In recent years, advances in emergency medicine and trauma systems have significantly improved survival following major injury. However, patients in remote, rural, wilderness, disaster, and resource-limited environments continue to experience substantial disparities in access to timely advanced care. Prolonged evacuation times, limited infrastructure, and restricted availability of trained personnel may delay definitive treatment and increase preventable mortality and complications in severe trauma.1–3

Tactical Combat Casualty Care (TCCC) has markedly improved battlefield survival by addressing the leading causes of preventable death, particularly massive hemorrhage, airway obstruction, and tension pneumothorax.4–6 However, modern operational environments characterized by delayed evacuation and austere conditions have highlighted the need for prolonged medical management beyond traditional prehospital timelines, leading to the development of Prolonged Field Care (PFC).4 PFC refers to the delivery of extended, advanced medical management in environments where evacuation to higher levels of care is delayed beyond standard prehospital timelines.7–9 Its primary objectives are to sustain physiological stability, prevent secondary injury, and manage complications until evacuation becomes possible. Over the past decade, PFC has evolved into a structured operational framework supported by clinical practice guidelines, training pathways, and scalable resource models.7,10

The aim of this narrative review is to provide an updated overview of the principles and clinical components of PFC and to discuss their potential adaptation and applicability within civilian trauma systems operating in remote and austere environments.

As this is a narrative review, no formal systematic review methodology was applied. Relevant literature was identified through non-systematic searches of PubMed/MEDLINE using combinations of the following keywords: “Prolonged Field Care”, “austere medicine”, “remote trauma”, “combat casualty care”, “damage-control resuscitation”, “prehospital critical care”, “telemedicine”, and “military medicine”.

The literature search primarily focused on English-language publications published between 2001 and 2026, although selected earlier references considered historically relevant to the development of PFC concepts were also included. Additional references were identified through manual screening of reference lists and relevant clinical practice guidelines.

Studies, reviews, guidelines, and operational reports were included based on their relevance to prolonged trauma management in austere, remote, military, civilian disaster-response, or resource-limited settings. Priority was given to peer-reviewed publications, military and civilian trauma guidelines, and recent literature considered clinically and operationally informative.

PFC is defined as the delivery of extended medical management in environments where evacuation to definitive care is delayed beyond standard prehospital timelines.7 Originally developed within military operational medicine and increasingly referenced in remote civilian trauma systems, PFC emphasizes sustaining physiology, preventing deterioration, and prioritizing interventions according to available resources rather than ideal conditions.11 Many of the operational and clinical principles of PFC originate from military medicine, although some concepts have progressively been explored in civilian remote and austere environments such as wilderness medicine, disaster response, maritime rescue, and rural emergency systems. Nevertheless, evidence supporting the transferability of military-derived PFC models to civilian trauma systems remains limited and heterogeneous.12,13

Recent operational experiences from modern conflicts, including the war in Ukraine, have highlighted the increasing relevance of PFC and damage control strategies when evacuation timelines are extended, reinforcing the need for scalable PFC capabilities in austere environments.14

To support decision-making in austere settings, PFC adopts a tiered capability model, structured around scalable clinical capacity15,16:

• ●

  Minimum capability focuses on essential life-saving interventions, basic monitoring, temperature control, fluid support, analgesia, and ongoing reassessment.

• ●

  Better capability incorporates additional tools and skills such as advanced monitoring, titrated sedation, supraglottic airway devices, controlled infusion systems, and access to telemedicine support.

• ●

  Best capability approximates a limited forward critical care environment, enabling invasive airway management, mechanical ventilation, advanced analgesia–sedation strategies, guided resuscitation, and broader diagnostic capability.

Advanced forward critical care capabilities may extend to highly specialized interventions such as extracorporeal life support during prolonged evacuation, as demonstrated in selected military case reports.17

This tiered framework does not prescribe a fixed standard but provides a structured method to match clinical priorities with environmental constraints, personnel competency, and logistical sustainability. The approach allows care teams to escalate, maintain, or adapt interventions based on resource availability and expected evacuation timelines, supporting both consistency and flexibility in remote trauma care. The table summarizes the evolving care priorities in PFC environments according to evacuation timelines (Table 1).

Data from recent combat operations confirm that patients requiring PFC frequently need advanced airway management, ventilatory support, blood transfusion, and sustained resuscitative interventions, underscoring the need for scalable capabilities in austere environments.6

Recent clinical practice guidelines developed by the Prolonged Field Care Working Group further operationalize this tiered model, applying the “minimum–better–best” framework to resource allocation, clinical decision-making, and continuity of care (e.g., burn management and documentation standards).9,18 These documents represent a mature and practical evolution of the PFC framework and may support adaptation to remote civilian environments.9,19

Effective pain management and appropriate sedation are essential components of PFC, particularly when evacuation is delayed and repeated interventions are required.

Ketamine offers flexibility across analgesic, dissociative, and induction dosing ranges and can support procedural interventions such as fracture reduction, wound care, and airway management during prolonged evacuation timelines.20,21 Ketamine is widely regarded as the cornerstone medication due to its favourable safety profile, haemodynamic stability, and preservation of airway reflexes and spontaneous respiration, making it particularly suitable for prehospital and resource-limited settings. Contemporary evidence demonstrates that ketamine provides effective analgesia and procedural sedation, with efficacy comparable to opioid-based strategies and a low incidence of serious adverse events.20–22

In remote and austere environments, the primary objective is to balance patient comfort and safety while preserving airway reflexes, spontaneous breathing, and haemodynamic stability. A scalable “minimum–better–best” capability framework may also be applied to analgesia and sedation strategies in PFC, ranging from basic oral analgesics and intramuscular agents to ketamine-based procedural sedation and advanced ventilatory-supported sedation in higher-resource environments.

Opioids may be used as adjuncts for sustained pain control; however, their administration requires careful monitoring because of the risk of respiratory depression, particularly in environments without continuous capnography or mechanical ventilation. Recent prehospital data indicate that protocol-driven administration of intravenous opioids by trained providers is effective and associated with a low incidence of clinically significant complications.23

Sedation strategies in PFC should prioritize the minimum effective dose, favouring titration and intermittent bolus administration over continuous infusions unless monitoring capabilities are sufficient. Non-pharmacologic measures—including positioning, immobilisation, temperature control, and reassurance—remain important adjuncts when resources are limited.

Telemedicine support may assist providers in selecting drug regimens, adjusting dosing, and managing complications such as emergence reactions or inadequate analgesia during prolonged care scenarios. Continuous reassessment is essential, with monitoring of mental status, respiratory function, haemodynamic parameters, and pain response when feasible. Within the PFC framework, appropriate analgesia and sedation contribute not only to patient comfort but also to improved physiological stability, procedural success, and overall survivability in austere trauma care environments.

In both military and civilian settings, compromised airway represents the second leading cause of preventable death after haemorrhage.24 The presence of foreign bodies, impaired consciousness, or incorrect patient positioning may rapidly lead to airway obstruction and death within minutes.25 Rapid and effective airway assessment and management are therefore essential and require appropriate techniques, equipment, and operator proficiency.26 This represents a significant challenge in remote and resource-limited evacuation environments.

Recent literature on airway management in PFC highlights how austere conditions, limited equipment, and prolonged evacuation timelines require providers to adapt conventional airway strategies and prioritize sustainable, resource-conscious interventions.27 Anatomical knowledge, manual skills, and provider experience remain fundamental determinants of successful outcomes.27 A scalable “minimum–better–best” capability approach may also be useful in airway management, ranging from basic positioning maneuvers and supraglottic airway devices in low-resource settings to advanced airway interventions and ventilatory support in higher-capability environments. Fig. 1 illustrates the key operational characteristics of airway management in PFC and remote environments.

Figure 1.

Key challenges and operational requirements for airway management in PFC in remote and austere environments. Original figure created by the authors.

In many cases, airway management in PFC does not necessarily require immediate mechanical ventilation. When feasible, maintaining spontaneous breathing with less invasive airway adjuncts may reduce resource consumption and operational burden, unless deep sedation mandates ventilatory support. An elective approach may be appropriate when airway deterioration is anticipated rather than imminent. A stepwise strategy is recommended, starting with basic airway manoeuvres and bag-valve-mask ventilation, progressing to supraglottic airway devices, and, when required, to endotracheal intubation or surgical airway access.

Modern airway techniques, including pre-oxygenation, supraglottic devices, videolaryngoscopy, and rapid sequence induction, have significantly reduced the incidence of failed airway control in prehospital trauma systems, with reported failure rates below 1%.28 Structured preparation remains essential, and checklists such as the MSMAID framework (Machine, Suction, Monitor, Airway, Intravenous access, Drugs) support systematic readiness. Telemedicine-assisted airway management has been explored as a potential strategy to support procedural guidance and clinical decision-making in austere and remote environments, particularly through videolaryngoscopy-supported tele-intubation systems and remote supervision models.29–31 However, evidence regarding the impact of these approaches on clinical outcomes in prolonged civilian austere care settings remains limited and heterogeneous.

The Joint Trauma System Prolonged Field Care airway clinical practice guidelines formalize a tiered “minimum–better–best” approach, aligning airway strategies with available resources, provider capabilities, and expected evacuation timelines, and providing structured algorithms for airway assessment, adjunct use, and post-intubation management when evacuation is delayed.9 A resource-tiered overview of airway management and sedation capabilities in PFC is summarized in Table 2.

Schyma et al. demonstrated that the Structured Critical Airway Management (SCRAM) bag can significantly reduce equipment preparation time, decrease error rates, and lower operator cognitive load during complex airway scenarios in remote environments.32 Mabry et al. developed a Tactical Combat Casualty Care–based algorithm for awake surgical airway (cricothyrotomy), identifying clinical scenarios, such as severe disruption of facial or cervical anatomy, in which a surgical airway should be considered the primary approach rather than a rescue procedure.33

In this context, orotracheal intubation is not recommended as a minimum standard in TCCC guidelines due to the need for sustained sedation, monitoring, and ventilatory support.34

In hospital trauma populations, prolonged mechanical ventilation frequently necessitates tracheostomy to facilitate weaning and airway protection, underscoring the importance of anticipating long-term airway management strategies even in austere and resource-constrained environments.35

Whenever clinically feasible, maintaining spontaneous breathing with less invasive airway devices reduces resource consumption and operational burden, providing a tactical and logistical advantage in prolonged care scenarios. Within extended evacuation timelines, airway strategies must therefore balance immediate clinical needs with sustainability of care. In this context, telemedicine support may further assist clinical decision-making and provide remote procedural guidance in complex airway scenarios.

Telemedicine is increasingly recognized as a core component of PFC in remote and resource-limited environments.36 When specialist expertise, advanced diagnostics, or procedural capabilities are unavailable on scene, telemedicine enables clinicians to access remote surgical, trauma, and critical care support.37 Nevertheless, telemedicine should not be considered a substitute for advanced bedside critical care capability in severely injured trauma patients. While remote specialist support may facilitate coordination, procedural guidance, and clinical decision-making, definitive management of complex traumatic injuries continues to depend on local provider expertise, available resources, and operational capabilities. Telemedicine capability may similarly follow a scalable “minimum–better–best” framework, ranging from basic communication support and asynchronous consultation to real-time specialist-guided critical care assistance in higher-resource operational environments. Recent civilian disaster and conflict-response experiences, including reports on Emergency Medical Team (EMT) coordination in conflict zones and the medical response during the Gaza humanitarian crisis, further highlight the importance of distributed communication systems, remote clinical support, and coordinated decision-making in resource-constrained environments.38,39

Telemedical support may take multiple forms, including asynchronous consultation, structured decision support, or real-time procedural guidance during interventions such as airway management, wound care, chest tube insertion, or fasciotomy when evacuation is delayed.36,40 This support may also be delivered as rapid asynchronous consultation, structured decision support, or live tele-mentoring during procedures, depending on communication bandwidth and operational constraints.40

In these contexts, telemedicine reduces diagnostic uncertainty, supports clinical prioritization, and assists providers in determining whether interventions must be performed immediately or can be safely deferred until higher-level care is available.41 The ability to transmit clinical images, point-of-care ultrasound recordings, and physiological monitoring data, even through low-bandwidth communication systems, can significantly enhance diagnostic confidence and continuity of care.42 Clinical monitoring in PFC may also follow a scalable “minimum–better–best” model depending on available equipment, personnel expertise, and evacuation timelines, ranging from serial clinical assessment alone to advanced point-of-care ultrasound and physiologic monitoring systems.

However, effective implementation of telemedicine in PFC depends on reliable communication systems, adequate power supply, trained personnel, and integration into established clinical protocols.43 Telemedicine is not intended to replace clinical competence or judgment, but to augment both. When properly integrated, it functions as a force multiplier, improving patient safety, reducing avoidable errors, and enabling small or isolated teams to operate as part of a distributed medical system. Within prolonged evacuation timelines, this capability may meaningfully improve outcomes and reduce complications.40,44

Although haemorrhage control is universally recognized as the priority in trauma management, as reflected by the MARCH-PAWS-L algorithm—where the “M” encompasses both massive haemorrhage and mass casualty (MASCAL) considerations, effective resuscitation cannot rely solely on bleeding control. Adequate vital organ perfusion remains a critical determinant of survival and, in austere environments characterized by prolonged evacuation times, early blood product administration represents a cornerstone of modern damage-control resuscitation strategies.45 Recent civilian and military evidence demonstrates that prehospital blood transfusion programs are feasible, safe, and increasingly implemented, with growing recommendations favoring whole blood and blood-component resuscitation as first-line therapy in traumatic haemorrhagic shock.6,46 Recent prospective evidence further supports the feasibility and potential survival benefit of whole blood resuscitation in severe traumatic haemorrhage during prolonged prehospital care and delayed evacuation scenarios.47

Reports from rural emergency systems indicate that prehospital massive transfusion during prolonged extrication may be life-saving when evacuation is delayed, supporting the expansion of blood product availability in austere environments. In prolonged and resource-constrained settings, the use of fresh whole blood has been proposed as a practical strategy to support damage-control resuscitation and may provide logistical and haemostatic advantages in austere environments.48,49 Experimental data also suggest that haemostatic function may remain preserved even after prolonged physical stress conditions in military personnel.50

Emerging technologies, such as autonomous drone delivery systems, may further expand access to blood products in remote environments; recent case reports describe successful prehospital transfusion delivered by unmanned aerial vehicles in combat settings, enabling early resuscitation despite delayed evacuation.50,51 Several of these approaches currently remain primarily derived from military operational experience and may not yet be broadly applicable across civilian prehospital systems.

In parallel, the use of fresh whole blood has been proposed as a feasible damage-control resuscitation strategy in prolonged and resource-constrained environments, with evidence suggesting preserved haemostatic function even after prolonged physical stress in military personnel.52 Pharmacologic adjuncts also play an important role in prolonged haemorrhage management. Early administration of tranexamic acid is widely recommended in traumatic haemorrhagic shock and has been associated with improved survival in prehospital trauma care.53,54 Prolonged evacuation timelines may also require consideration of delayed or maintenance dosing strategies depending on ongoing bleeding risk, resource availability, and monitoring capability.

Early fibrinogen replacement has emerged as a potentially valuable adjunct in trauma-induced coagulopathy, especially in prolonged evacuation scenarios where ongoing haemorrhage and delayed definitive care may exacerbate consumptive. In selected advanced-capability environments, fibrinogen supplementation may therefore represent an additional component of prolonged damage-control resuscitation.55,56

Haemorrhage control must therefore be considered within the broader resuscitative phase, in which system-dependent blood availability may influence triage and treatment pathways.9 While early damage-control interventions such as tourniquets, haemostatic dressings, and compressive measures are now well established in both military and civilian trauma care, prolonged haemorrhagic resuscitation introduces substantially greater logistical, transfusional, monitoring, and organizational complexity, particularly in civilian austere environments. In civilian trauma algorithms such as ABCD or XABCDE, initial attention is directed toward catastrophic external haemorrhage, typically arterial bleeding from extremities, scalp, or junctional regions, whereas internal haemorrhage is addressed later during the circulation phase and is rarely controllable in the prehospital setting apart from damage-control resuscitation strategies.57 This scalable capability framework may also apply to haemorrhage management, ranging from basic hemorrhage control and crystalloid resuscitation to advanced blood-product support and prolonged damage-control resuscitation strategies.

Pelvic haemorrhage represents a relevant exception, as external stabilization with pelvic circumferential compression devices can be applied in the prehospital setting based on clinical suspicion. Pelvic circumferential compression devices remain an important early stabilisation measure in suspected pelvic trauma, particularly in prolonged evacuation or low-resource scenarios where definitive haemorrhage control may be delayed.58,59 Although their direct effect on mortality remains uncertain, they may reduce pelvic volume, improve mechanical stability, and potentially limit venous bleeding while maintaining a relatively low complication profile when appropriately applied.60

Although widely recommended, the prehospital use of pelvic binders shows variable application and uncertain impact on survival outcomes, supporting their role primarily as a stabilisation measure rather than a definitive haemostatic intervention.61

Some injury patterns fall into an intermediate category, such as degloving injuries of the extremities or soft-tissue disruption associated with long-bone fractures, where bleeding occurs within potential spaces and may not be immediately apparent.62,63

Over recent years, haemorrhage control protocols have evolved substantially, leading to the abandonment of outdated practices and the refinement of current recommendations. The use of arterial pressure points and limb elevation has been largely abandoned and is no longer recommended in either military or civilian guidelines,34 as collateral circulation rapidly restores bleeding. Direct pressure over the bleeding site, combined with appropriate pressure dressings, remains the first-line approach. However, haemostatic dressings—such as chitosan-based gauzes (e.g., Celox, ChitoGauze) or mineral-based expandable agents (e.g., XStat), are preferred over standard bandages, as they enhance clot formation through biological or physicochemical mechanisms and are now integrated into Tactical Combat Casualty Care practice and evaluated in civilian setting.64

Tourniquets represent the fastest and most effective method for controlling life-threatening distal extremity haemorrhage.65 Their early application plays a critical role in preventing shock, as survival is markedly reduced when applied after the onset of haemodynamic collapse. Potential complications include venous tourniquet effect when insufficiently tightened, leading to compartment syndrome65; inappropriate use for venous bleeding; and unnecessary tissue damage when incorrectly placed. Historical concerns, such as reduced effectiveness over two-bone segments, have largely been disproved.

Prolonged tourniquet application, which is increasingly encountered in PFC scenarios, has been associated with significant metabolic and ischemic complications such as rhabdomyolysis and compartment syndrome; however, in austere combat environments it often remains a life-saving intervention when evacuation is delayed.66

Current TCCC guidelines recommend conversion from an emergency “high-and-tight” placement to a definitive tourniquet applied directly to the skin 2–3 inches proximal to the wound once conditions allow.34 The potential conversion of a tourniquet to a haemostatic or pressure dressing has gained increasing attention in both military and civilian literature; when the patient is not in shock and bleeding is controlled, conversion within 2–6 h may be appropriate depending on evacuation timelines and monitoring capability, while removal beyond 6 h should occur only in a controlled medical environment.67

CS is a life-threatening condition resulting from prolonged limb entrapment and external compression, leading to extensive skeletal muscle damage.68 It typically develops after at least one hour of continuous compression and requires urgent medical intervention to reduce the risk of renal failure, life-threatening arrhythmias, and death.69

CS represents a reperfusion injury characterised by traumatic rhabdomyolysis and the release of intracellular contents, including myoglobin, potassium, and phosphate, into the systemic circulation.68 Myoglobin accumulation may obstruct renal tubules and contribute to acute kidney injury, while hyperkalaemia significantly increases the risk of fatal cardiac dysrhythmia.68 At the same time, injured muscle tissue sequesters calcium, leading to hypocalcaemia, which may further worsen neuromuscular and cardiac instability.

The severity of CS correlates with both the duration of compression and the amount of muscle mass involved. Early and aggressive fluid resuscitation remains the cornerstone of treatment, aiming to correct hypovolaemia, dilute circulating toxins, preserve renal perfusion, and prevent tubular obstruction.70

However, decompression may also precipitate significant haemorrhage previously tamponaded by external pressure, and bleeding sources may be difficult or impossible to control in the presence of associated fractures.71 For this reason, a balanced resuscitation strategy is required to minimise exacerbation of bleeding while avoiding coagulopathy due to excessive haemodilution.72

Where available, specialist input through telemedicine may support clinical decision-making; however, fluid therapy must remain individualised and guided by clinical judgement rather than protocol alone.73 PFC recommendations outline treatment tiers and resource-dependent strategies, but these do not replace trained clinical decision-making.9 Fluid management should therefore be tailored to the patient’s physiological status, environmental constraints, and anticipated evacuation timelines. In severely resource-limited environments, management priorities may need to focus on a limited number of essential and feasible interventions, including early volume resuscitation, basic electrocardiographic monitoring when available, recognition of hyperkalaemia-associated arrhythmias, analgesia, and serial clinical assessment. More advanced strategies—including prolonged biochemical monitoring, invasive haemodynamic assessment, renal replacement therapies, and extended critical care support—may be unavailable or operationally unrealistic in many austere civilian environments. Accordingly, a scalable “minimum–better–best” approach may also be useful in crush syndrome management, adapting monitoring and therapeutic strategies according to available personnel, equipment, evacuation timelines, and logistical capability. A tiered, resource-adapted approach to fluid resuscitation in PFC is illustrated in Fig. 2.

Figure 2.

Resource-tiered fluid resuscitation strategy in PFC environments. The figure illustrates a scalable approach to volume replacement based on available resources and evacuation timelines, ranging from basic oral and rectal hydration strategies to intravenous crystalloid resuscitation with targeted urine output monitoring (100–200 mL/h) in prolonged care scenarios. Original figure created by the authors.

Ongoing monitoring is essential to guide treatment and prevent life-threatening complications associated with Crush Syndrome. The primary physiological target is a urine output of 100–200 mL/hour.68,69 Clinical surveillance focuses on early detection of hyperkalaemia-related cardiotoxicity, maintenance of adequate ventilation and oxygenation, and recognition of haemodynamic deterioration during resuscitation. Key monitored parameters include blood pressure, heart rate, respiratory status, infusion volumes, urine output, mental status, pain, oxygen saturation, and core temperature.68

Monitoring of myoglobinuria may be adapted to resource availability: from simple visual inspection of urine discoloration (minimum capability) to bedside urinalysis for haemoglobin or red blood cells (intermediate capability), and laboratory urine chemistry when available (advanced capability).74 Monitoring strategies must be adapted to environmental constraints and evacuation timelines while remaining aligned with PFC principles and sound clinical judgement.

Compartment syndrome is a limb-threatening condition caused by increased pressure within a closed osteofascial compartment, resulting in impaired microvascular perfusion and progressive tissue ischaemia.75 This process compromises osteomuscular function, leads to muscle necrosis, and in severe cases may result in limb amputation. Lower limbs are more commonly affected than upper limbs.75 The critical determinant of compartment syndrome is the muscle perfusion pressure, calculated as the difference between diastolic blood pressure and intracompartmental pressure. Values below 30 mmHg indicate impaired tissue perfusion, hypoxia, and anaerobic metabolism.76 Both external and internal factors may contribute to pressure elevation, including tight external compression, limb restraints, hematoma formation, extravasation of fluids, and tissue oedema secondary to ischemia–reperfusion injury.77 In unconscious or sedated patients, clinical suspicion should be based on indirect signs such as increasing limb tension, persistent tachycardia, rising lactate levels, and the mechanism of injury after excluding other causes of haemodynamic instability.

Immediate decompression through fasciotomy remains the definitive treatment, aiming to restore capillary perfusion and prevent irreversible tissue damage.78 However, fasciotomy in austere and remote environments presents substantial operational and clinical challenges. Diagnostic uncertainty in the absence of advanced monitoring capability may increase the risk of over-indication or delayed intervention, while haemorrhagic complications, infection risk, wound management difficulties, and the need for prolonged postoperative care may significantly complicate patient management in prolonged evacuation scenarios.79 These considerations are particularly relevant in civilian austere environments where surgical support, transfusional capability, and definitive postoperative care may be limited. Recent experiences have also explored telemedicine-supported procedural guidance and telementoring for fasciotomy decision-making in PFC settings.80

Accordingly, compartment syndrome management in austere environments may also require a scalable “minimum–better–best” approach, balancing clinical suspicion, monitoring capability, procedural expertise, postoperative care resources, and evacuation constraints. Clinically, compartment syndrome is characterised by tense swollen compartments, severe and progressive pain, pain on passive stretch, paresthesia, and eventually motor deficit. Peripheral pulses may be preserved and therefore are not a reliable indicator, particularly in normotensive patients.75,81

In remote or resource-limited environments, access to compartment pressure monitoring devices or immediate surgical consultation may be unavailable. In these settings, telemedicine support can function as a decision-support tool, enabling expert consultation, remote validation of clinical findings, and procedural guidance when fasciotomy is considered and evacuation is delayed.82 In such circumstances, the decision to proceed with decompression must be based on clinical assessment, anticipated evacuation timelines, and the balance between limb salvage and procedural risk in austere conditions.73

This review is narrative rather than systematic and may therefore be subject to selection bias. The search strategy was limited to a single database (PubMed) and to English-language publications, which may have excluded relevant studies and introduced language bias. In addition, access to detailed military operational data and outcome reporting remains limited, and the available literature is heterogeneous in design, population, and outcome measures. Most of the evidence derives from military settings, which may limit direct generalizability to civilian systems. A substantial proportion of the available literature also consists of doctrinal publications, expert opinion, operational reports, and conceptual discussions rather than prospective clinical investigations or validated civilian implementation studies. Operational differences between military and civilian systems may further limit direct generalizability. Despite these limitations, the available literature offers important operational and clinical insights into the potential adaptation of PFC principles to austere and remote civilian trauma care environments. Future prospective studies are needed to evaluate clinical outcomes and support the development of standardized implementation strategies in civilian settings. Operational, organizational, and logistical differences between military and civilian trauma systems may further limit the direct generalizability of several military-derived PFC strategies.

PFC has emerged as a promising operational framework for trauma management in remote, austere, and resource-limited environments. Although most of the available evidence originates from military operational medicine, its adaptation to civilian systems may offer a potentially adaptable framework for selected civilian austere and remote trauma systems, although further validation and system-specific implementation studies remain necessary.

Standardized training, resource-tiered planning, and continued development of clinical guidelines may help support clinical preparedness and operational capability in austere trauma environments. Further research is required to validate these clinical pathways and define their role within remote civilian trauma systems.

As operational environments, logistical constraints, and medical capabilities continue to evolve, PFC may provide a flexible and evidence-informed framework to support trauma care when time, distance, and limited resources challenge conventional healthcare systems.

SL: Conceptualization, initial project idea, literature screening, drafting of selected manuscript sections, and critical revision of the final text; GM: Literature research, contribution to drafting of selected manuscript sections and revision of manuscript content for clinical accuracy; AR: contribution to drafting of selected manuscript sections, and supervision of the final version; SDR: Conceptualization, methodology, data curation, literature analysis, manuscript structuring, full manuscript writing, and supervision of the final version. All authors reviewed and approved the final version of the manuscript.

Not applicable.

Not applicable. This study is a narrative review and did not involve human participants, identifiable data, or animal research.

None.