Tourniquet use in different emergency medicine professional groups. Are there differences in theoretical and practical training, frequency of use, and adherence to existing guidelines?

Tourniquet use in different emergency medicine professional groups. 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Are there differences in theoretical and practical training, frequency of use, and adherence to existing guidelines? Peter Hilbert-Carius, H. Wrigge, K. zur Nieden, B. Stichert, A. Großstück, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9010509/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Background Traumatic haemorrhage is one of the most common causes of death in injured patients. Targeted pre-hospital haemostasis can reduce morbidity and mortality. The use of tourniquets is advisable for external bleeding in the extremities that cannot be treated by compression and wound packing. There are corresponding recommendations for tourniquet use. Little is currently known about the level of training and the frequency of use of the various professional groups of potential tourniquet users. Methods Status survey on the level of training and frequency of use of tourniquets among various pre-hospital professional groups (Emergency Medical Technician / basic emergency medical technicians – EMT, Advanced Emergency Medical Technician / intermediate emergency medical technicians - AEMT, Paramedic / paramedic emergency medical technicians, Helicopter Emergency Medical Services-Technical Crew member - HEMS-TC, Prehospital Physician). In order to obtain an overview of the level of training and use of tourniquets among the various professional groups, we conducted a regional online survey in the ground-based emergency medical services in the region of Halle/Northern Saale District in Saxony-Anhalt, as well as for the helicopter emergency medical services in the Halle/Leipzig metropolitan region. The different professional groups were compared with regard to theoretical and practical training, frequency of use, and adherence to existing guidelines. Results 178 participants (74% male, 26% female) took part and answered the questionnaire, including 47% pre-hospital physician, 32% paramedic, 9% EMT, 8% HEMS-TC, 6% AEMT. The only statistically significant differences were found in theoretical education, with the lowest rate of education in the EMT group (67%) and the highest rate in the paramedic group (96%). When comparing theoretical education of all the emergency medical service personnel (91%) against the pre-hospital physicians (73%), it was significantly higher in the emergency medical service personnel group. No differences were found for practical training, frequency of use, and adherence to existing guidelines. Conclusion Apart from theoretical education, no differences are apparent regarding practical training, frequency of use, and adherence to existing guidelines for potential pre-hospital tourniquet users. However, education and training can still be improved. haemorrhage extremity trauma pre-hospital emergency medical service personnel emergency physicians Background Traumatic haemorrhage is one of the most common causes of death in injured patients ( 1 , 2 ). Targeted pre-hospital treatment can reduce morbidity and mortality ( 3 ). On the one hand, limb haemorrhage is often underestimated as a source of bleeding, but on the other hand, it can be effectively treated pre- and in-hospital with pressure bandages, wound packing or tourniquets ( 4 , 5 ). The use of tourniquets for limb haemorrhage that cannot be stopped with a pressure bandage or where the tactical situation requires the temporary application of a tourniquet has gained importance due to positive experiences in the military and the increase in terrorist activities over the last two decades ( 6 – 8 ). Nevertheless, the majority of experiences and data originate from war and crisis zones (Afghanistan, Iraq, Israel, Ukraine) ( 8 – 11 ). More recently, data from civilian emergency medicine has also been increasingly reported ( 12 – 16 ). However, there are only a few publications available from European countries and little is known about the differences in theoretical and practical training, frequency of use, and adherence to existing guidelines between the different professional groups (Emergency Medical Technician / basic emergency medical technicians – EMT, Advanced Emergency Medical Technician / intermediate emergency medical technicians- AEMT, Paramedic / paramedic emergency medical technicians, Helicopter Emergency Medical Services-Technical Crew member - HEMS-TC, Prehospital Physician) ( 6 , 17 – 20 ). Methods In order to obtain an overview of the level of training and use of tourniquets among the various professional groups, we conducted a regional online survey in the ground-based emergency medical services (EMS) in the region of Halle (Saale) /Saale District in Saxony-Anhalt, Germany, as well as for the helicopter emergency medical services (HEMS) in the Halle (Saale) /Leipzig metropolitan region. This area comprises 24 EMS stations, including 5 physician-staffed rapid response vehicles, two HEMS bases operating 4 helicopters, and one location with a physician-staffed intensive care transport vehicle. A questionnaire with multiple questions regarding education, availability, level of training, experience in the use of tourniquets in EMS and HEMS and personal opinions was available online from 02.07.24 to 15.10.2024 and a QR code was sent to the participants to get access to the survey (see supl. Figure 1). The questionnaire was developed by three experienced emergency physicians and evaluated by the authors. It consisted of various sections (general, training, availability, theoretical and practical aspects, opinions) with a total of 45 questions. In the current study, we analysed the questions with regard to education/training, practical experience in application and adherence to guidelines. We compared the different professional groups against each other where appropriate and all the emergency medical service personnel (EMT, AEMT, Paramedic, HEMS-TC) against the pre-hospital physicians, if significant differences were found between the professional groups. In the case that not all participants answered every question of the survey, all available answers were analysed. Statistical analysis was mainly descriptive, differences between groups were compared using chi 2 test for categorical data. All computations were performed using Prism GraphPad (GraphPad Software, 225 Franklin Street FL 26 Boston, MA 02110, USA). The data collection was approved by the hospital management and is in accordance with the European General Data Protection Regulation. As no personal data that could reveal the identity of a participant was collected as part of the study, the Ethics Committee of the Saxony-Anhalt Medical Association did not consider a new vote to be necessary and referred to the existing vote (56/21) on a study on tourniquets already conducted by the authors ( 21 ). Results During the study period, 178 participants took part and answered the questionnaire. Of the 178 participants (74% male, 26% female), 132 (74%) completed the whole survey. The results in the following sections refer to all available responses and not just to the 132 participants who completed the whole questionnaire. This means that the number of responses / participants may vary between questions. Table 1 provides an overview of available general information such as the age, qualifications, kind of emergency vehicle and length of service in the emergency medical services of the participants. Table 1 ) Age, qualifications, EMS vehicle and length of service in the emergency medical services of the participants Age of participants 17% (N = 27) 30–39 years 31% (N = 50) 40–49 years 32.5% (N = 52) 50–59 years 17% (N = 27) > 60 years 2.5% (N = 4) Profession of participants 1 physician 47% (N = 75) HEMS-TC 8% (N = 11) paramedic 32% (N = 51) AEMT 4% (N = 6) EMT 9% (N = 15) Emergency vehicle 2 Ambulance 46% (N = 73) Rapid response care 54% (N = 86) Rescue Helicopter 29% (N = 47) Intensive care transport vehicle 9% (N = 14) More than one vehicle 36% (N = 57) Time in EMS / HEMS 3 0% 1–2 years 7% (N = 9) 3–5 years 22% (N = 29) 6–10 years 20% (N = 27) > 10 years 51% (N = 67) 1 One participant did not specify the profession, 2 multiple answers possible, 3 time since completing training in the emergency medical service Of the 75 participating physicians, 63 (84%) were consultants (senior doctors) and 12 (16%) residents (junior doctors), which were divided into the following medical specialties: 56 (75%) anaesthesiology and intensive care medicine, 8 (10.5%) surgery, 9 (11%) internal medicine and 3 (4%) others. Education and Training 91% (N = 146) of the respondents had some kind of theoretical education and / or practical training in the tourniquet use and 9% (N = 14) had not, with no significant differences between the professional groups. Theoretical education was completed by 81% (N = 130) of the respondents and practical training by 87% (N = 139). The difference in the theoretical education between the professional groups was statistically significant (chi 2 statistic 12.03, p .017) with the lowest rate of education in the EMT group (67%) and the highest rate in the paramedic group (96%). When comparing the rate of theoretical education between all the emergency medical service personnel (91%) against the pre-hospital physicians (73%), theoretical education was significantly higher in the emergency medical service personnel group (chi 2 statistic 9.09, p .0026). 43% (N = 69) of respondents stated that they had received training or education on their own initiative (EMT 53%, AEMT 33%, Paramedics 53%, HEMS-TC 27%, physicians 37%). The difference in the professional groups was not statistically significant. As part of their vocational training in the emergency medical services, 43% (N = 69) received training and a total of 41% (N = 66) received training in the form of special courses (PHTLS-Pre-Hospital Trauma Life Support, etc.). 25% of the pre-hospital physicians received their training as part of the emergency doctor course. Practical experience in application 57% (N = 77) of respondents have applied a tourniquet to at least one patient, and 13% (N = 18) have had to apply more than one tourniquet at the same time. There were no significant differences between the professional groups in terms of the necessity of tourniquet application. 80% (N = 8) of EMT, 60% (N = 3) of AEMT, 55% (N = 21) of paramedics, 73% (N = 8) of HEMS-TCs and 54% (N = 37) of doctors stated that they had already applied a tourniquet. Regarding the frequency of use, 26% (N = 40) of the respondents stated that they had used a tourniquet 1–2 times, 18% (N = 29) 3–5 times, 5% (N = 8) 6–10 times and 1% (N = 1) > 10 times. When comparing the necessity of tourniquet application of all the emergency medical service personnel (64%) against the pre-hospital physicians (54%), the difference was not statistically significant. Adherence to existing guidelines The location for applying a tourniquet in the pre-hospital setting was defined by respondents as follows: 77% (N = 126) as distally as possible – but sufficiently proximally (at least 5 cm / a hand's width) from the source of bleeding, 12% (N = 20) directly above the site of bleeding and 11% (N = 18) above the joint of the affected limb. There was no statistically significant difference between the professional groups. Regarding the indication for pre-hospital tourniquet use, 90% of the answers were in accordance with current guidelines with no significant differences between the professional groups. There were considerable differences in the responses regarding the maximum occlusion time for the tourniquet. 1.5% (N = 2) of respondents estimated the maximum occlusion time for a tourniquet to be 30 minutes, 16% (N = 22) estimated it to be 60 minutes, 9% (N = 12) estimated it to be 90 minutes, the majority (66%, N = 93) estimated it to be 120 minutes, 6% (N = 9) estimated it to be 180 minutes, and 1.5% (N = 2) estimated it to be unlimited. No significant differences between the professional groups were found. Another important finding of the survey was that all rescue vehicles (ambulances, rescue helicopters, etc.) were equipped with tourniquets. Discussion Our survey demonstrates that the education/practical training and adherence to current guidelines for tourniquet use in emergency medical service professionals is far from being perfect but quite good. There are already surveys and descriptive analyses on the application of tourniquets in civilian EMS. Several studies have characterized patterns, trends, and outcomes of prehospital tourniquet use in the civilian setting ( 12 , 15 , 22 , 23 ). Surveys and data from the German-speaking zone are still missing. Large-scale analyses using the US National EMS Information System (NEMSIS) have described the prevalence, predictors, and demographic characteristics of tourniquet use by civilian EMS, showing an increase in adoption, especially in urban and advanced life support settings. These surveys found that tourniquets are most commonly applied for traumatic injuries, with upper extremity injuries being more frequent than lower extremity injuries, and that the prevalence of use increased ( 12 ). An American survey on the knowledge, experience, training of civilian pre-hospital providers revealed significant knowledge gaps and a low number of trained providers ( 23 ). The survey is comparable to our study with regards to number of participants (N = 151) and non-physician professional groups (basic, intermediate and paramedic emergency medical technicians). In contrast to our study, only 17% of the participants had used tourniquets in the pre-hospital setting, but the survey is already more than 13 years old and, however, one must bear in mind that tourniquet use in civilian EMS is increasing. Other regional and multicentre studies have reported on the incidence, mechanisms of injury, who applies the tourniquet (EMS, law enforcement, or layperson), and outcomes, including complication rates and effectiveness in haemorrhage control ( 24 , 25 ). These surveys consistently demonstrate that tourniquet use in civilian EMS is increasing, is effective for haemorrhage control, and is associated with low complication rates when applied appropriately ( 23 , 24 , 26 , 27 ). Pre-hospital tourniquet use in EMS is associated with improved survival, reduced shock on arrival, and decreased transfusion requirements, with a low rate of serious limb complications ( 28 – 30 ). In contrast to the US EMS and many other American / South American countries, in the German-speaking zone and some other European countries pre-hospital physicians can regularly be found in the EMS and HEMS. There are no large-scale published surveys or studies specifically focused on the use of tourniquets by pre-hospital physicians in EMS. The available literature primarily describes tourniquet application by EMS personnel, law enforcement, and laypersons in civilian pre-hospital settings. To our knowledge, the current study is the first investigating the education/training, practical experiences and guideline adherence of tourniquet application by pre-hospital physicians. Our data revealed that theoretical education in the pre-hospital physician group (73%) was significantly lower compared to the entirely different EMS professional groups (91%), raising the question why the pre-hospital physicians in our study had a quite low education rate. Unfortunately, we cannot answer that question, and the reason may be multifactorial. Regardless of any potentially existing multifactorial reasons, physicians are also obliged to familiarize themselves with the available equipment. Since tourniquets were available on all rescue vehicles, it would have been the physicians' duty to familiarize themselves with them. Which obviously didn't happen. In line with our results, the literature shows that the level of training in the use of tourniquets among pre-hospital emergency physicians is heterogeneous and often inadequate. Studies show that although tourniquets are increasingly being used in civilian EMS, the correct indication and application are often not optimal. Tourniquets are regularly applied without clear indication or are placed incorrectly, which points to deficits in education and training ( 31 – 33 ). Conclusion Compared to older studies, our survey shows that a high proportion of emergency medical services personnel have completed theoretical and practical training in the use of tourniquets. Emergency physicians are significantly less likely to have received theoretical training, which is something that definitely needs to be improved. More than half of respondents already had applied at least one tourniquet to a patient, which underlines the increasing tourniquet use in civilian EMS. Abbreviations AEMAT Advanced Emergency Medical Technician / intermediate emergency medical technicians EMS Emergency Medical Service EMT Emergency Medical Technician / basic emergency medical technicians HEMS Helicopter Emergency Medical Service HEMS-TC Helicopter Emergency Medical Services - Technical Crew member PHTLS Pre-Hospital Trauma Life Support US United States Declarations Ethics approval and consent to participate: The data collection was approved by the hospital management and is in accordance with the European General Data Protection Regulation. Given that, as in a previous study we conducted on the topic of Tourniquet, no personally identifiable data was collected, the study was classified by the Ethics Committee of the Saxony-Anhalt Medical Association as not requiring approval (Ref. 56/21). The need for consent to participate was waived by the Institutional Review Board (Krankenhausleitung BG Klinikum Bergmannstrost Halle GgmbH) and the Ethics Committee of the Saxony-Anhalt Medical Association. Consent for publication Not applicable. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding No funding Authors' contributions P. H-C. Study planning, questionnaire design, manuscript preparation, Information for the HEMS bases H. W. Questionnaire review, manuscript revision K. z. N. Questionnaire review, manuscript revision, Information for the EMS stations B. S. Questionnaire review, manuscript revision, Information for the HEMS bases A. G. Questionnaire review, manuscript revision M. L. 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Additional Declarations No competing interests reported. Supplementary Files Surveyontheleveloftrainingandexperienceintheuseoftourniquetsinground.docx Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 15 Apr, 2026 Reviews received at journal 14 Apr, 2026 Reviews received at journal 13 Apr, 2026 Reviews received at journal 07 Apr, 2026 Reviewers agreed at journal 05 Apr, 2026 Reviewers agreed at journal 03 Apr, 2026 Reviews received at journal 03 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers agreed at journal 02 Apr, 2026 Reviewers invited by journal 01 Apr, 2026 Editor assigned by journal 31 Mar, 2026 Editor invited by journal 26 Mar, 2026 Submission checks completed at journal 24 Mar, 2026 First submitted to journal 24 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Wrigge","email":"","orcid":"","institution":"BG Klinikum Bergmannstrost Halle","correspondingAuthor":false,"prefix":"","firstName":"H.","middleName":"","lastName":"Wrigge","suffix":""},{"id":617751732,"identity":"4edbb0e9-9cb8-4a64-8169-2b80f0fe72fa","order_by":2,"name":"K. zur Nieden","email":"","orcid":"","institution":"BG Klinikum Bergmannstrost Halle","correspondingAuthor":false,"prefix":"","firstName":"K.","middleName":"zur","lastName":"Nieden","suffix":""},{"id":617751735,"identity":"80db9998-fd67-4a1e-a27f-a36310481d11","order_by":3,"name":"B. Stichert","email":"","orcid":"","institution":"BG Klinikum Bergmannstrost Halle","correspondingAuthor":false,"prefix":"","firstName":"B.","middleName":"","lastName":"Stichert","suffix":""},{"id":617751736,"identity":"ae514594-e36e-4856-8be7-107b898b5cdd","order_by":4,"name":"A. Großstück","email":"","orcid":"","institution":"BG Klinikum Bergmannstrost Halle","correspondingAuthor":false,"prefix":"","firstName":"A.","middleName":"","lastName":"Großstück","suffix":""},{"id":617751742,"identity":"82066d11-14a5-4dfe-930c-83aadc6f5c74","order_by":5,"name":"M. Lautenschläger","email":"data:image/png;base64,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","orcid":"","institution":"Martin Luther University Halle-Wittenberg","correspondingAuthor":true,"prefix":"","firstName":"M.","middleName":"","lastName":"Lautenschläger","suffix":""}],"badges":[],"createdAt":"2026-03-02 13:08:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9010509/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9010509/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106345243,"identity":"ee68d48e-4a57-46a9-a4db-3173b0cc133c","added_by":"auto","created_at":"2026-04-07 16:18:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":554835,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9010509/v1/30ed0e48-ded8-462f-9444-94825e4c9d48.pdf"},{"id":106345036,"identity":"7df49db9-5a8e-4073-9639-7ee9c4438174","added_by":"auto","created_at":"2026-04-07 16:17:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":24578,"visible":true,"origin":"","legend":"","description":"","filename":"Surveyontheleveloftrainingandexperienceintheuseoftourniquetsinground.docx","url":"https://assets-eu.researchsquare.com/files/rs-9010509/v1/840b63d3e1dc083b2eb427e7.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Tourniquet use in different emergency medicine professional groups. Are there differences in theoretical and practical training, frequency of use, and adherence to existing guidelines?","fulltext":[{"header":"Background","content":"\u003cp\u003eTraumatic haemorrhage is one of the most common causes of death in injured patients (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Targeted pre-hospital treatment can reduce morbidity and mortality (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). On the one hand, limb haemorrhage is often underestimated as a source of bleeding, but on the other hand, it can be effectively treated pre- and in-hospital with pressure bandages, wound packing or tourniquets (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The use of tourniquets for limb haemorrhage that cannot be stopped with a pressure bandage or where the tactical situation requires the temporary application of a tourniquet has gained importance due to positive experiences in the military and the increase in terrorist activities over the last two decades (\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Nevertheless, the majority of experiences and data originate from war and crisis zones (Afghanistan, Iraq, Israel, Ukraine) (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). More recently, data from civilian emergency medicine has also been increasingly reported (\u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, there are only a few publications available from European countries and little is known about the differences in theoretical and practical training, frequency of use, and adherence to existing guidelines between the different professional groups (Emergency Medical Technician / basic emergency medical technicians \u0026ndash; EMT, Advanced Emergency Medical Technician / intermediate emergency medical technicians- AEMT, Paramedic / paramedic emergency medical technicians, Helicopter Emergency Medical Services-Technical Crew member - HEMS-TC, Prehospital Physician) (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18 CR19\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eIn order to obtain an overview of the level of training and use of tourniquets among the various professional groups, we conducted a regional online survey in the ground-based emergency medical services (EMS) in the region of Halle (Saale) /Saale District in Saxony-Anhalt, Germany, as well as for the helicopter emergency medical services (HEMS) in the Halle (Saale) /Leipzig metropolitan region. This area comprises 24 EMS stations, including 5 physician-staffed rapid response vehicles, two HEMS bases operating 4 helicopters, and one location with a physician-staffed intensive care transport vehicle. A questionnaire with multiple questions regarding education, availability, level of training, experience in the use of tourniquets in EMS and HEMS and personal opinions was available online from 02.07.24 to 15.10.2024 and a QR code was sent to the participants to get access to the survey (see supl. Figure\u0026nbsp;1). The questionnaire was developed by three experienced emergency physicians and evaluated by the authors. It consisted of various sections (general, training, availability, theoretical and practical aspects, opinions) with a total of 45 questions. In the current study, we analysed the questions with regard to education/training, practical experience in application and adherence to guidelines. We compared the different professional groups against each other where appropriate and all the emergency medical service personnel (EMT, AEMT, Paramedic, HEMS-TC) against the pre-hospital physicians, if significant differences were found between the professional groups. In the case that not all participants answered every question of the survey, all available answers were analysed. Statistical analysis was mainly descriptive, differences between groups were compared using chi\u003csup\u003e2\u003c/sup\u003e test for categorical data. All computations were performed using Prism GraphPad (GraphPad Software, 225 Franklin Street FL 26 Boston, MA 02110, USA).\u003c/p\u003e \u003cp\u003eThe data collection was approved by the hospital management and is in accordance with the European General Data Protection Regulation. As no personal data that could reveal the identity of a participant was collected as part of the study, the Ethics Committee of the Saxony-Anhalt Medical Association did not consider a new vote to be necessary and referred to the existing vote (56/21) on a study on tourniquets already conducted by the authors (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study period, 178 participants took part and answered the questionnaire. Of the 178 participants (74% male, 26% female), 132 (74%) completed the whole survey.\u003c/p\u003e \u003cp\u003eThe results in the following sections refer to all available responses and not just to the 132 participants who completed the whole questionnaire. This means that the number of responses / participants may vary between questions.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides an overview of available general information such as the age, qualifications, kind of emergency vehicle and length of service in the emergency medical services of the participants.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cb\u003e)\u003c/b\u003e Age, qualifications, EMS vehicle and length of service in the emergency medical services of the participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge of participants\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17% (N\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30\u0026ndash;39 years\u003c/p\u003e \u003cp\u003e31% (N\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40\u0026ndash;49 years\u003c/p\u003e \u003cp\u003e32.5% (N\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u0026ndash;59 years\u003c/p\u003e \u003cp\u003e17% (N\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;60 years\u003c/p\u003e \u003cp\u003e2.5% (N\u0026thinsp;=\u0026thinsp;4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfession of participants\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ephysician\u003c/p\u003e \u003cp\u003e47% (N\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHEMS-TC\u003c/p\u003e \u003cp\u003e8% (N\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eparamedic\u003c/p\u003e \u003cp\u003e32% (N\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAEMT\u003c/p\u003e \u003cp\u003e4% (N\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEMT\u003c/p\u003e \u003cp\u003e9% (N\u0026thinsp;=\u0026thinsp;15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency vehicle\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAmbulance\u003c/p\u003e \u003cp\u003e46% (N\u0026thinsp;=\u0026thinsp;73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRapid response care\u003c/p\u003e \u003cp\u003e54% (N\u0026thinsp;=\u0026thinsp;86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRescue Helicopter\u003c/p\u003e \u003cp\u003e29% (N\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIntensive care transport vehicle\u003c/p\u003e \u003cp\u003e9% (N\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMore than one vehicle\u003c/p\u003e \u003cp\u003e36% (N\u0026thinsp;=\u0026thinsp;57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime in EMS / HEMS\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;2 years\u003c/p\u003e \u003cp\u003e7% (N\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u0026ndash;5 years\u003c/p\u003e \u003cp\u003e22% (N\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003cp\u003e20% (N\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e \u003cp\u003e51% (N\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e1\u003c/sup\u003eOne participant did not specify the profession, \u003csup\u003e2\u003c/sup\u003emultiple answers possible, \u003csup\u003e3\u003c/sup\u003e time since completing training in the emergency medical service\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf the 75 participating physicians, 63 (84%) were consultants (senior doctors) and 12 (16%) residents (junior doctors), which were divided into the following medical specialties: 56 (75%) anaesthesiology and intensive care medicine, 8 (10.5%) surgery, 9 (11%) internal medicine and 3 (4%) others.\u003c/p\u003e\n\u003ch3\u003eEducation and Training\u003c/h3\u003e\n\u003cp\u003e91% (N\u0026thinsp;=\u0026thinsp;146) of the respondents had some kind of theoretical education and / or practical training in the tourniquet use and 9% (N\u0026thinsp;=\u0026thinsp;14) had not, with no significant differences between the professional groups. Theoretical education was completed by 81% (N\u0026thinsp;=\u0026thinsp;130) of the respondents and practical training by 87% (N\u0026thinsp;=\u0026thinsp;139). The difference in the theoretical education between the professional groups was statistically significant (chi\u003csup\u003e2\u003c/sup\u003e statistic 12.03, p .017) with the lowest rate of education in the EMT group (67%) and the highest rate in the paramedic group (96%). When comparing the rate of theoretical education between all the emergency medical service personnel (91%) against the pre-hospital physicians (73%), theoretical education was significantly higher in the emergency medical service personnel group (chi\u003csup\u003e2\u003c/sup\u003e statistic 9.09, p .0026). 43% (N\u0026thinsp;=\u0026thinsp;69) of respondents stated that they had received training or education on their own initiative (EMT 53%, AEMT 33%, Paramedics 53%, HEMS-TC 27%, physicians 37%). The difference in the professional groups was not statistically significant. As part of their vocational training in the emergency medical services, 43% (N\u0026thinsp;=\u0026thinsp;69) received training and a total of 41% (N\u0026thinsp;=\u0026thinsp;66) received training in the form of special courses (PHTLS-Pre-Hospital Trauma Life Support, etc.). 25% of the pre-hospital physicians received their training as part of the emergency doctor course.\u003c/p\u003e\n\u003ch3\u003ePractical experience in application\u003c/h3\u003e\n\u003cp\u003e57% (N\u0026thinsp;=\u0026thinsp;77) of respondents have applied a tourniquet to at least one patient, and 13% (N\u0026thinsp;=\u0026thinsp;18) have had to apply more than one tourniquet at the same time. There were no significant differences between the professional groups in terms of the necessity of tourniquet application. 80% (N\u0026thinsp;=\u0026thinsp;8) of EMT, 60% (N\u0026thinsp;=\u0026thinsp;3) of AEMT, 55% (N\u0026thinsp;=\u0026thinsp;21) of paramedics, 73% (N\u0026thinsp;=\u0026thinsp;8) of HEMS-TCs and 54% (N\u0026thinsp;=\u0026thinsp;37) of doctors stated that they had already applied a tourniquet. Regarding the frequency of use, 26% (N\u0026thinsp;=\u0026thinsp;40) of the respondents stated that they had used a tourniquet 1\u0026ndash;2 times, 18% (N\u0026thinsp;=\u0026thinsp;29) 3\u0026ndash;5 times, 5% (N\u0026thinsp;=\u0026thinsp;8) 6\u0026ndash;10 times and 1% (N\u0026thinsp;=\u0026thinsp;1)\u0026thinsp;\u0026gt;\u0026thinsp;10 times. When comparing the necessity of tourniquet application of all the emergency medical service personnel (64%) against the pre-hospital physicians (54%), the difference was not statistically significant.\u003c/p\u003e\n\u003ch3\u003eAdherence to existing guidelines\u003c/h3\u003e\n\u003cp\u003eThe location for applying a tourniquet in the pre-hospital setting was defined by respondents as follows: 77% (N\u0026thinsp;=\u0026thinsp;126) as distally as possible \u0026ndash; but sufficiently proximally (at least 5 cm / a hand's width) from the source of bleeding, 12% (N\u0026thinsp;=\u0026thinsp;20) directly above the site of bleeding and 11% (N\u0026thinsp;=\u0026thinsp;18) above the joint of the affected limb. There was no statistically significant difference between the professional groups. Regarding the indication for pre-hospital tourniquet use, 90% of the answers were in accordance with current guidelines with no significant differences between the professional groups. There were considerable differences in the responses regarding the maximum occlusion time for the tourniquet. 1.5% (N\u0026thinsp;=\u0026thinsp;2) of respondents estimated the maximum occlusion time for a tourniquet to be 30 minutes, 16% (N\u0026thinsp;=\u0026thinsp;22) estimated it to be 60 minutes, 9% (N\u0026thinsp;=\u0026thinsp;12) estimated it to be 90 minutes, the majority (66%, N\u0026thinsp;=\u0026thinsp;93) estimated it to be 120 minutes, 6% (N\u0026thinsp;=\u0026thinsp;9) estimated it to be 180 minutes, and 1.5% (N\u0026thinsp;=\u0026thinsp;2) estimated it to be unlimited. No significant differences between the professional groups were found.\u003c/p\u003e \u003cp\u003eAnother important finding of the survey was that all rescue vehicles (ambulances, rescue helicopters, etc.) were equipped with tourniquets.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e Our survey demonstrates that the education/practical training and adherence to current guidelines for tourniquet use in emergency medical service professionals is far from being perfect but quite good. There are already surveys and descriptive analyses on the application of tourniquets in civilian EMS. Several studies have characterized patterns, trends, and outcomes of prehospital tourniquet use in the civilian setting (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Surveys and data from the German-speaking zone are still missing.\u003c/p\u003e \u003cp\u003eLarge-scale analyses using the US National EMS Information System (NEMSIS) have described the prevalence, predictors, and demographic characteristics of tourniquet use by civilian EMS, showing an increase in adoption, especially in urban and advanced life support settings. These surveys found that tourniquets are most commonly applied for traumatic injuries, with upper extremity injuries being more frequent than lower extremity injuries, and that the prevalence of use increased (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAn American survey on the knowledge, experience, training of civilian pre-hospital providers revealed significant knowledge gaps and a low number of trained providers (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). The survey is comparable to our study with regards to number of participants (N\u0026thinsp;=\u0026thinsp;151) and non-physician professional groups (basic, intermediate and paramedic emergency medical technicians). In contrast to our study, only 17% of the participants had used tourniquets in the pre-hospital setting, but the survey is already more than 13 years old and, however, one must bear in mind that tourniquet use in civilian EMS is increasing.\u003c/p\u003e \u003cp\u003eOther regional and multicentre studies have reported on the incidence, mechanisms of injury, who applies the tourniquet (EMS, law enforcement, or layperson), and outcomes, including complication rates and effectiveness in haemorrhage control (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThese surveys consistently demonstrate that tourniquet use in civilian EMS is increasing, is effective for haemorrhage control, and is associated with low complication rates when applied appropriately (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Pre-hospital tourniquet use in EMS is associated with improved survival, reduced shock on arrival, and decreased transfusion requirements, with a low rate of serious limb complications (\u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn contrast to the US EMS and many other American / South American countries, in the German-speaking zone and some other European countries pre-hospital physicians can regularly be found in the EMS and HEMS. There are no large-scale published surveys or studies specifically focused on the use of tourniquets by pre-hospital physicians in EMS. The available literature primarily describes tourniquet application by EMS personnel, law enforcement, and laypersons in civilian pre-hospital settings. To our knowledge, the current study is the first investigating the education/training, practical experiences and guideline adherence of tourniquet application by pre-hospital physicians. Our data revealed that theoretical education in the pre-hospital physician group (73%) was significantly lower compared to the entirely different EMS professional groups (91%), raising the question why the pre-hospital physicians in our study had a quite low education rate. Unfortunately, we cannot answer that question, and the reason may be multifactorial. Regardless of any potentially existing multifactorial reasons, physicians are also obliged to familiarize themselves with the available equipment. Since tourniquets were available on all rescue vehicles, it would have been the physicians' duty to familiarize themselves with them. Which obviously didn't happen. In line with our results, the literature shows that the level of training in the use of tourniquets among pre-hospital emergency physicians is heterogeneous and often inadequate. Studies show that although tourniquets are increasingly being used in civilian EMS, the correct indication and application are often not optimal. Tourniquets are regularly applied without clear indication or are placed incorrectly, which points to deficits in education and training (\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCompared to older studies, our survey shows that a high proportion of emergency medical services personnel have completed theoretical and practical training in the use of tourniquets. Emergency physicians are significantly less likely to have received theoretical training, which is something that definitely needs to be improved. More than half of respondents already had applied at least one tourniquet to a patient, which underlines the increasing tourniquet use in civilian EMS.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAEMAT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdvanced Emergency Medical Technician / intermediate emergency medical technicians\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Medical Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEmergency Medical Technician / basic emergency medical technicians\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHEMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHelicopter Emergency Medical Service\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHEMS-TC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHelicopter Emergency Medical Services - Technical Crew member\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePHTLS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePre-Hospital Trauma Life Support\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUnited States\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data collection was approved by the hospital management and is in accordance with the European General Data Protection Regulation. Given that, as in a previous study we conducted on the topic of Tourniquet, no personally identifiable data was collected, the study was classified by the Ethics Committee of the Saxony-Anhalt Medical Association as not requiring approval (Ref. 56/21). The need for consent to participate was waived by the Institutional Review Board (Krankenhausleitung BG Klinikum Bergmannstrost Halle GgmbH) and the Ethics Committee of the Saxony-Anhalt Medical Association.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eP. H-C. Study planning, questionnaire design, manuscript preparation, Information for the HEMS bases\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eH. W. Questionnaire review, manuscript revision\u003c/p\u003e\n\u003cp\u003eK. z. N. Questionnaire review, manuscript revision, Information for the EMS stations\u003c/p\u003e\n\u003cp\u003eB. S. Questionnaire review, manuscript revision, Information for the HEMS bases\u003c/p\u003e\n\u003cp\u003eA. G. Questionnaire review, manuscript revision\u003c/p\u003e\n\u003cp\u003eM. L. Study planning, questionnaire design, manuscript preparation\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their sincere thanks to the participants in the survey.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWilharm A, Pflug A, Loos F, Sommerfeld O, Hofmann GO, Sauer S. Causes of Death in the Seriously Injured -Why do Severely Injured Patients Die Today? Z Orthop Unfall. 2023;161(3):297\u0026ndash;303.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePfeifer R, Tarkin IS, Rocos B, Pape HC. Patterns of mortality and causes of death in polytrauma patients\u0026ndash;has anything changed? Injury. 2009;40(9):907\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKragh JF Jr., Walters TJ, Baer DG, Fox CJ, Wade CE, Salinas J, et al. Survival with emergency tourniquet use to stop bleeding in major limb trauma. Ann Surg. 2009;249(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTrentzsch H, Goossen K, Prediger B, Schweigkofler U, Hilbert-Carius P, Hanken H, et al. Stop the bleed - Prehospital bleeding control in patients with multiple and/or severe injuries - A systematic review and clinical practice guideline - A systematic review and clinical practice guideline. Eur J Trauma Emerg Surg. 2025;51(1):92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKo YC, Tsai TY, Wu CK, Lin KW, Hsieh MJ, Lu TP, et al. Effectiveness and safety of tourniquet utilization for civilian vascular extremity trauma in the pre-hospital settings: a systematic review and meta-analysis. World J Emerg Surg. 2024;19(1):10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHossfeld B, Lechner R, Josse F, Bernhard M, Walcher F, Helm M, et al. [Prehospital application of tourniquets for life-threatening extremity hemorrhage: Systematic review of literature]. Unfallchirurg. 2018;121(7):516\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGotthardt P, Fandler M, Plappert T. Tourniquet im Einsatz Notfall + Rettungsmedizin. 2018;21(1):62\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLechner R, Kulla M, Josse F, Hossfeld B. Pr\u0026auml;hospitale Anlage von Tourniquets zur Kontrolle massiver Extremit\u0026auml;tenblutungen \u0026ndash; ein Update. Der Notarzt. 2019;35(01):45\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButler F, Holcomb JB, Dorlac W, Gurney J, Inaba K, Jacobs L, et al. Who needs a tourniquet? And who does not? Lessons learned from a review of tourniquet use in the Russo-Ukrainian war. J Trauma Acute Care Surg. 2024;97(2S Suppl 1):S45\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHolcomb JB. Transport Time and Preoperating Room Hemostatic Interventions Are Important: Improving Outcomes After Severe Truncal Injury. Crit Care Med. 2018;46(3):447\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoward JT, Kotwal RS, Stern CA, Janak JC, Mazuchowski EL, Butler FK, et al. Use of Combat Casualty Care Data to Assess the US Military Trauma System During the Afghanistan and Iraq Conflicts, 2001\u0026ndash;2017. JAMA Surg. 2019;154(7):600\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Sayed MJ, Tamim H, Mailhac A, Mann NC. Trends and Predictors of Limb Tourniquet Use by Civilian Emergency Medical Services in the United States. Prehosp Emerg Care. 2017;21(1):54\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInaba K, Siboni S, Resnick S, Zhu J, Wong MD, Haltmeier T et al. Tourniquet use for civilian extremity trauma. J Trauma Acute Care Surg. 2015;79(2):232-7;quiz 332-3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKauvar DS, Dubick MA, Walters TJ, Kragh JF. Jr. Systematic review of prehospital tourniquet use in civilian limb trauma. J Trauma Acute Care Surg. 2018;84(5):819\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCarthy EM, Burns K, Schuster KM, Cone DC. Tourniquet Use in the Prehospital Setting. Prehosp Emerg Care. 2024;28(3):531\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScerbo MH, Mumm JP, Gates K, Love JD, Wade CE, Holcomb JB, et al. Safety and Appropriateness of Tourniquets in 105 Civilians. Prehosp Emerg Care. 2016;20(6):712\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButler FK. Jr. TCCC Updates: Two Decades of Saving Lives on the Battlefield: Tactical Combat Casualty Care Turns 20. J Spec Oper Med. 2017;17(2):166\u0026ndash;72.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHewett Brumberg EK, Douma MJ, Alibertis K, Charlton NP, Goldman MP, Harper-Kirksey K, et al. 2024 American Heart Association and American Red Cross Guidelines for First Aid. Circulation. 2024;150(24):e519\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuinn RH, Wedmore I, Johnson E, Islas A, Anglim A, Zafren K, et al. Wilderness Medical Society practice guidelines for basic wound management in the austere environment. Wilderness Environ Med. 2014;25(3):295\u0026ndash;310.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHossfeld B, Helm M, Josse F, Kulla M, Lampl LA, Bernhard M, et al. Handlungsempfehlung: Pr\u0026auml;hospitale Anwendung von Tourniquets. An\u0026auml;sth Intensivmed. 2016;57:7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLautenschlager M, Braun D, Wrigge H, Hossfeld B, Streibert F, Hilbert-Carius P. [Tourniquet use in the Helicopter Emergency Medical Service: Analysis based on data of the DRF Luftrettung (German Air Rescue) in the period 2015\u0026ndash;2020]. Anaesthesist. 2022;71(4):264\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcCarty JC, Hashmi ZG, Herrera-Escobar JP, de Jager E, Chaudhary MA, Lipsitz SR, et al. Effectiveness of the American College of Surgeons Bleeding Control Basic Training Among Laypeople Applying Different Tourniquet Types: A Randomized Clinical Trial. JAMA Surg. 2019;154(10):923\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWall PL, Welander JD, Smith HL, Buising CM, Sahr SM. What do the people who transport trauma patients know about tourniquets? J Trauma Acute Care Surg. 2014;77(5):734\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarnard LM, Guan S, Zarmer L, Mills B, Blackwood J, Bulger E, et al. Prehospital tourniquet use: An evaluation of community application and outcome. J Trauma Acute Care Surg. 2021;90(6):1040\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchroll R, Smith A, Alabaster K, Schroeppel TJ, Stillman ZE, Teicher EJ, et al. AAST multicenter prospective analysis of prehospital tourniquet use for extremity trauma. J Trauma Acute Care Surg. 2022;92(6):997\u0026ndash;1004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKue RC, Dyer KS, Blansfield JS, Burke PA. Tourniquet use at the Boston Marathon. J Trauma Acute Care Surg. 2015;79(4):701\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKue RC, Temin ES, Weiner SG, Gates J, Coleman MH, Fisher J, et al. Tourniquet Use in a Civilian Emergency Medical Services Setting: A Descriptive Analysis of the Boston EMS Experience. Prehosp Emerg Care. 2015;19(3):399\u0026ndash;404.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHashmi ZG, Hu PJ, Jansen JO, Butler FK, Kerby JD, Holcomb JB. Characteristics and Outcomes of Prehospital Tourniquet Use for Trauma in the United States. Prehosp Emerg Care. 2023;27(1):31\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenry R, Matsushima K, Ghafil C, Henry RN, Theeuwen H, Golden AC, et al. Increased Use of Prehospital Tourniquet and Patient Survival: Los Angeles Countywide Study. J Am Coll Surg. 2021;233(2):233\u0026ndash;9. e2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSmith AA, Ochoa JE, Wong S, Beatty S, Elder J, Guidry C, et al. Prehospital tourniquet use in penetrating extremity trauma: Decreased blood transfusions and limb complications. J Trauma Acute Care Surg. 2019;86(1):43\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBedri H, Ayoub H, Engelbart JM, Lilienthal M, Galet C, Skeete DA. Tourniquet Application for Bleeding Control in a Rural Trauma System: Outcomes and Implications for Prehospital Providers. Prehosp Emerg Care. 2022;26(2):246\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGushing J, Blair SG, Albrecht RM, Sawar Z, Stewart K, Knoles C, et al. Prehospital tourniquet placement in extremity trauma. Am J Surg. 2023;226(6):901\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMikdad S, Mokhtari AK, Luckhurst CM, Breen KA, Liu B, Kaafarani HMA, et al. Implications of the national Stop the Bleed campaign: The swinging pendulum of prehospital tourniquet application in civilian limb trauma. J Trauma Acute Care Surg. 2021;91(2):352\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"haemorrhage, extremity trauma, pre-hospital, emergency medical service personnel, emergency physicians","lastPublishedDoi":"10.21203/rs.3.rs-9010509/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9010509/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTraumatic haemorrhage is one of the most common causes of death in injured patients. Targeted pre-hospital haemostasis can reduce morbidity and mortality. The use of tourniquets is advisable for external bleeding in the extremities that cannot be treated by compression and wound packing. There are corresponding recommendations for tourniquet use. Little is currently known about the level of training and the frequency of use of the various professional groups of potential tourniquet users.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eStatus survey on the level of training and frequency of use of tourniquets among various pre-hospital professional groups (Emergency Medical Technician / basic emergency medical technicians \u0026ndash; EMT, Advanced Emergency Medical Technician / intermediate emergency medical technicians - AEMT, Paramedic / paramedic emergency medical technicians, Helicopter Emergency Medical Services-Technical Crew member - HEMS-TC, Prehospital Physician). In order to obtain an overview of the level of training and use of tourniquets among the various professional groups, we conducted a regional online survey in the ground-based emergency medical services in the region of Halle/Northern Saale District in Saxony-Anhalt, as well as for the helicopter emergency medical services in the Halle/Leipzig metropolitan region. The different professional groups were compared with regard to theoretical and practical training, frequency of use, and adherence to existing guidelines.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e178 participants (74% male, 26% female) took part and answered the questionnaire, including 47% pre-hospital physician, 32% paramedic, 9% EMT, 8% HEMS-TC, 6% AEMT. The only statistically significant differences were found in theoretical education, with the lowest rate of education in the EMT group (67%) and the highest rate in the paramedic group (96%). When comparing theoretical education of all the emergency medical service personnel (91%) against the pre-hospital physicians (73%), it was significantly higher in the emergency medical service personnel group. No differences were found for practical training, frequency of use, and adherence to existing guidelines.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e Apart from theoretical education, no differences are apparent regarding practical training, frequency of use, and adherence to existing guidelines for potential pre-hospital tourniquet users. However, education and training can still be improved.\u003c/p\u003e","manuscriptTitle":"Tourniquet use in different emergency medicine professional groups. 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