Background: Extremity tourniquets are established lifesaving interventions for severe traumatic hemorrhage, but much of the supporting evidence comes from systems in which evacuation and surgical care occur rapidly. Wilderness, rural, disaster, and contemporary battlefield environments may expose patients to substantially longer tourniquet times. This review examined duration-related outcomes of prolonged emergency tourniquet use and the implications for delayed evacuation. Methods: A rapid review was performed using PubMed/MEDLINE, Google Scholar, backward citation searching, and relevant wilderness and military guidance through Aug 6, 2026. Human trauma studies reporting tourniquet duration and clinical outcomes were eligible. Primary prolonged-use cohorts were included in an exploratory random-effects meta-analysis of amputation proportion. Prolonged use was defined as more than 120 minutes for the primary synthesis; a sensitivity analysis was restricted to cohorts with tourniquet duration greater than 4 hours. Results: Three primary prolonged-use cohorts provided extractable patient-level amputation data (105 patients). The pooled amputation proportion was 35.3% (95% CI, 26.8%-44.9%; I²=0%). Restriction to the two cohorts with tourniquet duration greater than 4 hours produced a similar estimate of 34.9% (95% CI, 25.8%-45.2%). Prolonged cohorts also reported substantial rates of nerve injury, infection, acute kidney injury, rhabdomyolysis, dialysis, and compartment syndrome. In contrast, military and civilian studies dominated by shorter application times reported low tourniquet-attributable morbidity and substantial hemorrhage-control benefit. Conclusions: Emergency tourniquets remain appropriate for life-threatening extremity hemorrhage, but the risk profile changes as evacuation time lengthens. The available evidence supports aggressive reassessment and, when trained personnel and appropriate conditions are present, timely conversion to another effective hemorrhage-control method before ischemic exposure becomes prolonged. Beyond approximately 6 hours, reperfusion and release become higher-risk decisions that should occur with advanced monitoring and resuscitative capability whenever possible. The certainty of evidence is low because prolonged-use studies are small, retrospective, and strongly confounded by injury severity.

Background: Pain management in wilderness and austere care must balance humane, effective analgesia against limited monitoring, environmental exposure, restricted drug inventories, and evacuation delays that may last hours. This review evaluates practical analgesic strategies for prolonged wilderness evacuation and quantitatively synthesizes directly comparable prehospital ketamine-versus-morphine trials. Methods: A focused systematic search of PubMed/MEDLINE-indexed literature and backward citation chaining was conducted through September 5, 2026. Human prehospital, wilderness, remote, austere, and prolonged-field-care studies evaluating acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, ketamine, or regional anesthesia were prioritized. Guidelines and systematic reviews were used to contextualize operational feasibility. A random-effects meta-analysis pooled studies reporting directly comparable changes in 0-10 pain intensity for ketamine versus morphine. Results: Direct evidence specific to prolonged civilian wilderness evacuation was sparse. Across the broader prehospital literature, acetaminophen and NSAIDs provided useful low-complexity analgesia for mild-to-moderate pain and as components of multimodal therapy. Opioids remained effective for severe pain but impose respiratory, hemodynamic, nausea, sedation, and monitoring burdens. Ketamine produced analgesia broadly comparable with morphine in contemporary randomized trials, with faster onset in some studies and a different adverse-effect profile characterized by more emergence phenomena but less opioid-associated nausea, hypotension, or respiratory compromise in some datasets. Two directly comparable trials (n=559) yielded a pooled mean difference in pain-score change of -0.27 points favoring ketamine (95% CI, -0.70 to 0.17; I2=13%), indicating no clinically important difference in analgesic efficacy. Regional techniques, particularly fascia iliaca compartment block for proximal femur injury, showed substantial opioid-sparing potential when performed by trained clinicians. Conclusions: No single agent is optimal for prolonged wilderness evacuation. The most defensible strategy is staged multimodal analgesia matched to pain severity, physiology, evacuation duration, provider skill, and monitoring capacity. Oral acetaminophen and/or an NSAID form a practical foundation when not contraindicated; severe pain may justify titrated ketamine or an opioid, while regional anesthesia can be valuable for selected injuries. The major evidence gap is not short-term analgesic efficacy but safety, redosing, monitoring, and functional outcomes during evacuations lasting many hours.

Introduction Cervical spine injuries in wilderness and austere environments present unique challenges due to the lack of commercial immobilization devices and prolonged evacuation times. Improvised cervical collars—made from items such as SAM® splints, rolled towels, or fleece garments—are frequently used in these settings, yet their biomechanical effectiveness and field practicality have not been systematically reviewed. This article synthesizes current evidence on the efficacy, safety, and feasibility of improvised cervical immobilization techniques used in remote environments. Method We conducted a systematic review in accordance with PRISMA guidelines, searching five databases (PubMed, Scopus, Web of Science, CINAHL, and Google Scholar) for studies published between January 2000 and March 2025. Inclusion criteria encompassed biomechanical or qualitative evaluations of improvised cervical immobilization methods in human volunteers or cadaveric models, with relevance to wilderness, prehospital, or austere settings. Eleven studies met inclusion criteria. Results Findings suggest that improvised collars particularly SAM splints and rolled fleece or towel collars can reduce cervical motion to levels comparable to standard rigid collars in most planes of movement. Spray-foam devices demonstrated even greater stability in cadaveric models. Soft improvised collars consistently outperformed foam commercial collars in both stability and comfort. Improvised methods also showed favorable usability in the field, though their application requires proper training. Conclusion Improvised cervical spine immobilization techniques can be biomechanically effective and operationally valuable in remote care contexts. When rigid collars are unavailable, well-applied improvised devices offer a viable alternative and should be included in wilderness medicine education. Further field-based research is warranted to evaluate real-world outcomes.

Introduction: Access to potable water remains a fundamental need in wilderness and disaster medicine. Improvised hydration techniques—such as solar stills, transpiration bags, and rain catchment—are widely taught but poorly compared. This review evaluates six low-resource water procurement methods for survival relevance. Methods: A structured narrative review was conducted across PubMed, Google Scholar, and grey-literature sources from January 1990 to March 2025. Included studies reported water yield, labor time, disinfection potential, or energy cost. A modified Newcastle–Ottawa Scale assessed study quality (max = 8). Comparative energy-return-on-hydration (EROH) was calculated using MET estimates. Results: Twenty-seven studies (17 field, 10 lab) from 10 countries were included (NOS median 5, IQR 4–6). Rain catchment yielded 5–10 L/event with minimal labor and no energy cost. Direct filtration produced >10 L/day when surface water was available. Boiling achieved complete pathogen removal but required fuel and time. Solar stills produced <0.6 L/day and demanded 375–500 kcal per build. Dew and transpiration methods yielded <1 L/day and required favorable humidity or sunlight. Solar stills were the least energy-efficient method. Table 1 summarizes comparative metrics; Figure 2 presents a decision-support algorithm. Conclusions: Solar stills, though historically emphasized in survival curricula, offer poor yield and an unfavorable energy profile. Modern tools like filters, catchment tarps, and chemical disinfection should be prioritized in both practice and training. Wilderness educators and responders should re-align survival instruction with evidence-based hydration strategies.