title: The state of the union: Nationwide absence of uniform guidelines for the prehospital use of tourniquets to control extremity exsanguination.
abstract: BACKGROUND
  After the Sandy Hook shootings and the resulting Hartford Consensus, as well as the recent Boston Marathon bombing, the need for a uniform, detailed, and aggressive prehospital extremity exsanguination control protocol became clear. We hypothesized that most states within the United States lack a detailed uniform protocol.
  
  
  METHODS
  We performed a systematic nationwide assessment of emergency medical services (EMS) prehospital extremity exsanguination control protocols. An online search (updated February 7, 2015) identified state-, region-, or county-specific EMS protocols in all 50 states. If unavailable online, protocols were retrieved directly by contacting each state's Department of Public Health (or other appropriate agency). Two investigators independently screened each extremity exsanguination control protocol. Protocols were first grouped into three categories: I, tourniquet not mentioned; II, tourniquet mentioned, without specific guidance; III, tourniquet mentioned, with specific guidance related to type, indications, application technique, and safety concerns. Each protocol was then scored on a five-point scale for comparison.
  
  
  RESULTS
  Forty-two states (84%) had statewide and 14 (28%) had at least one county-specific protocol. Seven states (16%) had no statewide protocol but at least one county-specific protocol (range, 1-10). Mississippi had neither statewide nor county-specific protocols. Of statewide protocols, 4 (9.5%) were in Category I, 23 (54.8%) in Category II, and 15 (35.7%) in Category III. The mean score for statewide tourniquets was 2.4/5 (SD, 1.25; range, 0-5). Thirteen (31%) statewide protocols referred to "commercial" or "approved" tourniquets; only three (7%) recommended a particular commercial device. The mean score for the county-specific protocols of states with no statewide protocol was 3.10 (SD, 1.56; range, 0-5) CONCLUSIONS: Throughout the United States, there is considerable variability in EMS protocols addressing the management of extremity exsanguination and an alarming absence of specific guidance for tourniquet use. Most states do not have a uniform, detailed, and aggressive prehospital extremity exsanguination control protocol.
  
  
  METHODS
  Epidemiologic and prognostic study, level III.
authors.affiliation: From the Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Elie
authors.initials: E
authors.lastname: Ramly
authors.forename: Gem
authors.initials: G
authors.lastname: Runyan
authors.forename: David Richard
authors.initials: DR
authors.lastname: King
mesh_terms: D001134:Arm Injuries / Q000150:complications* / Q000628:therapy; D002985:Clinical Protocols / Q000592:standards*; D004632:Emergency Medical Services / Q000379:methods / Q000592:standards*; D058734:Exsanguination / Q000453:epidemiology / Q000209:etiology / Q000628:therapy*; D005121:Extremities / Q000098:blood supply / Q000293:injuries; D006801:Humans; D015994:Incidence; D007869:Leg Injuries / Q000150:complications* / Q000628:therapy; D017410:Practice Guidelines as Topic / Q000592:standards*; D011379:Prognosis; D015996:Survival Rate / Q000639:trends; D014111:Tourniquets / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology