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

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.

Time to Reconsider Analgesia in Mass Casualty Incidents

The provision of analgesia in mass casualty incidents has traditionally been viewed as low-priority and reserved for later stages of care. Poor pain management is commonplace in trauma victims, and inadequate acute pain management can hinder evacuation efforts and may lead to the development of chronic pain and posttraumatic stress disorder. New, safe, and simple methods for administering quality analgesia have proven to be safe and effective in the prehospital setting and, as such, could easily be implemented into mass casualty incident protocols and allow for analgesia at earlier stages in such incidents, thereby improving patient care.

Lessons Learned on a High-Altitude Expedition to Mount Kilimanjaro

High-altitude expeditions expose teams to particular medical, environmental, and social challenges that can have unintended and severe consequences for crew members. In June 2017, the 9-d Equal Playing Field (EPF) expedition to Mount Kilimanjaro to set a world record for the highest-altitude soccer match ever played demonstrated the variety of challenges that may arise during these types of trips. This trip included a full-length soccer match at 5714 m (18,746 ft), leading to additional challenges for expedition members participating in the athletic event. The EPF medical team identified the challenges that occurred during the expedition and documented the methods used to resolve these challenges in real time. From the challenges faced during the expedition, we describe the lessons learned for future expeditions to Mount Kilimanjaro and other high-altitude environments. Challenges arose with medical tent visibility, medical disqualification, underreporting of medical events, and acute pain management, while anticipated challenges with interpersonal conflict did not occur. The rigorous preparation and anticipation by the EPF medical team prior to expedition departure may have helped mitigate this conflict as well as prevented unintended severe medical events from occurring.

Intranasal Fentanyl for On-the-Hill Analgesia by Ski Patrol

INTRODUCTION

Intranasal fentanyl offers a means for safe and effective pain management in austere environments. Prehospital analgesia traditionally involves intravenous or intramuscular medication. However, for wilderness rescuers, these methods are often impractical.

METHODS

We conducted a retrospective review of health records to evaluate the safety and efficacy of intranasal fentanyl administered by EMT-Basic certified ski patrollers. Our primary aim was to measure the reduction in initial pain scores to subsequent measurements at 5, 10, and 15 min using the pain numeric rating scale (0-10). Clinically significant reduction in severe pain has been established as ≥1.8 points. We used paired t-tests and multilevel modeling to measure statistical significance and potential interactions and reviewed patient charts for adverse events, including respiratory depression or the use of naloxone.

RESULTS

We compiled the results from the winter seasons for 2007 through 2012 and 2016 through 2020. A total of 247 patients were included. The initial pain score was 8.6±1.5 (mean±SD). The decrease in pain scores from 0 to 5, 10, and 15 min, respectively, was -1.8, -2.4, and -2.9 (P<0.0001), which demonstrated a clinically and statistically significant decrease in pain scores. There were no adverse events.

CONCLUSIONS

Traditional standard of care analgesics are invasive, elongate scene times, and increase the risk of environmental exposure and provider needlestick. Intranasal fentanyl offers a safe, noninvasive, and rapid analgesia that is well-suited for austere winter environments, such as those encountered at ski resorts. This study demonstrates the safety and efficacy of the administration of intranasal fentanyl by EMT-Basic certified providers.

The Use of Intravenous Lidocaine as an Analgesic Modality in the Austere Environment: Two Cases

Providing effective analgesia for trauma in austere settings is particularly difficult and often complicated by equipment and medication limitations and harsh environmental conditions. Common modalities that are employed in conventional clinical practices may not be available or pragmatic in austere environments. Furthermore, side effects such as sedation, altered mentation, or hypoxemia require additional resources and attention. We report 2 cases that demonstrate the use of intravenous lidocaine for the management of acute pain, secondary to trauma, in an austere environment. In the first, the administration of intravenous lidocaine reduced pain, secondary to a tibia fracture, thereby facilitating splinting. In the second, a patient, who had sustained rib fractures, was also treated with intravenous lidocaine. In this case, the analgesic effects of the medication resulted in reduction in pain and improvement in pulmonary function. Of note, the narrow therapeutic window of this modality was made evident as both patients transiently experienced tinnitus following the initial lidocaine bolus. This report describes 2 cases in which intravenous lidocaine was used to manage acute pain, in an austere environment, while avoiding many of the detrimental effects that accompany alternative analgesics.

Preliminary Evidence-Based Method of Medical Kit Design for Wilderness Expeditions Modeled by a High-Altitude Expedition to Mount Kilimanjaro

BACKGROUND

Wilderness expeditions require extensive planning and the correct medical supplies to ensure clinical care is possible in the event of illness or injury. There are gaps in the literature regarding evidence-based methods for medical kit design.

OBJECTIVES

This report describes a preliminary method for predicting medical events to determine medical supply requirements for a wilderness expedition. The performance of this method was evaluated using data from the 2017 Equal Playing Field (EPF) expedition to Mount Kilimanjaro.

METHODS

Eight reports documenting medical events during wilderness expeditions were reviewed. Incidence data were consolidated into a new dataset, and a subset of data from adventure race expeditions (ARS) was created. The cumulative incidence of medical events was then predicted for the 9-day EPF expedition. The medical supply list was determined based on indication. The effectiveness of the full dataset and ARS to predict the cumulative incidence of medical events by category during the EPF expedition was evaluated using regression analysis.

RESULTS

The ARS predicted a higher incidence rate of medical events than the full dataset did but underestimated the EPF expedition incidence rate. The full dataset was a weak predictor of the cumulative incidence of medical events by category during the EPF expedition, while the ARS was a strong predictor. The finalized medical kit overestimated all nonreusable supplies.

CONCLUSIONS

The medical kit created using this method managed all medical events in the field. This report demonstrates the potential utility of using a tailored, evidence-based approach to design a medical kit for wilderness expeditions.

Wilderness Medicine

With more families spending time outdoors or embarking on wilderness adventures, pediatricians may be tasked with providing appropriate counseling to parents and children. Although the breadth of wilderness medicine can be extensive, this article will focus on preventive measures, common injuries, and injury treatment options in an outdoor environment. [Pediatr Ann. 2021;50(6):e234-e239.].

Multiple trauma management in mountain environments - a scoping review : Evidence based guidelines of the International Commission for Mountain Emergency Medicine (ICAR MedCom). Intended for physicians and other advanced life support personnel

Background

Multiple trauma in mountain environments may be associated with increased morbidity and mortality compared to urban environments.

Objective

To provide evidence based guidance to assist rescuers in multiple trauma management in mountain environments.

Eligibility criteria

All articles published on or before September 30th 2019, in all languages, were included. Articles were searched with predefined search terms.

Sources of evidence

PubMed, Cochrane Database of Systematic Reviews and hand searching of relevant studies from the reference list of included articles.

Charting methods

Evidence was searched according to clinically relevant topics and PICO questions.

Results

Two-hundred forty-seven articles met the inclusion criteria. Recommendations were developed and graded according to the evidence-grading system of the American College of Chest Physicians. The manuscript was initially written and discussed by the coauthors. Then it was presented to ICAR MedCom in draft and again in final form for discussion and internal peer review. Finally, in a face-to-face discussion within ICAR MedCom consensus was reached on October 11th 2019, at the ICAR fall meeting in Zakopane, Poland.

Conclusions

Multiple trauma management in mountain environments can be demanding. Safety of the rescuers and the victim has priority. A crABCDE approach, with haemorrhage control first, is central, followed by basic first aid, splinting, immobilisation, analgesia, and insulation. Time for on-site medical treatment must be balanced against the need for rapid transfer to a trauma centre and should be as short as possible. Reduced on-scene times may be achieved with helicopter rescue. Advanced diagnostics (e.g. ultrasound) may be used and treatment continued during transport.

Prehospital Use of Ketamine in Mountain Rescue: A Survey of Emergency Physicians of a Single-Center Alpine Helicopter-Based Emergency Service

INTRODUCTION

Although ketamine use in emergency medicine is widespread, studies investigating prehospital use are scarce. Our goal was to assess the self-reported modalities of ketamine use, knowledge of contraindications, and occurrence of adverse events associated with its use by physicians through a prospective online survey.

METHODS

The survey was administered to physicians working for Air-Glaciers, a Swiss alpine helicopter-based emergency service, and was available between September 24 and November 23, 2018. We enrolled 39 participants (participation rate of 87%) in our study and collected data regarding their characteristics, methods of ketamine use, knowledge of contraindications, and encountered side effects linked to the administration of ketamine. We also included a clinical scenario to investigate an analgesic strategy.

RESULTS

Ketamine was considered safe and judged irreplaceable by most physicians. The main reason for ketamine use was acute analgesia during painful procedures, such as manipulation of femur fractures. The doses of ketamine administered with or without fentanyl ranged from 0.2 to 0.7 mg·kg^-1 intravenously. Most physicians reported using fentanyl and midazolam along with ketamine. The median dose of midazolam was 2 (interquartile range 1-2) mg for a 70-kg adult. Monitoring and oxygen administration were used infrequently. Hallucinations were the most common adverse events. Knowledge of ketamine contraindications was poor.

CONCLUSIONS

Ketamine use was reported by mountain rescue physicians to be safe and useful for acute analgesia. Most physicians use fentanyl and midazolam along with ketamine. Adverse neuropsychiatric events were rare. Knowledge regarding contraindications to the administration of ketamine should be improved.

Practicing Military Medicine in Truly Austere Environments: What to Expect, How to Prepare, When to Improvise

Introduction

The majority of the published literature on contemporary military medicine contradicts the concept of austere. Operational medicine is part of every armed conflict around the world, while armed forces of most countries internationally have limited medical resources especially in the front line. The aim of this review is to identify the particularities of a truly austere environment and present a short guide of preparation and action for military medical personnel internationally.

Materials and Methods

An exhaustive search of the existing English literature on operational and military medicine in austere environments was carried out in EMBASE and PubMed databases.

Results

This review included seminal and contemporary papers on the subject and synthesized a multiperspective short guide for operational medical personnel.

Discussion

Experience from forward surgical teams of the U.S. Army and humanitarian teams of physicians in war zones who work under precarious and austere circumstances has shown that the management of casualties requires different strategies than in higher levels of combat casualty care and in a civilian setting. A number of factors that must be controlled can be categorized into human, environmental, equipment-related, and socioeconomic. Surgeons and other medical personnel should have knowledge of these aspects beforehand and be adequately trained in peacetime. Physicians must master a number of essential skills and drugs, and be familiar with dosage regimens and side effects.

Conclusion

The military surgeon must be specially trained and prepared to use a wide range of skills in truly austere environments in contemporary conflicts.

Research Gaps in Wilderness Medicine

INTRODUCTION

Wilderness medicine involves the treatment of individuals in remote, austere environments. Given the high potential for injuries as well as the unique treatment modalities required in wilderness medicine, evidence-based clinical practice guidelines are necessary to provide optimal care. In this study, we identify evidence gaps from low-quality recommendations in wilderness medicine clinical practice guidelines and identify new/ongoing research addressing them.

METHODS

We included relevant clinical practice guidelines from the Wilderness Medical Society and obtained all 1C or 2C level recommendations. Patient/Problem/Population, intervention, comparison, outcome (PICO) questions were created to address each recommendation. Using 24 search strings, we extracted titles, clinical trial registry number, and recruitment status for 8899 articles. We categorized the articles by trial design to infer the effect they may have on future recommendations.

RESULTS

Twelve clinical practice guidelines met inclusion criteria. From these we located 275 low-quality recommendations and used them to create 275 PICO questions. Thirty-three articles were relevant to the PICO questions. Heat-related illness had the highest number of relevant articles (n=9), but acute pain and altitude sickness had the most randomized clinical trials (n=6).

CONCLUSION

Overall, few studies were being conducted to address research gaps in wilderness medicine. Heat-related illness had the most new or ongoing research, whereas no studies were being conducted to address gaps in eye injuries, basic wound management, or spine immobilization. Animals, cadavers, and mannequin research are useful in cases in which human evidence is difficult to obtain. Establishing research priorities is recommended for addressing research gaps identified by guideline panels.

Current Ketamine Practice: Results of the 2016 American Society of Pain Management Nursing Survey on Ketamine

BACKGROUND

Ketamine is increasingly utilized for a variety of pain management challenges. Audience comments from a ketamine presentation at the 2015 American Society of Pain Management Nursing (ASPMN) Conference reflected wide variation in ketamine practices as well as barriers to use.

AIM

The goal was to gain a greater understanding of ASPMN member practice patterns and barriers related to ketamine as adjunctive therapy for pain management.

DESIGN

A questionnaire survey design was used.

SETTINGS

Respondents represented 35 states and 2 countries.

PARTICIPANTS

The participants were 146 respondents from ASPMN membership (1,485 members).

METHODS

The survey was distributed by ASPMN on SurveyMonkey. Practice setting and ketamine administration practices were assessed with areas for comments. Results were reviewed using frequencies to describe responses and formatted into tables. Comments were individually reviewed and grouped into common themes.

RESULTS

Administration of ketamine as an analgesic was reported by 63% of respondents. Continuous intravenous ketamine infusions were the most common route of administration (65%); however, wide variability in dosing and length of therapy was reported. A wide variety of practices and challenges related to ketamine utilization were noted.

CONCLUSIONS

Numerous studies have indicated the analgesic benefits of ketamine in pain management. The lack of practice standardization has created challenges to its consistent use and outcome measurement. Additionally, the off-label use of ketamine for pain management creates its own unique challenges. However, given the current national climate with intense focus on pain management, interdisciplinary practitioners have an ideal opportunity to evaluate ketamine's use in a comprehensive approach to pain management.

A Survey of Wilderness Medicine Analgesia Practice Patterns

INTRODUCTION

In 2014, the Wilderness Medical Society (WMS) published guidelines for the treatment of acute pain in remote settings. We surveyed wilderness medicine providers on self-reported analgesia prescribing practices.

METHODS

We conducted a prospective, anonymous survey. Respondents were recruited from the WMS annual symposium in 2016. All willing attendees were included.

RESULTS

During the symposium, we collected a total of 124 surveys (68% response rate). Respondent age was 42±12 (24-79) years (mean±SD with range), 58% were male, and 69% reported physician-level training. All respondents had medical training of varying levels. Of the physicians reporting a specialty, emergency medicine (59%, n=51), family medicine (13%, n=11), and internal medicine (8%, n=7) were reported most frequently. Eighty-one (65%) respondents indicated they prefer a standardized pain assessment tool, with the 10-point numerical rating scale being the most common (54%, n=67). Most participants reported preferring oral acetaminophen (81%, n=101) or nonsteroidal anti-inflammatory drugs (NSAID) (91%, n=113). Of those preferring NSAID, most reported administering acetaminophen as an adjunct (82%, n=101). Ibuprofen was the most frequently cited NSAID (71%, n=88). Of respondents who preferred opioids, the most frequently preferred opioid was oxycodone (26%, n=32); a lower proportion of respondents reported preferring oral transmucosal fentanyl citrate (9%, n=11). Twenty-five (20%, n=25) respondents preferred ketamine.

CONCLUSIONS

Wilderness medicine practitioners prefer analgesic agents recommended by the WMS for the treatment of acute pain. Respondents most frequently preferred acetaminophen and NSAIDs.

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.

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.

Mountain medical kits: epidemiology-based recommendations and analysis of medical supplies carried by mountain climbers in Colorado

OBJECTIVE

: To provide medical kit recommendations for short mountain wilderness recreation trips (hiking, trekking, backpacking, mountaineering etc.) based on the epidemiology of injury and illness sustained and best treatment guidelines. Additionally, to compare these recommendations to the medical kit contents of mountain climbers in Colorado.

METHODS

: A primary literature review concerning the epidemiology of injury and illness in mountain wilderness settings was performed. This information and literature on the efficacy of given treatments were used to derive recommendations for an evidence-based medical kit. The contents of 158 medical kits and the most likely demographics to carry them were compiled from surveys obtained from mountain climbers on 11 of Colorado's 14 000-foot peaks.

RESULTS

: Musculoskeletal trauma, strains, sprains and skin wounds were the most common medical issues reported in the 11 studies, which met inclusion criteria. Adhesive bandages (Band-Aids) were the most common item and non-steroidal anti-inflammatory drugs were the most common medication carried in medical kits in Colorado. More than 100 distinct items were reported overall.

CONCLUSION

: Mountain climbing epidemiology and current clinical guidelines suggest that a basic mountain medical kit should include items for body substance isolation, materials for immobilization, pain medications, wound care supplies, and medications for gastrointestinal upset and flu-like illness. The medical kits of Colorado mountain climbers varied considerable and often lacked essential items such as medical gloves. This suggests a need for increased guidance. Similar methodology could be used to inform medical kits for other outdoor activities, mountain rescue personnel, and travel to areas with limited formal medical care.

A two-year retrospective review of the determinants of pre-hospital analgesia administration by alpine helicopter emergency medical physicians to patients with isolated limb injury

Up to 75% of pre-hospital trauma patients experience moderate to severe pain but this is often poorly recognised and treated with insufficient analgesia. Using multi-level logistic regression analysis, we aimed to identify the determinants of pre-hospital analgesia administration and choice of analgesic agent in a single helicopter-based emergency medical service, where available analgesic drugs were fentanyl and ketamine. Of the 1156 patients rescued for isolated limb injury, 657 (57%) received analgesia. Mean (SD) initial pain scores (as measured by a numeric rating scale) were 2.8 (1.8), 3.3 (1.6) and 7.4 (2.0) for patients who did not receive, declined, and received analgesia, respectively (p < 0.001). Fentanyl as a single agent, ketamine in combination with fentanyl and ketamine as a single agent were used in 533 (84%), 94 (14%) and 10 (2%) patients, respectively. A high initial on-scene pain score and a presumptive diagnosis of fracture were the main determinants of analgesia administration. Fentanyl was preferred for paediatric patients and ketamine was preferentially administered for severe pain by physicians who had more medical experience or had trained in anaesthesia.