Austere Field Protocols

Austere Field Protocols

Definition of Recommended Austere Field Protocols

Field Protocols

Field protocols are structured, practical guidelines that support timely, effective, and ethically sound medical decision-making in austere, remote, or resource-limited environments. Developed to reflect both evidence-based medicine and the operational realities of the field, these protocols are designed for use by trained responders operating with varying levels of clinical supervision. They prioritise patient safety, clinical clarity, and adaptability—offering stepwise interventions, clear inclusion/exclusion criteria, and guidance for documentation and escalation. While they do not replace clinical judgment, these protocols serve as critical cognitive aids to guide care when time, resources, and access to definitive support are limited.

These protocols have been developed to serve as a reference to organisations desirous of authorising appropriately trained and certified personnel to operate under an extended scope of practice.

These protocols are based on the standards and accreditation framework published by the Institute for Austere & Emergency Sciences (IAES).

The treatments outlined herein, in the Author’s opinion, represent reasonable and prudent interventions that a trained and certified practitioner should provide when confronted with these presentations, in the Austere Context.

For simplicity, we advocate the following definition of the Austere Context:

Any environment in which definitive medical care or access to requisite resources may be frustrated, resulting in an increased likelihood of negative health outcomes for the patient.

 It is recommended that organisations operating in environments that may be considered or may become an Austere Context: consider these protocols, enquire as to the legality of their adoption in their jurisdiction, modify them to meet the requirements of the organisation and the environment in which it operates, and have them endorsed by their medical director, or an appropriate, external medical advisor for use.

In most jurisdictions, in the presence of a duty of care, authorisation comes from the organisation through which the duty of care arises. Where a practitioner is operating under either a Good Samaritan law or principle, authorisation comes from the patient 

The remainder of this document is focused on the former.

The organisation may need a prescription or permits to obtain some of the medications listed in these protocols.

These protocols should not be adopted without the recommendation and endorsement of your organisation’s medical director, or a licensed medical professional acting in the capacity of medical advisor to your organisation or program.

These protocols are not intended as a direct layman’s guide to the performance of the skills contained herein, require training and certification, and should be practiced regularly.



Austere BLS

Protocol 1 and 2

Austere First Aid

Protocols 1 through 4

Austere Advanced First Aid

Protocols 1 through 5

Austere Emergency First Responder

Protocols 1 through 7

Austere Medic

Protocols 1 through 9

Requirements for Authorisation

It is further recommended that the following conditions are placed on authorised use of organizational protocols:

ID

Requirement

1

The practitioner is employed or under written contract with the organisation

2

The practitioner is on duty with the organisation at the time of the provision of care

3

The practitioner is duly trained and certified in the skills contemplated by the protocol

4

Said training and certification has been verified by the organisation and copies of such proof are held on file

5

The practitioner, in applying the protocol, believes that the application thereof is in the best medical interest of the patient and is likely to either:

a.     reduce risk to the patient and/or rescuers during evacuation; or

b.    alleviate pain and/or suffering for the patient under care; or

c.     increase the likelihood of a positive health outcome for the patient.

Outline:
IAES advocates Basic Life Support in accordance with the latest recommendations as issued by the International Liaison Committee on Resuscitation, at the time of teaching. The finer details may be modified depending upon the country in which a specific course is taught, to be compliant with local and/or regional guidelines including but not limited to those issued by AHA, ERC, ARC, RCA, or specific national bodies such as ministries or departments of health.

Indications:
Absence of a central pulse.

Contraindications:
None

Pharmacology:
None

Equipment:
None 

Protocol:

  1. Evacuation should not be delayed to perform CPR on a patient with a core body temperature below 32° degrees C (90° F).
  2. In addition to the accepted reasons not to commence CPR in an Urban Context, CPR should NOT be commenced in an Austere context where the patient has been submerged or otherwise without a source of oxygen for greater than 60 minutes.
  3. In addition to the accepted reasons to terminate resuscitation efforts in an Urban Context, it is reasonable to terminate CPR in an Austere context where ROSC has not been achieved on a normothermic patient after 30 minutes of uninterrupted, high-quality CPR.



Outline:
Anaphylaxis is a life-threatening, pathological response to an antigen. Early diagnosis and administration of epinephrine is critical.

Indications:
Possible exposure to an antigen with at least two (2) of:

  1. S/Sx of distributive shock; and/or
  2. S/Sx of respiratory distress (often with stridor and/or wheezing); and/or
  3. Nausea, vomiting, diarrhoea; and/or
  4. Truncal urticaria, itching, hives or swelling of the face, throat, or tongue.

Contraindications:
None

Pharmacology

  • Epinephrine
  • Antihistamine
  • Prednisone

Equipment

  • 1ml syringe with 26G needle
  • Sharps disposal container

 Protocol

  1. Inject Epinephrine (IM) 0.01 mg/kg to a maximum initial dose of 0.5mg into the lateral aspect of the mid-thigh (auto-injector), or lateral aspect of the deltoid (syringe). Repeat Q5M PRN.
  2. Provide the generic treatment for respiratory issues: SCAN – providing PPV if indicated.
  3. If the patient collapses and no pulse is detected, commence CPR.
  4. Administer Antihistamine (PO), per the recommended dosage of the selected antihistamine.
  5. Evacuate with additional epinephrine on hand, monitoring for a biphasic reaction.
  6. If evacuation will be delayed or is expected to be of extended duration, consider Prednisone (PO) 1mg/kg/day.

Various auto-injectors are available on the market. An auto-injector dispensing 0.1mg or 0.15mg is suitable for a patient weighing up to 25kg, and an auto-injector dispensing 0.3mg or 0.5mg is suitable for a patient weighing more than 25kg.



Outline:
The contextual consequence of a seemingly minor infection has the potential to be devastating in the Austere Context. As ever, the top priority is given to the control of bleeding, followed by efforts to prevent infection, including prophylactic ABX where available and authorised. 

Indications:
Wounds, including penetrating objects.

Contraindications:
None

Pharmacology

  • Fucidin
  • Cephalexin

Equipment

  • 50ml luer-lock syringe with 18G cannula, teat cannula or similar
  • Sharps disposal container

Protocol

Shallow Wounds

  1. Clean the wound with water clean enough to drink, or 1% povidone iodine solution.
  2. Apply an antibiotic ointment such as Fucidin.
  3. Cover with a clean, (preferably sterile) dressing.
  4. Inspect the wound and change the dressing Q24H.

Open Wounds

  1. Examine and clean the wound removing foreign material as completely as possible.
  2. Wash the surrounding area with soap and water, or another appropriate disinfectant.
  3. Irrigate the wound with water clean enough to drink, or in the absence thereof, 1% povidone iodine solution.
  4. Repeat steps 1, 2, or 3 as required to ensure the wound is as clean as possible.
  5. Cover with a sterile dressing, allowing for drainage.
  6. Clean the wound and change the dressing Q24H.
  7. Consider prophylactic ABX PO if available and authorised (cephalexin or similar).
  8. If a local infection develops (think SHARP), irrigate the wound thoroughly, allow for drainage and apply warm compress. Administer ABX PO if available and authorised and move the patient towards appropriate medical care.
  9. If a systemic infection develops, evacuate urgently.
  10. Ensure the patient has had tetanus prophylaxis within the last 10 years, failing which the patient will require a tetanus shot within the next 24-48 hours.

     

High Risk Wounds

In addition to the protocol for open wounds, in the presence of a high risk wound:

  1. Use the 50ml syringe with cannula to irrigate the wound under pressure, with copious amounts of water clean enough to drink.
  2. If the wound cannot be adequately cleansed for any reason, rinse the wound with 1% povidone iodine solution.
  3. Do not irrigate a deep puncture wound under pressure where the fluid may not be able to drain away. 
  4. Do not close the wound.
  5. Ensure the patient has had tetanus prophylaxis within the last 5 years, failing which the patient will require a tetanus shot within the next 24-48 hours.
  6. In the case of wounds caused by animals, assess for rabies exposure – the chances of which vary by geography. Seek advice from a competent, local authority and move the patient towards prophylaxis as soon as possible if advised. This does not have to be done urgently, but should be accomplished within the next few days.

     

Impaled Objects

In addition to the protocol for open and high risk wounds, in the presence of an impaled object:

  1. Urban first aid teaches that impaled objects should be stabilised in place and never removed. In the Austere Context, we remove impaled objects for two reasons:
    1. To allow cleaning of the wound in order to prevent the development of infection; and
    2. To reduce the complexity of and facilitate safe evacuation.
  2. Removing impaled objects is not without significant risk, however in the Austere Context, the procedure will increase the likelihood of a positive health outcome for the patient.
  3. Impaled objects should be remove in the Austere Context unless:
    1. the object is impaled in the globe of the eye; OR
    2. removal of said object would result in significant tissue damage; OR
    3. removal of said object would result in intractable pain; OR
    4. removal of said object would result in uncontrollable bleeding.
  4. When removing an impaled object, be prepared to manage a significant bleed.
  5. Bleeding control takes precedence over all other forms of care.

Outline:
All living tissue must be continuously perfused with oxygenated blood to function and survive.  Anything that interferes with oxygenation and perfusion is a serious threat to life or limb.

Indications

  • Mid-shaft femur fractures
  • Angulated fractures complicating splinting or evacuation
  • Fractures with compromised distal CSM

Contraindications

  • Neck of  femur fractures
  • Pelvic compromise
  • Traumatic amputation or avulsion

Pharmacology

  • Appropriate Analgesia

 Equipment

  • Traction spins for mid-shaft femur fraction

Protocol

Long Bone Injuries

  1. Consider analgesia.
  2. Provide gentle traction into normal anatomical position, realigning the bone ends.
  3. If significant resistance or intractable pain develops, discontinue efforts; splint, immobilise and evacuate urgently.
  4. If distal CSM has been restored, splint and evacuate.
  5. Assess for distal CSM.
  6. If distal CSM has not been restored, repeat from step 1.

Joint Injuries

  1. Consider analgesia.
  2. Gently manipulate the joint towards normal anatomical position.
  3. If significant resistance or intractable pain develops, discontinue efforts; splint, immobilise and evacuate urgently.
  4. If distal CSM has been restored, splint and evacuate.
  5. Assess for distal CSM.
  6. If distal CSM has not been restored, repeat from step 1.

 

Outline:
Spinal injuries in the field are rare but serious. Evidence now supports a shift from rigid immobilisation to Spinal Motion Restriction (SMR) using patient cooperation, comfort positioning, and minimal handling. This protocol prioritises safe assessment and selective application of SMR only when clearly indicated.

Indications for Spinal Motion Restriction (SMR):
SMR should be applied if any of the following are true:

  • Altered mental status (GCS <15 or ACVPU ≠ A&O × 4)

  • New neurological symptoms (e.g., numbness, tingling, weakness, paralysis)

  • Midline spinal pain or tenderness on palpation

  • Evidence of intoxication (alcohol, drugs)

  • Distracting injury (e.g., long bone fracture, major bleeding)

  • High-risk mechanism of injury (e.g., fall from height, axial load, rollover crash, diving injury)

  • Inability to safely and reliably assess the spine due to pain, communication barriers, or other factors

Exclusion Criteria / Clearance for No SMR:
If the patient meets all of the following criteria, SMR is not required:

  • Alert and oriented (GCS 15, A&O × 4)

  • No spinal pain or tenderness

  • No neurological deficits

  • No intoxication

  • No distracting injury

  • Low-risk mechanism

  • Can actively rotate neck 45° left and right without pain

Procedure:

  1. Scene and Mechanism Assessment

    • Assess risk based on mechanism (e.g., fall, impact, rapid deceleration)

  2. Initial Neurological Exam

    • Check ACVPU or GCS

    • Assess motor strength and sensation in all limbs

    • Look for incontinence or priapism

  3. Spinal Exam

    • Palpate the full spine for midline tenderness or deformity

    • Ask about spinal pain

  4. Spinal Clearance

    • Use NEXUS or Canadian C-Spine Rule where trained

    • If all low-risk criteria are met, perform controlled active neck rotation

    • If painless and full range of motion, SMR is not required

  5. If SMR Is Indicated

    • Do not use rigid cervical collars or spine boards 

    • Instruct patient to self-restrict movement (verbal coaching)

    • Maintain in a position of comfort (often supine or semi-reclined)

    • Use padded SKED or litter only if necessary for transport

    • Avoid unnecessary logrolls or forced positioning

    • Reassess neurological status regularly

Evacuation Guidelines
Evacuate promptly if:

  • Neurological symptoms are present or develop

  • Severe spinal pain/tenderness persists

  • SMR cannot be maintained due to pain, terrain, or patient distress

  • Clearance cannot be completed safely

Documentation Requirements:

  • Mechanism of injury

  • Spinal and neurological exam findings

  • Whether NEXUS or Canadian C-Spine Rule was used

  • Whether SMR was applied or not, and rationale

  • Patient position during care and transport

  • Any changes in symptoms or condition

Outline: It is common for joint dislocations to be accompanied by compromised distal CSM and significant pain. The reduction of simple joint dislocations in the field is not only humane, but can lead to improved long-term health outcomes for the patient. For the purposes of this protocol, simple joint dislocations are defined as dislocations of the shoulder, patella or digits due to an indirect mechanism of injury. Any other dislocation should be treated as a dysfunctional MSK injury, splinted in a position that does not compromise distal CSM and transported to definitive medical care.

Indications

  • Anterior dislocation of the shoulder, caused by an indirect mechanism of injury
  • Lateral dislocation of the patella, caused by an indirect mechanism of injury
  • Dislocation of digits, caused by an indirect mechanism of injury

Contraindications

  • Uncooperative patient
  • Direct mechanism of injury
  • Dislocation of any other joint

Pharmacology

  • Appropriate analgesia

Equipment

  • A weight of approximately 3-5kg (hanging traction method)
  • A bed sheet, hammock, sleeping bag or tarpaulin (traction/counter traction method)

Protocol

Shoulder

There are numerous recognised techniques to achieve reduction of an anteriorly dislocated shoulder. Varying techniques may be used in sequence to achieve the desired reduction. It is advisable to be familiar with the application of multiple techniques.

  1. Assess and document neurovascular status before attempting reduction
  2. Attempt reduction
  3. If pain increases significantly or physical resistance is encountered, discontinue reduction attempts and manage as a dysfunctional MSK injury.
  4. Assess and document neurovascular status at the completion of attempt
  5. If the reduction was unsuccessful, consider an alternative technique

Common techniques include: Cunningham, Stimson Hanging Traction, Baseball Position, Scapular Manipulation, FaReS, External Rotation, Milch, Traction/Counter traction. The details of these techniques are beyond the scope of this protocol. If the patient cannot adduct the arm against their chest, consider Stimson Hanging Traction or Cunningham as a first option.

Patella

  1. Assess and document neurovascular status before attempting reduction
  2. Slowly and gently straighten the knee and flex the patient’s hip.
  3. If the patella does not spontaneously reduce, apply gentle, medial pressure to the displaced patella, guiding it back into normal anatomic position.
  4. If pain increases significantly or physical resistance is encountered, discontinue reduction attempts and manage as a dysfunctional MSK injury.
  5. Stabilise the patella with tape or an appropriate elastic bandage.
  6. Assess and document neurovascular status at the completion of attempt
  7. Evacuate towards medical care at convenience. 
  8. Patients may walk if the pain is not intractable.

Digits

  1. Assess and document neurovascular status before attempting reduction
  2. Apply axial traction distal to the dislocation and counter-traction proximal to the dislocation.
  3. If pain increases significantly or physical resistance is encountered, discontinue reduction attempts and manage as a dysfunctional MSK injury.
  4. Splint in normal anatomical position.
  5. Assess and document neurovascular status at the completion of attempt
  6. Evacuate towards medical care at convenience.

Outline:
Severe asthma is a potentially life-threatening exacerbation of a chronic obstructive pulmonary condition marked by bronchospasm, airway inflammation, and increased mucus production. In the austere setting, rapid escalation, early administration of medications, and proactive airway management are essential to prevent respiratory failure or arrest.

Indications:

  • Acute asthma exacerbation unresponsive to initial salbutamol (MDI) treatment

  • Signs of respiratory failure or a silent chest

  • Marked use of accessory muscles, altered mental status, cyanosis, or hypoxia

  • Inadequate response to initial bronchodilator therapy within 5 minutes

Contraindications:
None specific to protocol interventions in life-threatening asthma; exercise clinical judgment if multiple comorbidities or allergy to medications exist.

Pharmacology:

  • Salbutamol (NEB): Beta-2 agonist bronchodilator

  • Ipratropium Bromide (NEB): Anticholinergic bronchodilator

  • Epinephrine (IM): Alpha and beta agonist for refractory bronchospasm

  • Prednisone (PO) / Hydrocortisone (IM): Corticosteroids to reduce inflammation

Equipment:

  • Oxygen delivery system with nebuliser setup

  • IM injection supplies (1–3 mL syringe, 26G needle)

  • Airway and PPV support equipment

Protocol A (Moderate to Severe Asthma Refractory to MDI):

  1. Nebulised Therapy (if available):

    • Adults and children ≥6 years: 5 mg Salbutamol + 500 mcg Ipratropium via nebuliser

    • Children <6 years: 5 mg Salbutamol + 250 mcg Ipratropium

    • Repeat every 20 minutes as needed

  2. IM Epinephrine

    • If no nebuliser available or patient is deteriorating:

      • Administer 0.01 mg/kg of 1:1,000 epinephrine IM

      • Max dose 0.5 mg

      • Site: lateral thigh (preferred) or deltoid

      • Repeat every 5 minutes as needed

  3. Steroids (Single Dose)

    • Prednisone PO: 60 mg for adults, 1 mg/kg for children; or

    • Hydrocortisone IM: 200 mg for adults, 4 mg/kg up to 100 mg for children

  4. Supportive Care

    • Provide oxygen as available

    • Initiate PPV if respiratory fatigue is evident

    • Monitor and document response to treatment

  5. Evacuate to definitive care urgently

    • If evacuation is delayed, continue treatments as above and reassess frequently

Protocol B (Respiratory Failure or Silent Chest):

  1. Immediate IM Epinephrine

    • Administer as per above, regardless of nebuliser availability

  2. Nebulised Therapy

    • Administer concurrently or after epinephrine if possible

  3. Corticosteroid Administration

    • As per dosage above

  4. Advanced Airway Considerations

    • Initiate PPV if apnoeic or in respiratory arrest

    • Prepare for resuscitation if no improvement

  5. Evacuate as Priority 1

    • Continue protocol, reassess every 5–10 minutes, and prepare for deterioration

Documentation Requirements:

  • Vital signs before and after each intervention

  • Timing, dose, and site of medication administration

  • Patient’s response, including respiratory effort, LOC, SpO2

Outline:
Tension pneumothorax is a rapidly fatal condition resulting from trapped air in the pleural space under pressure, compressing the lungs and mediastinum, impairing ventilation and venous return. In austere settings where evacuation may be delayed, trained responders must recognise and treat this condition immediately.

Indications:

Suspected tension pneumothorax in the presence of ALL:

  • Respiratory distress or hypoxia not relieved by oxygen

  • Unilateral decreased or absent breath sounds

  • Signs of shock (e.g. tachycardia, hypotension, altered mental status)

  • Jugular venous distension, tracheal deviation (late sign)

  • Chest trauma (blunt or penetrating)

When in doubt, treat. Delaying treatment can be fatal.

 

Contraindications:

  • None in the presence of life-threatening tension physiology. This is a life-saving procedure.

Procedure:

1. Prepare

  • Gloves, antiseptic, 10–14G angiocatheter (preferably ≥8 cm), or manual decompression device

  • Monitor vitals throughout; prepare for re-decompression or chest seal placement

2. Confirm Site
Use the preferred and alternative anatomical landmarks:

Preferred Site (current evidence-based recommendation)

  • 5th intercostal space, anterior axillary line (AAL)

    • Locate the nipple line (5th rib), then move laterally to the anterior axillary line

    • Insert just above the 6th rib to avoid neurovascular bundle

Alternative Site (if 5th ICS AAL not accessible or known)

  • 2nd intercostal space, midclavicular line (MCL)

    • Palpate down from the clavicle to 2nd rib, insert above 3rd rib

    • More difficult in muscular or obese patients; higher failure rate

Less preferred but acceptable (if trained):

  • 4th or 5th ICS, midaxillary line (MAL)

    • May be used in combination with larger decompression needles or chest seals

    • Site commonly used in chest tube placement

3. Decompression Technique

  • Prep the skin with antiseptic

  • Insert the catheter at 90° angle over the superior border of the rib

  • Advance until a “pop” or rush of air is felt/heard

  • Advance the catheter fully, withdraw the needle

  • Secure catheter; consider flutter valve or improvised seal

4. Monitor for Improvement

  • Assess for:

    • Improved respiratory rate and effort

    • Return of breath sounds

    • Improved perfusion and mentation

    • Stabilised vital signs

If no improvement:

  • Reassess for catheter failure, kinking, blockage, or misplacement

  • Repeat decompression at an adjacent site if required

Post-Decompression Care:

  • Continue high-flow oxygen if available

  • Monitor for recurrence or development of open pneumothorax

  • Reassess every 5–10 minutes

  • Prepare for further decompression or prolonged care as needed

  • Evacuate urgently

Documentation Requirements:

  • Time and location of decompression

  • Site used and rationale for selection

  • Clinical indicators before and after decompression

  • Any complications or repeat interventions

  • Patient response

Outline:
Trauma cardiac arrest (TCA) is a distinct clinical entity that requires a tailored approach, differing from medical arrest protocols. In the austere setting, reversible causes—particularly tension pneumothorax and massive haemorrhage—must be addressed rapidly. Bilateral chest decompression is recommended for all patients in traumatic arrest with a mechanism consistent with thoracic injury, regardless of breath sounds.

Indications:

  • Confirmed or imminent cardiac arrest following trauma, including:

    • Pulselessness, apnoea, unresponsiveness

    • Agonal respirations with no palpable central pulse

    • Bradycardia with signs of impending arrest

Mechanism:

  • Blunt or penetrating trauma to the thorax, abdomen, or proximal extremities

Immediate Priorities:

  1. Catastrophic haemorrhage control

    • Tourniquets, wound packing, haemostatics

  2. Airway management

    • Open airway, OPA/NPA or supraglottic if trained

    • Ventilate with BVM

  3. Ventilation

    • Ventilate with high-flow oxygen (if available), 1 breath every 5–6 seconds

    • Avoid hyperventilation

  4. Circulation support

    • No chest compressions unless reversible causes addressed and in blunt trauma arrest

    • Prioritise treating cause, not default CPR

Bilateral Chest Decompression (All TCA Patients)

Justification:
Tension pneumothorax is a rapidly reversible cause of trauma arrest. In high-acuity or low-resource settings, bilateral decompression is a safe and effective presumptive intervention.

Procedure:

  • Use a 10–14G angiocatheter (8 cm+ preferred) or pneumodart

  • Insert at either:

    • 5th ICS, anterior axillary line (AAL) (preferred)

    • 2nd ICS, midclavicular line (MCL) (if AAL not accessible)

  • Perform on both sides, regardless of auscultation or percussion findings

Note: Do not delay decompression for auscultation or ultrasound if cardiac arrest is suspected.

 

Optional Interventions (As Skill and Scope Allow)

  • Pelvic binder (if blunt trauma to pelvis or lower torso)

  • IV/IO access for fluid resuscitation or blood products

  • Tranexamic acid (TXA) if available and within protocol

  • Needle pericardiocentesis (if penetrating chest trauma + signs of tamponade)

Termination of Resuscitation (TOR)

Criteria

  • Consider discontinuation if:

    • No return of spontaneous circulation (ROSC) after 10-15 min AND

    • No signs of life on arrival (no breathing, movement, organised ECG) AND

    • Arrest due to blunt trauma with no reversible cause found OR

    • Unsafe to continue due to environmental risk

Post-ROSC Care

  • Continue ventilation and oxygenation

  • Reassess for tension, shock, bleeding

  • Prepare for prolonged care or expedited evacuation

  • Monitor vitals every 5–10 minutes

Documentation Requirements

  • Time of arrest and interventions

  • Site, timing, and response to chest decompression

  • Medications or fluids administered

  • Time of TOR or ROSC

  • Vital signs if applicable

  • Any deviation from protocol and justification