Can immersive virtual reality assess hypothermia resuscitation decision-making? A cross-sectional study in a civil–military disaster management context

Objectives To evaluate the feasibility and acceptability of an immersive virtual reality (VR) scenario for assessing decision-making in accidental hypothermia resuscitation within a civil–military disaster-management exercise, and to explore neurophysiological signals as hypothesis-generating correlates of decision-making. Design Cross-sectional observational study. Setting A multinational civil–military disaster-management exercise in Bulgaria (September 2025). Participants Convenience sample of first responders who completed the VR scenario and post-experience questionnaire (n=62; mean age 30.6 years (SD 7.8); 59/62 male (95.2%) and 3/62 female (4.8%); 43/62 civilian (69.4%) and 19/62 military (30.6%)). Interventions Participants completed an interactive 360° immersive VR scenario with multiple-choice decision points covering key steps in accidental hypothermia management. A subsample underwent exploratory neurophysiological monitoring (electroencephalogram (EEG)/ECG) during the scenario. Primary and secondary outcome measures Primary outcome was decision accuracy across scenario decision points. Secondary outcomes included perceived usefulness, ease of use, presence and physical discomfort. Exploratory outcomes (subsample) included EEG-derived engagement index and frontal alpha asymmetry. Results Sixty-two participants completed the simulation. Perceived usefulness and ease of use reached the highest median score (7.0 (IQR 6–7.0)), with >95% agreement across items. Decision accuracy across decision points ranged from 37.5% to 85.7%, with lower accuracy in hypothermia-specific algorithm steps compared with general resuscitation actions. In a very small exploratory EEG/ECG subsample, illustrative case-level, event-locked individual traces suggested possible differences preceding incorrect responses (hypothesis-generating only). Conclusions Immersive VR was feasible and well accepted for assessing hypothermia resuscitation decision-making in a civil–military exercise. Observed performance highlighted hypothermia-specific decision gaps. Controlled and longitudinal studies are needed to evaluate learning gain and training effectiveness.