Patients with prolonged tourniquet application represent an understudied problem. The lack of clear national or international standards for care complicates the regulation of treatment tactics.

The aim of this study was to develop and evaluate an algorithm for the care of patients with acute lower limb ischemia caused by prolonged (>2 hours) tourniquet application.

Materials and methods. A retrospective analysis of 142 patients (mean age 36.71 ± 0.82 years) with isolated lower limb trauma and a tourniquet applied to the thigh for >2 hours was conducted at Communal Non-Profit Enterprise “Zaporizhzhia Regional Clinical Hospital” of Zaporizhzhia Regional Council from 2023 to July 2025. Patients were divided into two groups: a control group (2023, n = 64), who received unsystematic care, and a main group (from May 2024, n = 78), who were treated using the algorithm. These were further stratified into subgroups: A (2–4 hours), B (4–6 hours), and C (>6 hours). The algorithm was structured as follows: tourniquet removal at <2 hours; tourniquet removal after fasciotomy therapy at 2–4 hours; fasciotomy without relaxation, followed by muscle assessment (turgor, color, contractility, electrocoagulation), at >4 hours without contractures; amputation in cases of contractures. The analysis included a comparison of laboratory parameters (potassium, pH, and lactate) upon admission and 24–48 hours later, as well as amputation rates.

Results. Laboratory parameters upon admission did not correlate with ischemia time (p > 0.05). In subgroup B, the algorithm reduced the increase in potassium (0.20 mmol/L vs. 0.67 mmol/L, p = 0.02) and decreased the rate of delayed amputations (6.25 % vs. 44.4 %). The overall frequency of amputations was similar (50.00 % vs. 61.11 %), but the rate of primary amputations increased (43.8 % vs. 16.7 %), which led to a reduction in reperfusion complications.

Conclusions. The algorithm is effective in protracted conflicts with evacuation delays, allowing for the intraoperative assessment of muscles and avoiding unjustified reperfusion. It reduces delayed amputations and complications without increasing the overall frequency of amputations, highlighting the limitations of laboratory markers. The algorithm could form the basis of national guidelines but requires multicenter prospective validation.