casualty care presents a significant challenge both in terms of providing adequate care and in terms of data collection and analysis. The experience described in this article is one example of effective, ongoing prehospital data gathering process. Efforts to provide medical relief to victims of the Syrian civil war continue to this day. While we hope for a better future, as long as these lessons continue to accumulate, it is our obligation to use them to support improvement of trauma care and hopefully save more lives.

LEVEL OF EVIDENCE

Therapeutic, level III.

An Experience of Improvised Laryngoscopy

Airway management in the wilderness runs the gamut from basic airway support to endotracheal intubation. Fortunately, direct laryngoscopy is a seldom called upon skill in expedition medicine. However, the medical skills required during a mission or expedition are never truly known in advance. Improvisation during evolving medical events is a mainstay of expedition medicine education and practice. It is unlikely, given constraints of weight and size of expedition medical kits, that a conventional laryngoscope would find its way into a standard "go bag." Faced with the real but rare event of needing to intubate a patient in an austere environment, how can improvisation be used? Multiple ideas for improvised laryngoscopes can be found in the wilderness medicine literature, but which, if any, of these devices have true clinical utility? To this end, participants of a recent Wilderness Medical Society preconference in medical elements of light search and rescue were given the opportunity to devise and construct their own improvised laryngoscopes and attempt intubation of a training mannequin. Participants with varying degrees of intubating experience improvised effective laryngoscopes from provided materials and successfully intubated an airway mannequin.

Localisation of the cricothyroid membrane by digital palpation in the emergency department

Introduction

A surgical approach to airway management may be essential in situations of difficult or failed airway, where immediate airway access is needed to provide oxygenation. However, the procedure is uncommonly performed and expertise among emergency clinicians may be limited.

Objectives

The aim of this study was to assess the accuracy of cricothyroid membrane (CTM) identification by junior and senior emergency trainees by identification of surface anatomy landmarks. A secondary aim was to determine patient variables associated with accurate identification of CTM.

Methods

A prospective observational study was conducted in a tertiary emergency department in the Kingdom of Saudi Arabia. Saudi Emergency Medicine board trainees participated in the study. Data were also obtained on gender and body habitus of patients. Junior trainees attempted to locate the membrane by palpation and marked it with an ultraviolet mark (blinded) pen followed by senior trainees. A certified ultrasound physician, also blinded to the trainee attempts, marked the membrane within a 5 mm circumference using a different coloured ultraviolet pen and was used as the reference gold standard.

Results

There were 80 patients enrolled with junior and senior doctors assessing location for emergency cricothyrotomy. Proportion of correct localisation was 30% (95% CI 20% to 41%) among junior trainees and 33% (95% CI 22% to 44%) among seniors (P=0.73). Level of training, sex, height and weight of patients were not associated with success.

Conclusions

Clinical localisation of CTM by emergency medicine trainees was poor even in non-stressful settings, and warrants further dedicated education and/or use of adjunct techniques.

Tactical Combat Casualty Care and Wilderness Medicine: Advancing Trauma Care in Austere Environments

Tactical Combat Casualty Care (TCCC) is a set of evidence-based, best-practice prehospital trauma care guidelines customized for use on the battlefield. Military units that have trained all of their unit members in TCCC have now documented the lowest incidence of preventable deaths in the history of modern warfare and TCCC is now the standard for battlefield trauma care in the US Military. TCCC and wilderness medicine share the goal of optimizing care for patients with trauma in austere environments that impose significant challenges in both equipment and evacuation capability. This article reviews the current battlefield trauma care recommendations in TCCC and discusses their applicability to the wilderness setting.

Emergency Surgical Airways Following Activation of a Difficult Airway Management Team in Hospitalized Critically Ill Patients: A Case Series

INTRODUCTION

An emergency surgical airway (ESA) is widely recommended for securing the airway in critically ill patients who cannot be intubated or ventilated. Little is known of the frequency, clinical circumstances, management methods, and outcomes of hospitalized critically ill patients in whom ESA is performed outside the emergency department or operating room environments.

METHODS

We retrospectively reviewed all adult patients undergoing ESA in our intensive care units (ICUs) and other hospital units from 2008 to 2012 following activation of our difficult airway management team (DAMT).

RESULTS

Of 207 DAMT activations for native airway events, 22 (10.6%) events culminated in an ESA, with 59% of these events occurring in ICUs with the remainder outside the ICU in the context of rapid response team activations. Of patients undergoing ESA, 77% were male, 63% were obese, and 41% had a history of a difficult airway (DA). Failed planned or unplanned extubations preceded 61% of all ESA events in the ICUs, while bleeding from the upper or lower respiratory tract led to ESA in 44% of events occurring outside the ICU. Emergency surgical airway was the primary method of airway control in 3 (14%) patients, with the remainder of ESAs performed following failed attempts to intubate. Complications occurred in 68% of all ESAs and included bleeding (50%), multiple cannulation attempts (36%), and cardiopulmonary arrest (27%). Overall hospital mortality for patients undergoing ESA was 59%, with 38% of deaths occurring at the time of the airway event.

CONCLUSION

An ESA is required in approximately 10% of DA events in critically ill patients and is associated with high morbidity and mortality. Efforts directed at early identification of patients with a difficult or challenging airway combined with a multidisciplinary team approach to management may reduce the overall frequency of ESA and associated complications.

Out-of-Hospital Surgical Airway Management: Does Scope of Practice Equal Actual Practice?

INTRODUCTION

Pennsylvania, among other states, includes surgical airway management, or cricothyrotomy, within the paramedic scope of practice. However, there is scant literature that evaluates paramedic perception of clinical competency in cricothyrotomy. The goal of this project is to assess clinical exposure, education and self-perceived competency of ground paramedics in cricothyrotomy.

METHODS

Eighty-six paramedics employed by four ground emergency medical services agencies completed a 22-question written survey that assessed surgical airway attempts, training, skills verification, and perceptions about procedural competency. Descriptive statistics were used to evaluate responses.

RESULTS

Only 20% (17/86, 95% CI [11-28%]) of paramedics had attempted cricothyrotomy, most (13/17 or 76%, 95% CI [53-90%]) of whom had greater than 10 years experience. Most subjects (63/86 or 73%, 95% CI [64-82%]) did not reply that they are well-trained to perform cricothyrotomy and less than half (34/86 or 40%, 95% CI [30-50%]) felt they could correctly perform cricothyrotomy on their first attempt. Among subjects with five or more years of experience, 39/70 (56%, 95% CI [44-68%]) reported 0-1 hours per year of practical cricothyrotomy training within the last five years. Half of the subjects who were able to recall (40/80, 50% 95% CI [39-61%]) reported having proficiency verification for cricothyrotomy within the past five years.

CONCLUSION

Paramedics surveyed indicated that cricothyrotomy is rarely performed, even among those with years of experience. Many paramedics felt that their training in this area is inadequate and did not feel confident to perform the procedure. Further study to determine whether to modify paramedic scope of practice and/or to develop improved educational and testing methods is warranted.

Augmentation of point of injury care: Reducing battlefield mortality-The IDF experience

STUDY OBJECTIVE

In 2012, the Israel Defense Forces Medical Corps (IDF-MC) set a goal of reducing mortality and eliminating preventable death on the battlefield. A force buildup plan entitled "My Brother's Keeper" was launched addressing: trauma medicine, training, change of Clinical Practice Guidelines (CPGs), injury prevention, data collection, global collaboration and more. The aim of this article is to examine how military medical care has evolved due "My Brother's Keeper" between Second Lebanon War (SLW, 2006) to Operation Protective Edge (OPE, 2014).

METHODS

Records of all casualties during OPE and SLW were extracted and analyzed from the I.D.F Trauma Registry. Noncombat injuries and civilian injuries from missile attacks were excluded from this analysis.

RESULTS

The plans main impacts were; incorporation of a physician or paramedic as an integral part of each fighting company, implementation of new CPGs, introduction of new approaches for extremity haemorrhage control and Remote Damage Control Resuscitation at point of injury (POI) using single donor reconstituted freeze dried plasma (25 casualties) and transexamic acid (98 casualties). During OPE, 704 soldiers sustained injuries compared with 833 casualties during SLW. Fatalities were 65 and 119, respectively, cumulating to Case Fatality Rate of 9.2% and 14.3%, respectively.

CONCLUSIONS

Significant changes in the way the IDF-MC provides combat casualty care have been made in recent years. It is the transformation from concept to doctrine and integration into a structured and Goal-Oriented Casualty Care System, especially POI care that led to the unprecedented survival rates in IDF as shown in this conflict.

Airway Management in Severe Combat Maxillofacial Trauma

OBJECTIVES

Airway stabilization is critical in combat maxillofacial injury as normal anatomical landmarks can be obscured. The study objective was to characterize the epidemiology of airway management in maxillofacial trauma.

STUDY DESIGN

Retrospective database analysis.

SETTING

Military treatment facilities in Iraq and Afghanistan and stateside tertiary care centers.

SUBJECTS

In total, 1345 military personnel with combat-related maxillofacial injuries sustained March 2004 to August 2010 were identified from the Expeditionary Medical Encounter Database using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes.

METHODS

Descriptive statistics, including basic demographics, injury severity, associated injuries, and airway interventions, were collected. A logistic regression was performed to determine factors associated with the need for tracheostomy.

RESULTS

A total of 239 severe maxillofacial injuries were identified. The most common mechanism of injury was improvised explosive devices (66%), followed by gunshot wounds (8%), mortars (5%), and landmines (4%). Of the subjects, 51.4% required intubation on their initial presentation. Of tracheostomies, 30.4% were performed on initial presentation. Of those who underwent bronchoscopy, 65.2% had airway inhalation injury. There was a significant relationship between the presence of head and neck burn and association with airway inhalation injury (P < .0001). There was also a significant relationship between the severity of facial injury and the need for intubation (P = .002), as well as the presence of maxillofacial fracture and the need for tracheostomy (P = .0001).

CONCLUSIONS

There is a high incidence of airway injury in combat maxillofacial trauma, which may be underestimated. Airway management in this population requires a high degree of suspicion and low threshold for airway stabilization.

Challenges and possibilities in forward resuscitation

The environmental and logistical constraints of the prehospital setting make it a challenging place for the treatment of trauma patients. This is perhaps more pronounced in the management of battlefield casualties before extraction to definitive care. In seeking solutions, interest has been renewed in implementing damage control resuscitation principles in the prehospital setting, a concept termed remote damage control resuscitation. These developments, while improving conflict survival rates, are not exclusive to the military environment, with similar situations existing in the civilian setting. By understanding the pathophysiology of shock, particularly the need for oxygen debt repayment, improvements in the assessment and management of trauma patients can be made. Technology gaps have previously hampered our ability to accurately monitor the prehospital trauma patient in real time. However, this is changing, with devices such as tissue hemoglobin oxygen saturation monitors and point-of-care lactate analysis currently being refined. Other monitoring modalities including newer signal analysis and artificial intelligence techniques are also in development. Advances in hemostatic resuscitation are being made as our understanding and ability to effectively monitor patients improve. The reevaluation of whole-blood use in the prehospital environment is yielding favorable results and challenging the negative dogma currently associated with its use. Management of trauma-related airway and respiratory compromise is evolving, with scope to improve on currently accepted practices. The purpose of this review is to highlight the challenges of treating patients in the prehospital setting and suggest potential solutions. In doing so, we hope to maintain the enthusiasm from people in the field and highlight areas for prehospital specific research and development, so that improved rates of casualty survival will continue.

Wilderness medicine

BACKGROUND

Human activity in wilderness areas has increased globally in recent decades, leading to increased risk of injury and illness. Wilderness medicine has developed in response to both need and interest.

METHODS

The field of wilderness medicine encompasses many areas of interest. Some focus on special circumstances (such as avalanches) while others have a broader scope (such as trauma care). Several core areas of key interest within wilderness medicine are discussed in this study.

RESULTS

Wilderness medicine is characterized by remote and improvised care of patients with routine or exotic illnesses or trauma, limited resources and manpower, and delayed evacuation to definitive care. Wilderness medicine is developing rapidly and draws from the breadth of medical and surgical subspecialties as well as the technical fields of mountaineering, climbing, and diving. Research, epidemiology, and evidence-based guidelines are evolving. A hallmark of this field is injury prevention and risk mitigation. The range of topics encompasses high-altitude cerebral edema, decompression sickness, snake envenomation, lightning injury, extremity trauma, and gastroenteritis. Several professional societies, academic fellowships, and training organizations offer education and resources for laypeople and health care professionals.

CONCLUSIONS

THE FUTURE OF WILDERNESS MEDICINE IS UNFOLDING ON MULTIPLE FRONTS: education, research, training, technology, communications, and environment. Although wilderness medicine research is technically difficult to perform, it is essential to deepening our understanding of the contribution of specific techniques in achieving improvements in clinical outcomes.