Combat Casualty Care in the Russo-Ukrainian War: Operational Adaptations for Near-Peer Conflict

BackgroundThe Russo-Ukrainian War provides the clearest contemporary example of how near-peer warfare is reshaping combat casualty care. Persistent unmanned aerial surveillance, contested airspace, precision fires, attacks on health care infrastructure, degraded logistics, and prolonged evacuation challenge assumptions developed during operations in Iraq and Afghanistan. The resulting changes in prolonged casualty care, decentralized resuscitation, military-civilian integration, telemedicine, and autonomous logistics are best understood as operational adaptations to these battlefield conditions rather than independent innovations.MethodsThis narrative review synthesizes operational observations from Ukraine with military medical doctrine and literature published through July 2026. Particular attention is given to prolonged evacuation, tourniquet utilization, whole-blood resuscitation, thermobaric and drone-related injury, autonomous medical logistics, attacks on health care, and NATO planning for large-scale combat operations.ResultsContested evacuation emerged as the organizing problem across the casualty-care continuum. Ukraine adapted by distributing resuscitative and surgical capability, integrating civilian hospitals, expanding prolonged casualty care and forward blood support, using telemedicine and digital coordination, hardening or relocating treatment sites, and employing uncrewed systems for resupply and casualty movement.ConclusionsUkraine demonstrates that future combat casualty care doctrine must be designed around delayed movement, persistent surveillance, degraded infrastructure, and mass-casualty demand. These lessons should inform NATO medical planning, trauma-system resilience, and preparation for future large-scale combat operations.