Rethinking Limb Tourniquet Conversion in the Pre-Hospital Environment.

Limb tourniquets are among the most effective lifesaving interventions after severe injury. Tourniquets used for less than two hours have proven safe, even when in hindsight the tourniquet was determined not to have been necessary. However, tourniquets used for longer than 2 hours may result in severe ischemic changes, fasciotomy rhabdomyolysis, renal failure, amputation and death.Given their frequent use after even minor limb injury (>50%), as soon as safely feasible all limb tourniquets must be reassessed. They may be transitioned to a hemostatic dressing with tourniquet release, (tourniquet conversion, TC), or moved to just above the injury site (tourniquet replacement, TR). Their near ubiquitous application by medical and non-medical personnel has resulted in significant discussion regarding who should perform TC/TR if arrival at a forward medical location is delayed. In the ongoing war in Ukraine, the first near peer large scale combat operation in 80 years, prolonged evacuation times are common and have highlighted the need for early TC/TR prior to hospital arrival. Similar concerns exist in the austere rural and wilderness civilian setting where prolonged tourniquet application is common, given the long distances to a trauma center.This article describes proposed changes in tourniquet use and how the anticipated duration of tourniquet application dictates increased training requirements. Increased emphasis on who needs a tourniquet and then TC/TR is necessary to maximize benefit while minimizing potential harm.Level of Evidence and Study Type: N/A.