West Virginia Becomes First State in Nation to Develop Statewide Tourniquet Takedown Protocols for EMS
West Virginia has become the first state in the country to develop statewide tourniquet removal or ‘takedown’ protocols for Emergency Medical Services (EMS), and, after one year of measurable success in the field, is becoming the model for tourniquet training at the national level.
“An opportunity like this one doesn’t present itself every day,” shared Secretary of Health Dr. Arvin Singh. “This is something that takes time, dedication, and hard work to see to fruition. I am extremely proud of those who have had a hand in developing these protocols and am excited to see their impact on the future of healthcare, not just for West Virginia but for other states and their communities as well.”
A tourniquet is a device used to apply pressure to a limb in the effort to control bleeding, especially in cases that involve severe bleeding such as gunshot wounds. West Virginia’s protocols were developed by Acting State Health Officer Dr. P.S. Martin alongside Dr. Greg Schaefer, a trauma surgeon at West Virginia University, after recognizing that, although tourniquet use in prehospital trauma care is well-documented in controlling hemorrhage and improving surgical outcomes, limited data exists regarding the success of and potential risks of tourniquet removal in the field by EMS providers.
Dr. Martin found that there were cases in which tourniquets had been applied as part of routine pre-hospital care that could have been reassessed and removed but were not due to current guidelines.
“There is this taboo in the medical community surrounding tourniquet takedown,” Dr. Martin explained. “Once one is in place a lot of hospitals do not want to remove it unless there is a vascular surgeon present. However, every minute a tourniquet is applied, there is a risk of tissue death and limb loss. We wanted to find those situations where tourniquets could be removed and do so through proper training and see what that data looked like to show that takedown is not only viable but preferred in the right situations.”
Together, Dr. Martin and Dr. Schaefer developed statewide takedown protocols, which allow providers two chances to remove the tourniquet. Upon receiving patients with tourniquets, providers will now assess the tourniquet by first making sure it has been properly placed and replacing it if not. Then, they will expose the wound, apply a properly packed wound dressing, and wait approximately three to five minutes while slowly releasing the tourniquet’s pressure. If bleeding resumes, they will retighten the tourniquet and repack the wound with one more chance for removal after 15 minutes, if they are not already at the hospital.
Since June 15, 2024, Dr. Martin has been evaluating cases where a tourniquet was applied and subsequently removed in the field. Data was extracted from electronic patient care records, including structured fields and provider narratives, to ensure only cases with confirmed tourniquet applications were included. A total of 98 cases met the inclusion criteria, with approximately 20 percent undergoing tourniquet takedown. Of those who underwent tourniquet removal, 16 did not have to have their tourniquets redeployed.
Comparative analysis showed no statistically significant difference in patient outcomes between takedown and non-takedown groups, although the takedown cohort exhibited a higher proportion of clinical improvement at 64.7%. Additionally, no patients in the takedown group experienced deterioration, while 2.9% of non-takedown patients worsened, suggesting that tourniquet takedown, when performed by trained EMS personnel, may be associated with clinical improvement.
“Tourniquets can be extremely helpful in saving lives, but they can also be overused,” says Dr. Martin. “There is sometimes this knee jerk reaction that if we see blood we want to stop it, and that’s not the wrong reaction but sometimes a tourniquet is not always the answer, especially when a less invasive, less limb threatening method will do the job. Prolonged tourniquet use, when they are not necessary, can be very limb threatening when you are dealing with the prolonged transport times faced by those in rural West Virginia. This study brings light to that and, we hope, shows that we don’t have to fear tourniquet removal but can actually use it to bring the best care possible to patients.”
In May, Dr. Martin shared his findings at the National Association of State Emergency Medical Services Officials’ (NASEMSO) Annual Meeting in Grand Rapids, Michigan, marking West Virginia as the first state to provide patient data on tourniquet takedown conversion at the national level. NASEMSO and the National EMS Quality Alliance will use that data as they work to build national takedown protocols and quality measures.
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