Critical Care Anywhere: Principles for High-Functioning Management in Low-Resource Environments Principles for high-functioning management in low-resource environments

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Jason Stankiewicz Robert C. Ward Michael T. McCurdy


Critically ill patients can present at any time and location, and they demand high quality care. Historical experiences from military, wilderness, and disaster medicine settings have helped shape the modern concept of caring for the most severely ill with limited available resources. We introduce a method to help design a successful critical care medical support endeavor, which includes properly defining components of Navigation, Environment, Resupply, Energy, Unconventional problems, and Support (NEREUS). Additionally, we provide recommendations for optimal team personnel composition, including utilization of paramedics, critical care providers, nurses, and respiratory therapists across the spectrum of care provided at point of injury, en route to definitive care, and definitive care. A review of critical care principles relevant to the austere setting proceeds with a systematic organization according to airway, breathing, circulation, and neurologic management. Lastly, we employ our proposed method of organizing a critical care medical support endeavor to a post-hurricane scenario. In summary, this review provides the historical background, modern definition, and practical framework for successfully administering critical care in scenarios with limited available resources. We emphasize the need to appropriately adapt critical care concepts to meet the unique demands of a specific scenario.

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STANKIEWICZ, Jason; WARD, Robert C.; MCCURDY, Michael T.. Critical Care Anywhere: Principles for High-Functioning Management in Low-Resource Environments. Medical Research Archives, [S.l.], v. 9, n. 1, jan. 2021. ISSN 2375-1924. Available at: <>. Date accessed: 07 mar. 2021. doi:
Review Articles


1. Geiling J, Burkle FM, Ammundson D, et al. Resource-poor settings: infrastructure and capacity building: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014 Oct;146(4 Suppl):e156S-67S.
2. Rodway GW. The foundations of wilderness medicine: some historical features. Wilderness Environ Med. 2012 Jun;23(2):165-9.
3. Pearn J. Gunpowder, the Prince of Wales’s feathers and the origins of modern military surgery. ANZ J Surg. 2012 Apr;82(4):240-4.
4. Roberts MJ. The development of intensive care in the military environment. J Anesth Hist. 2016 Oct;2(4):133-41.
5. Bowlby A. The work of the “clearing hospitals” during the past six weeks. Br Med J. 1914 Dec;2(2816):1053-4.
6. Olson CM, Bailey J, Mabry R, Rush S, Morrison JJ, Kuncir EJ. Forward aeromedical evacuation: a brief history, lessons learned from the Global War on Terror, and the way forward for US policy. J Trauma Acute Care Surg. 2013 Aug;75(2 Suppl 2):S130-6.
7. Thompson P, Strandenes G. The history of fluid resuscitation for bleeding. In: Spinella PC, (eds). Damage control resuscitation. Switzerland: Springer Nature; 2020: 3-29.
8. Welch PG. Deployment dialysis in the US Army: history and future challenges. Mil Med. 2000 Oct;165(10):737-41.
9. Slutsky AS. History of mechanical ventilation. From Vesalius to ventilator-induced lung injury. Am J Respir Crit Care Med. 2015 May;191(10):1106-15.
10. Morris MJ. Acute respiratory distress syndrome in combat casualties: military medicine and advances in mechanical ventilation. Mil Med. 2006 Nov;171(11):1039-44.
11. Butler FK. Two decades of saving lives on the battlefield: Tactical Combat Casualty Care turns 20. Mil Med. 2017 Mar;182(3):e1563-8.
12. Beninati W, Meyer MT, Carter TE. The critical care air transport program. Crit Care Med. 2008 Jul;36(7 Suppl):S370-6.
13. Dara SI, Farmer JC. Preparedness lessons from modern disasters and wars. Crit Care Clin. 2009 Jan;25(1):47-65.
14. Geiling J, Burkle FM, West TE, et al. Resource-poor settings: response, recovery, and research: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014 Oct;146(4 Suppl):6e168S-77S.
15. Centers for Disease Control and Prevention (CDC). Post-earthquake injuries treated at a field hospital --- Haiti, 2010. MMWR Morb Mortal Wkly Rep. 2011 Jan;59(51):1673-7.
16. Losonczy LI, Barnes SL, Liu S, et al. Critical care capacity in Haiti: a nationwide cross-sectional survey. PLoS One. 2019 Jun;14(6):e0218141.
17. Diaz JV, Riviello ED, Papali A, Adhikari NKJ, Ferreira JC. Global critical care: moving forward in resource-limited settings. Ann Glob Health. 2019 Jan;85(1):1-11.
18. Ervin JN, Kahn JM, Cohen TR, Weingart LR. Teamwork in the intensive care unit. Am Psychol. 2018 May-Jun;73(4):468-77.
19. Smith KK. Critical care nursing in an austere environment. Crit Care Med. 2008 Jul;36(7 Suppl):S297-303.
20. NHTSA Office of EMS. National EMS scope of practice model 2019. [cited 2020 December 19]. Available from:
21. American Academy of Pediatrics; American College of Emergency Physicians; American College of Surgeons Committee on Trauma; Emergency Medical Services for Children; Emergency Nurses Association; National Association of EMS Physicians; National Association of State EMS Officials. Equipment for ground ambulances. Prehospital Emerg Care. 2014 Jan-Mar;18(1):92-7.
22. Schauer SG, Naylor JF, Uhaa N, April MD, De Lorenzo RA. An inventory of the combat medics’ aid bag. J Spec Oper Med. 2020 Spring;20(1):61-4.
23. Maddry JK, Ball EM, Cox DB, Flarity KM, Bebarta VS. En route resuscitation - utilization of CCATT to transport and stabilize critically injured and unstable casualties. Mil Med. 2019 May;184(5-6):e172-6.
24. Kashani KB, Farmer JC. The support of severe respiratory failure beyond the hospital and during transportation. Curr Opin Crit Care. 2006 Feb;12(1):43-9.
25. Keenan S, Riesberg JC. Prolonged field care: beyond the “golden hour.” Wilderness Environ Med. 2017 Jun;28(2S):S135-9.
26. Fink M, Vincent J, Abraham E, Moore F, Kochanek P, editors. Textbook of Critical Care. 7th Ed. Philadelphia, PA: Elsevier Inc.; 2017.
27. Irwin R, Lilly C, Mayo P, Rippe J, editors. Irwin & Rippe’s Intensive Care Medicine. 8th Ed. Philadelphia, PA: Wolters Kluwer; 2018.
28. Parrillo J, Dellinger R, editors. Critical Care Medicine: Principles of Diagnosis and Management in the Adult. 5th Ed. Philadelphia, PA: Elsevier Inc.; 2019.
29. Ferrada P, Callcut RA, Skarupa DJ, et al. Circulation first - the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial. World J Emerg Surg. 2018 Feb;13(1):4-9.
30. Iwami T, Kitamura T, Kawamura T, et al. Chest compression only cardiopulmonary resuscitation for out-of-hospital cardiac arrest with public-access defibrillation: a nationwide cohort study. Circulation. 2012 Dec;126(24):2844-51.
31. Brown CA, Cox K, Hurwitz S, Walls RM. 4,871 emergency airway encounters by air medical providers: a report of the Air Transport Emergency Airway Management (NEAR VI: “A-TEAM”) project. West J Emerg Med. 2014 Mar;15(2):188-93.
32. Mommers L, Keogh S. SPEEDBOMB: a simple and rapid checklist for prehospital rapid sequence induction. Emerg Med Australas. 2015 Apr;27(2):165-8.
33. Wallace MC, Britton T, Meek R, et al. Comparison of five video-assisted intubation devices by novice and expert laryngoscopists for use in the aeromedical evacuation environment. Mil Med Res. 2017 Jun;4(1):1-10.
34. Son M, Zimmer D, McCauley R, et al. Evaluation of Google Glass with camera adapter and GoPro as teaching tools for endotracheal intubation in the austere medical environment. Open J Anesthesiol. 2018 Aug;8(1):229-39.
35. Paix BR, Griggs WM. Emergency surgical cricothyroidotomy: 24 successful cases leading to a simple “scalpel-finger-tube” method. Emerg Med Australas. 2012 Feb;24(1):23-30.
36. McNiven ND, Pracy JP, McGrath BA, Robson AK. The role of scalpel-bougie cricothyroidotomy in managing emergency front of neck airway access. a review and technical update for ENT surgeons. Clin Otolaryngol. 2018 Jun;43(3):791-4.
37. Johnson CA, Goodwine DS, Passier I. Improvised cricothyrotomy on a mountain using hiking gear. Wilderness Environ Med. 2016 Dec;27(4):500-3.
38. Sahu AK, Bhoi S, Aggarwal P, et al. Endotracheal tube placement confirmation by ultrasonography: a systematic review and meta-analysis of more than 2500 patients. J Emerg Med. 2020 Aug;59(2):254-64.
39. Halpern P, Dang T, Epstein Y, Van Stijn-Bringas Dimitriades D, Koenig KL. Six hours of manual ventilation with a bag-valve-mask device is feasible and clinically consistent. Crit Care Med. 2019 Mar;47(3):e222-6.
40. L’Her E, Roy A, Marjanovic N. Bench-test comparison of 26 emergency and transport ventilators. Crit Care. 2014 Oct;18(5):1-14.
41. Marjanovic N, L’Her E. A comprehensive approach for the ergonomic evaluation of 13 emergency and transport ventilators. Respir Care. 2016 May;61(5):632-9.
42. Blakeman TC, Branson RD. Oxygen supplies in disaster management. Respir Care. 2013 Jan;58(1):173-83.
43. Blakeman TC, Rodriquez D, Britton TJ, et al. Evaluation of oxygen concentrators and chemical oxygen generators at altitude and temperature extremes. Mil Med. 2016 May;181(5 Suppl):160-8.
44. Schauf M. EMS Airway: what? we ran out of oxgygen? [cited 2020 Dec 19]. Available from:
45. Lutman D, Petros AJ. How many oxygen cylinders do you need to take on transport? a nomogram for cylinder size and duration. Emerg Med J. 2006 Sep;23(9):703-4.
46. Fludger S, Klein A. Portable ventilators. Contin Educ Anaesthesia, Crit Care Pain. 2008 Dec;8(6):199-203.
47. Canepa CA, Harris NS. Ultrasound in austere environments. High Alt Med Biol. 2019 Jun;20(2):103-11.
48. Lamsam L, Gharahbaghian L, Lobo V. Point-of-care ultrasonography for detecting the etiology of unexplained acute respiratory and chest complaints in the emergency department: a prospective analysis. Cureus. 2018 Aug;10(8):e3218.
49. Russell TC, Crawford PF. Ultrasound in the austere environment: a review of the history, indications, and specifications. Mil Med. 2013 Jan;178(1):21-8.
50. Butler FK, Holcomb JB, Shackelford S, et al. Management of suspected tension pneumothorax in Tactical Combat Casualty Care: TCCC guidelines change 17-02. 2018 Summer;18(2):19-35.
51. Hersey D, Witter T, Kovacs G. Transport of a prone position acute respiratory distress syndrome patient. Air Med J. 2018 May-Jun;37(3):206-10.
52. Dorlac GR, Fang R, Pruitt VM, et al. Air transport of patients with severe lung injury: development and utilization of the acute lung rescue team. J Trauma. 2009 Apr;66(4 Suppl):S164-71.
53. Fang R, Allan PF, Womble SG, et al. Closing the “care in the air” capability gap for severe lung injury: the Landstuhl acute lung rescue team and extracorporeal lung support. J Trauma. 2011 Jul;71(1 Suppl):S91-7.
54. Devlin JW, Skrobik Y, Gélinas C, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018 Sep;46(9):e825-73.
55. Freeman CL, Evans CS, Barrett TW. Managing sedation in the mechanically ventilated emergency department patient: a clinical review. J Am Coll Emerg Physicians Open. 2020 Apr;1(3):263-9.
56. Hossfeld B, Bein B, Boettiger BW, et al. Recommended practice for out-of-hospital emergency anaesthesia in adults: statement from the Out-of-Hospital Emergency Anaesthesia Working Group of the Emergency Medicine Research Group of the German Society of Anaesthesiology and Intensive Care. Eur J Anaesthesiol. 2016 Dec;33(12):881-97.
57. Prottengeier J, Moritz A, Heinrich S, Gall C, Schmidt J. Sedation assessment in a mobile intensive care unit: a prospective pilot-study on the relation of clinical sedation scales and the bispectral index. Crit Care. 2014 Nov;18(6):1-7.
58. Petitpas F, Guenezan J, Vendeuvre T, et al. Use of intra-osseous access in adults: a systematic review. Crit Care. 2016 Apr;20(1):1-9.
59. Brown NJD, Duttchen KM, Caveno JWJ. An Evaluation of Flow Rates of Normal Saline through Peripheral and Central Venous Catheters. Abstract presented at: the Anesthesiology 2008 Annual Meeting; October 21, 2008; Orlando, FL.
60. Tian DH, Smyth C, Keijzers G, et al. Safety of peripheral administration of vasopressor medications: a systematic review. Emerg Med Australas. 2020 Apr;32(2):220-7.
61. Fyntanidou B, Fortounis K, Amaniti K, et al. The use of central venous catheters during emergency prehospital care: a 2-year experience. Eur J Emerg Med. 2009 Aug;16(4):194-8.
62. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically ill. Emerg Med Clin North Am. 2010 Feb;28(1):29-56.
63. Drew B, Bennett BL, Littlejohn L. Application of current hemorrhage control techniques for backcountry care: part one, tourniquets and hemorrhage control adjuncts. Wilderness Environ Med. 2015 Jun;26(2):236-45.
64. Shackelford S, Hammesfahr R, Morissette D, et al. The use of pelvic binders in Tactical Combat Casualty Care: TCCC guidelines change 1602 7 November 2016. J Spec Oper Med. 2017 Spring;17(1):135-147.
65. Littlejohn L, Bennett BL, Drew B. Application of current hemorrhage control techniques for backcountry care: part two, hemostatic dressings and other adjuncts. Wilderness Environ Med. 2015 Jun;26(2):246-54.
66. Peng HT. Hemostatic agents for prehospital hemorrhage control: a narrative review. Mil Med Res. 2020 Mar;7(1):1-18.
67. Strandenes G, De Pasquale M, Cap AP, et al. Emergency whole-blood use in the field: a simplified protocol for collection and transfusion. Shock. 2014 May;41(Suppl 1):76-83.
68. Strandenes G, Hervig TA, Bjerkvig CK, et al. The lost art of whole blood transfusion in austere environments. Curr Sports Med Rep. 2015 Mar-Apr;14(2):129-34.
69. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: The PROPPR randomized clinical trial. JAMA. 2015 Feb;313(5):471-82.
70. McCurdy MT, Liew-Spilger A, Walsh M. Mortality and ratio of blood products used in patients with severe trauma. JAMA. 2015 May;313(20):2077-8.
71. Patino AM, Marsh RH, Nilles EJ, et al. Facing the shortage of IV fluids – a hospital-based oral rehydration strategy. N Engl J Med. 2018 Apr;1475-7.
72. Semler MW, Self WH, Wanderer JP, et al. Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018 Mar;378(9):829-39.
73. Squizzato A, Galli L, Gerdes VEA. Point-of-care ultrasound in the diagnosis of pulmonary embolism. Crit Ultrasound J. 2015 May;7(1):5-8.
74. Kuisma M, Silfvast T, Voipio V, Malmström R. Prehospital thrombolytic treatment of massive pulmonary embolism with reteplase during cardiopulmonary resuscitation. Resuscitation. 1998 Jul;38(1):47-50.
75. Nagdev A, Stone MB. Point-of-care ultrasound evaluation of pericardial effusions: does this patient have cardiac tamponade? Resuscitation. 2011 Jun;82(6):671-3.
76. Loughborough W. Emergency pericardiocentesis under dynamic ultrasound guidance in the resource limited setting. African J Emerg Med. 2014 Jan;4(3):127-9.
77. Ellis BC, Brown SGA. Management of anaphylaxis in an austere or operational environment. J Spec Oper Med. 2014 Winter;14(4):1-5.
78. Shaker MS, Wallace DV, Golden DBK, et al. Anaphylaxis - a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol. 2020 Apr;145(4):1082-123.
79. Kwizer A, Adhikari NKJ, Angus DC, et al. Recognition of sepsis in resource-limited settings. In: Dondorp AM, Dunser M, Schultz M (eds). Sepsis management in resource-limited settings. Switzerland: Springer; 2019;69-84.
80. Rudd KE, Seymour CW, Aluisio AR, et al. Association of the quick sequential (sepsis-related) organ failure assessment (qSOFA) score with excess hospital mortality in adults with suspected infection in low- and middle-income countries. JAMA 2018 Jun;319(21):2202-11.
81. Holden D, Ramich J, Timm E, Pauze D, Lesar T. Safety considerations and guideline-based safe use recommendations for “bolus-dose” vasopressors in the emergency department. Ann Emerg Med. 2018 Jan;71(1):83-92.
82. Vahdatpour C, Collins D, Goldberg S. Cardiogenic Shock. J Am Heart Assoc. 2019 Apr;8(8):1-12.
83. Muhlestein JB, Le V, Albert D, et al. Smartphone ECG for evaluation of STEMI: results of the ST LEUIS pilot study. J Electrocardiol. 2015 Mar-Apr;48(2):249-59.
84. O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013 Jan;127(4):e362-425.
85. Brown AJ, Ha FJ, Michail M, West EJ. Prehospital diagnosis and management of acute myocardial infarction. In: Watson TJ, Ong PJL, Tcheng JE (eds). Primary angioplasty: a practical guide. Singapore: Springer; 2018; 15-30.
86. Field JM, Hazinski MF, Sayre MR, et al. Part 1: executive summary: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010 Nov;122(18 Suppl 3):S640-56.
87. Parsons IT, Cox AT, Rees PSC. Military application of mechanical CPR devices: A pressing requirement? J R Army Med Corps. 2018 Nov;164(6):438-41.
88. Otten EJ, Dorlac WC. Managing traumatic brain injury: translating military guidelines to the wilderness. Wilderness Environ Med. 2017 Jun;28(2S):S117-23.
89. Ohle R, McIsaac SM, Woo MY, Perry JJ. Sonography of the optic nerve sheath diameter for detection of raised intracranial pressure compared to computed tomography: a systematic review and meta-analysis. J Ultrasound Med. 2015 Jul;34(7):1285-94.
90. Chalela JA, Britell PE. Tactical neurocritical care. Neurocrit Care. 2019 Apr;30(2):253-60.
91. Ehntholt MS, Parasram M, Mir SA, Lerario MP. Mobile stroke units: bringing treatment to the P\patient. Curr Treat Options Neurol. 2020 Feb;22(2):0-11.
92. Runchey S, McGee S. Does this patient have a hemorrhagic stroke? clinical findings distinguishing hemorrhagic stroke from ischemic stroke. JAMA. 2010 Jun;303(22):2280-6.
93. Nicks B, Henley J, Mfinanga J, Manthey D. Neurologic emergencies in resource-limited settings: a review of stroke care considerations. African J Emerg Med. 2015 Oct;5(1):37-44.
94. Hawkins SC, Williams J, Bennett BL, et al. Wilderness Medical Society clinical practice guidelines for spinal cord protection. Wilderness Environ Med. 2019 Dec;30(4S):S87-99.
95. Fehlings MG, Tetreault LA, Wilson JR, et al. A clinical practice guideline for the management of acute spinal cord injury: introduction, rationale, and scope. Glob Spine J. 2017 Sep;7(3 Suppl):84S-94.
96. Silverman EC, Sporer KA, Lemieux JM, et al. Prehospital care for the adult and pediatric seizure patient: current evidence-based recommendations. West J Emerg Med. 2017 Apr;18(3):419-36.
97. Glauser T, Shinnar S, Gloss D, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the guideline committee of the American Epilepsy Society. Epilepsy Curr. 2016 Jan-Feb;16(1):48-61.
98. Hew-Butler T, Loi V, Pani A, Rosner MH. Exercise-associated hyponatremia: 2017 update. Front Med (Lausanne). 2017 Mar;4:1-10.

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