A01 From application to conversion: the development of a tourniquet reassessment algorithm for nonmedical military personnel by a NATO specialist team

Background Prehospital emergency care in non-permissive environments remains a critical area for research and development in combat casualty care. The limb tourniquet is a proven life-saving tool in battlefield medicine, effectively preventing death from extremity hemorrhage. However, prolonged tourniquet application can result in serious complications, including nerve damage, necrosis, renal failure, limb loss and even death, particularly in environments with extended evacuation times, such as the current conflict in Ukraine. 1 Reports from the Russo-Ukrainian conflict indicate that up to 75% of tourniquets are applied without medical indication and many remain in place well beyond the generally safe 2-hour window, compounding the risk of adverse outcomes. 2 3 Operational challenges such as contested airspace, targeting by FPV drones, and limited medical personnel frequently lead to prolonged evacuation delays. 4 Moreover, reports suggest that civilian and military personnel are increasingly at risk of being targeted, leaving nonmedical personnel to manage casualties with tourniquets already in place. 5–7 While military medical personnel are trained in tourniquet reassessment and conversion, nonmedical personnel typically lack the structured guidance necessary for managing these casualties. This challenge is further compounded by the difficulty untrained personnel face in assessing wound severity in tactical environments without prior tourniquet conversion training. This has underscored the need for a tourniquet reassessment protocol tailored to nonmedical personnel for prolonged casualty care scenarios. 8 Methods To address these challenges a NATO Science and Technology Organization, Human Factors and Medicine Panel Specialist Team (399) was formed to evaluate the data on tourniquet use to recommend strategies to mitigate the risk of tourniquet complications. This team was composed of subject matter experts from eight different countries, including trauma surgeons, emergency physicians, and combat medics. A structured literature review was conducted to examine military and civilian studies on tourniquet application, reassessment, and conversion. A total of 127 studies were identified through searches of the OVID Medline, Embase, DTIC, Web of Science, and CENTRAL databases. Fourteen key articles were selected based on relevance, recency, and citation frequency. These studies provided critical insights into reassessment strategies, informing the development of a conversion algorithm for nonmedical personnel. The preferences and views of nonmedical military personnel were gathered through direct observations and discussions in operational environments. Results Through this work, the team developed a standardized Tourniquet Reassessment Algorithm for Nonmedical Military Personnel (figure 1). This algorithm was specifically designed to simplify complex decision-making for lay users. Key to this simplification was outlining clear procedural terms—removal, conversion, and repositioning—at the outset, along with establishing specific time periods (6 hours) with corresponding recommendations. Recognizing the challenges of prolonged evacuation, the algorithm integrates telemedicine consultation for the critical 2 to 6-hour window. Furthermore, for maximum clarity and applicability, the protocol was refined to a fourth-grade English reading level and reviewed by non-native English speakers. Conclusion The resulting protocol emphasizes timely reassessment of tourniquets while prioritizing hemorrhage control. This algorithm provides a structured, pragmatic, and evidence-based approach for nonmedical personnel managing prolonged tourniquet application, enhancing usability and patient safety. While primarily informed by observations from the conflict in Ukraine, its applicability extends to other scenarios characterized by prolonged evacuation and limited medical resources, such as natural disasters and rural trauma events. Further research and field validation are necessary to optimize implementation and training for nonmedical personnel in combat environments. Abstract A01 Figure 1 Tourniquet reassessment algorithm for nonmedical military personnel References Lukiianchuk V, Linchevskyy O, Dorlac WC, Russo RM, Andreatta PB, Aarabi S, et al . Morbidity and mortality associated with ischemia-reperfusion injury after prolonged tourniquet use: a wartime single-center treatment algorithm. J Trauma Acute Care Surg . 2025. Medby C, Ricks J, Ingram B, Forestier C, Parkhouse D, Gurney I, et al . Removal of tourniquets: the next step in saving lives and limbs. BMJ Mil Health . 2024. Butler F, Holcomb JB, Dorlac W, Gurney J, Inaba K, Jacobs L, et al . Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war. Journal of Trauma and Acute Care Surgery . 2024; 97 (2S). Patterson JL, Bryan RT, Turconi M, Leiner A, Plackett TP, Rhodes LL, et al . Life over limb: why not both? revisiting tourniquet practices based on lessons learned from the war in Ukraine. J Spec Oper Med . 2024. 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The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, the Uniformed Services University, or the United States Government. We are military service members and employees of the US government. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. 101 defines a United States Government work as work prepared by a military service member or employee of the United States Government as part of that person’s official duties. This abstract reflects either the NATO Centre of Excellence for Military Medicine’s or the author’s positions, views, findings, interpretations, and conclusions as an independent academic opinion. Unless otherwise specified, this is not endorsed or approved by the NATO and does not reflect NATO’s or individual governments’ policies or positions. Disclosures The authors received no financial or material support related to this abstract. Dr. Holcomb is on the board of directors of CCJ Medical Devices, QinFlow, Hemostatics, and Zibrio. He receives research grant support from the DoD, DARPA, NIH and CSL focused on hemorrhage control and resuscitation. He consults with WFIRM, Geneva Foundation, Aspen Medical, Infrascan and is the co-inventor of the Junctional Emergency Tourniquet Tool and thus receives royalties from UT Health. Dr. Russo receives grant support from the DoD and is a clinical advisor for Tournitek, a USAF funded small business focused on reducing extremity ischemia. Dr Dorlac consults with Aspen Medical and is an investor in Zibrio and Decisio Health.