Table 3
Source publication
Background
The traditional sequence of trauma care: Airway, Breathing, Circulation (ABC) has been practiced for many years. It became the standard of care despite the lack of scientific evidence. We hypothesized that patients in hypovolemic shock would have comparable outcomes with initiation of bleeding treatment (transfusion) prior to intubation...
Contexts in source publication
Context 1
... groups had a similar percentage of patients that re- ceived blood transfusion overall (CAB 62.1% vs. ABC 69.4% p = 0.11) and there was no difference in those receiv- ing massive transfusion (Table 3). There was no statistical difference regarding those surviving to ICU admission with 72.8 and 67.8% admitted initially to the ICU in each group (Table 3). ...
Context 2
... 69.4% p = 0.11) and there was no difference in those receiv- ing massive transfusion (Table 3). There was no statistical difference regarding those surviving to ICU admission with 72.8 and 67.8% admitted initially to the ICU in each group (Table 3). The median LOS in the CAB was slightly longer at 8 days compared with 4 days, but the difference did not reach statistical significance (p = 0.24). ...
Citations
... Recent insights have spurred a reevaluation of the primary survey sequence of trauma (ABCs), favoring the prioritization of resuscitation and circulation (CAB) and, when possible, delaying intubation in patients with exsanguinating injuries [6][7][8][9][10][11]. Prioritizing circulation is a multifaceted approach based on current data suggesting that euvolemic, hemostatic resuscitation strategies using blood products over crystalloid fluids and delaying intubation until either blood products are given or a procedure to stop or slow down bleeding has been performed can improve outcomes in patients with severe traumatic injuries [5,11,12]. ...
... Studies comparing the traditional ABC approach to the CAB model indicate that prioritizing circulation is effective, particularly in trauma patients with hemorrhagic shock [7,11,[16][17][18][19][20]. This evolving approach underscores the importance of rethinking intubation timing, emphasizing evidence-based practices, rapid response, and collaboration for enhanced patient survival in severe bleeding scenarios [7,11,[16][17][18][19][20][21]. ...
... Studies comparing the traditional ABC approach to the CAB model indicate that prioritizing circulation is effective, particularly in trauma patients with hemorrhagic shock [7,11,[16][17][18][19][20]. This evolving approach underscores the importance of rethinking intubation timing, emphasizing evidence-based practices, rapid response, and collaboration for enhanced patient survival in severe bleeding scenarios [7,11,[16][17][18][19][20][21]. ...
Introduction
Hemorrhage is a major cause of preventable trauma deaths, and the ABC approach is widely used during the primary survey. We hypothesize that prioritizing circulation over intubation (CAB) can improve outcomes in patients with exsanguinating injuries.
Methods
A prospective observational study involving international trauma centers was conducted. Patients with systolic blood pressure below 90 who were intubated within 30 min of arrival were included. Prioritizing circulation (CAB) was defined as delaying intubation until blood products were started, and/or bleeding control was performed before securing the airway. Demographics, clinical data, and outcomes were recorded.
Results
The study included 278 eligible patients, with 61.5% falling within the “CAB” cohort and 38.5% in the “ABC” cohort. Demographic and disease characteristics, including age, sex, ISS, use of blood products, and other relevant factors, exhibited comparable distributions between the two cohorts. The CAB group had a higher proportion of penetrating injuries and more patients receiving intubation in the operating room. Notably, patients in the CAB group demonstrated higher GCS scores, lower SBP values before intubation but higher after intubation, and a significantly lower incidence of cardiac arrest and post-intubation hypotension. Key outcomes revealed significantly lower 24-hour mortality in the CAB group (11.1% vs. 69.2%), a lower rate of renal failure, and a higher rate of ARDS. Multivariable logistic regression models showed a 91% reduction in the odds of mortality within 24 h and an 89% reduction at 30 days for the CAB cohort compared to the ABC cohort. These findings suggest that prioritizing circulation before intubation is associated with improved outcomes in patients with exsanguinating injuries.
Conclusion
Post-intubation hypotension is observed to be correlated with worse outcomes. The consideration of prioritizing circulation over intubation in patients with exsanguinating injuries, allowing for resuscitation, or bleeding control, appears to be associated with potential improvements in survival. Emphasizing the importance of circulation and resuscitation is crucial, and this approach might offer benefits for various bleeding-related conditions.
... Overall, there is a growing body of evidence and discussion suggesting that a circulation-first approach is justified when caring for trauma patients, particularly those in hemorrhagic shock. 20,21 Patients in hemorrhagic shock are particularly prone to the circulatory collapse associated with early intubation and require adequate resuscitation before airway control. Larger prospective clinical studies in both military and civilian populations are essential to definitively establish the preferred method of resuscitation. ...
Prioritizing circulation in trauma care and delaying intubation in noncompressible cases improve outcomes. By prioritizing circulation, patient survival significantly improves, advocating evidence-based shifts in trauma care.
... Possible mechanisms for worse cardiac arrest outcomes when airway management is prioritized include delay in initiation of compressions, interruption of effective compressions for insertion of an advanced airway, and positive pressure ventilation resulting in decreased venous return and subsequent blood flow to the heart and brain (8). Despite the obvious differences between cardiac arrest and traumatic injury, a growing body of evidence suggests that principles supporting the CAB sequence may also apply to the management of traumatically injured patients in hemorrhagic shock, especially those with noncompressible torso hemorrhage (NCTH) (9,10). Although Advanced Trauma Life Support (ATLS) guidelines continue to advocate an ABC sequence for the management of injured patients, similar mechanisms may explain worse outcomes when the management of the airway and breathing are prioritized over efforts to correct hemorrhagic shock (8,9,11). ...
... Despite the obvious differences between cardiac arrest and traumatic injury, a growing body of evidence suggests that principles supporting the CAB sequence may also apply to the management of traumatically injured patients in hemorrhagic shock, especially those with noncompressible torso hemorrhage (NCTH) (9,10). Although Advanced Trauma Life Support (ATLS) guidelines continue to advocate an ABC sequence for the management of injured patients, similar mechanisms may explain worse outcomes when the management of the airway and breathing are prioritized over efforts to correct hemorrhagic shock (8,9,11). We believe that the current one-size-fits-all ABC sequence may not be best for patients with traumatic injury. ...
... Data demonstrating the potential superiority of a circulation-first approach to cardiac arrest have prompted the evolution from ABC to compression-only CPR with deferred placement of a definitive airway (4,7,9,15). Clinical studies and large animal models have demonstrated that during prolonged cardiac arrest, the most important factor for survival is the adequacy of coronary perfusion pressure produced by chest compressions (16)(17)(18)(19). ...
The original guidelines of cardiopulmonary resuscitation focused on the establishment of an airway and rescue breathing before restoration of circulation through cardiopulmonary resuscitation. As a result, the airway-breathing-circulation approach became the central guiding principle of resuscitation. Despite new guidelines by the American Heart Association for a circulation-first approach, Advanced Trauma Life Support guidelines continue to advocate for the airway-breathing-circulation sequence. Although definitive airway management is often necessary for severely injured patients, endotracheal intubation (ETI) before resuscitation in patients with hemorrhagic shock may worsen hypotension and precipitate cardiac arrest. In severely injured patients, a paradigm shift should be considered, which prioritizes restoration of circulation before ETI and positive pressure ventilation while maintaining a focus on basic airway assessment and noninvasive airway interventions. For this patient population, the most reasonable current strategy may be to target a simultaneous resuscitation approach, with immediate efforts to control hemorrhage and provide basic airway interventions while prioritizing volume resuscitation with blood products and deferring ETI until adequate systemic perfusion has been attained. We believe that a circulation-first sequence will improve both survival and neurologic outcomes for a traumatically injured patient and will continue to advocate this approach, as additional clinical evidence is generated to inform how to best tailor circulation-first resuscitation for varied injury patterns and patient populations.
... The Advanced Trauma Life Support (ATLS) course of the American College of Surgeons Committee on Trauma [2] promotes a systematic approach to every trauma patient, prioritizing airway-breathing-circulation, ie, the ABCs. Recently, it has been suggested that "C"-definitive control of hemorrhage and restoration of adequate circulating volumeshould be prioritized first in patients with hemorrhagic shock [3]. Hemorrhage control and resuscitation can and should begin in the prehospital arena. ...
This is a paper about pelvic fracture-related bleeding control.
... While a Glasgow Coma Scale (GCS) score <8 was traditionally used as an indication for advanced airway management (7,10), subsequent research suggests that a GCS score of < 8 alone does not correlate well with hypoxia, aspiration, need for prolonged intensive care unit care, or mortality, and thus must be only one component of the decision for advanced airway management (11). In cases of hemodynamic instability, patients must be resuscitated prior to placement of advanced airways to reduce the risk of further hypoperfusion, cardiovascular collapse, and worse outcomes including peri-intubation arrest (12,13). ...
... The traditional sequence of airway, breathing, and circulation (ABCs) has been practiced in trauma care for decades despite the lack of supporting evidence. More recently, authors have advocated for a CAB or circulation-first approach (13). The Trauma Hemostasis and Oxygenation Research (THOR) study group consensus opinion is that the focus in hemorrhagic shock should be on improving blood flow over increasing oxygenation (44). ...
Definitive management of trauma is not possible in the out-of-hospital environment. Rapid treatment and transport of trauma casualties to a trauma center are vital to improve survival and outcomes. Prioritization and management of airway, oxygenation, ventilation, protection from gross aspiration, and physiologic optimization must be balanced against timely patient delivery to definitive care. The optimal prehospital airway management strategy for trauma has not been clearly defined; the best choice should be patient-specific.
NAEMSP recommends:
• The approach to airway management and the choice of airway interventions in a trauma patient requires an iterative, individualized assessment that considers patient, clinician, and environmental factors.
• Optimal trauma airway management should focus on meeting the goals of adequate oxygenation and ventilation rather than on specific interventions. Emergency medical services (EMS) clinicians should perform frequent reassessments to determine if there is a need to escalate from basic to advanced airway interventions.
• Management of immediately life-threatening injuries should take priority over advanced airway insertion.
• Drug-assisted airway management should be considered within a comprehensive algorithm incorporating failed airway options and balanced management of pain, agitation, and delirium.
• EMS medical directors must be highly engaged in assuring clinician competence in trauma airway assessment, management, and interventions.
... These changes and ET application at the site of injury before the onset of shock are associated with improved survival [6]. This innovative approach introduced by the military is currently advocated for civilian practice [7]. Most of the tourniquet reports published focus on military experience gained from its application by ground troops and field hospitals [8][9][10]. ...
Background: Future navy officers require unique training for emergency medical response in the isolated maritime environment. The authors issued a workshop on extremity bleeding control, using four different commercial extremity tourniquets onboard a training sail ship. The purposes were to assess participants' perceptions of this educational experience and evaluate self-application simplicity while navigating on high seas.
Methods: A descriptive observational study was conducted as part of a workshop issued to volunteer training officers. A post-workshop survey collected their perceptions about the workshops' content usefulness and adequacy, tourniquet safety, self-application simplicity, and device preference. Tourniquet preference was measured by frequency count while the rest of the studied variables on a one-to-ten Likert scale. Frequencies and percentages were calculated for the studied variables, and application simplicity means compared using the ANOVA test (p < 0.05).
Results: Fifty-one Spanish training naval officers, aged 20 or 21, perceived high sea workshop content's usefulness, adequacy, and safety level at 8.6/10, 8.7/10, and 7.5/10, respectively. As for application simplicity, CAT and SAM-XT were rated equally with a mean of 8.5, followed by SWAT (7.9) and RATS (6.9), this one statistically different from the rest (p < 0.01). Windlass types were preferred by 94%.
Conclusions: The training sail ship's extremity bleeding control workshop was perceived as useful and its content adequate by the participating midshipmen. Windlass types were regarded as easier to apply than elastic counterparts. They were also preferred by nine out of every ten participants.
... However, hemodynamic management, including hemorrhage control and vascular access either simultaneously or even before airway efforts, may be warranted. 29,30 Most indications for advanced airway management include hypoventilation, hypoxia, airway protection, and shock. Unique to the austere setting is the need to secure requisite equipment available prior to performing a procedure, as well as the need for resources for ongoing management of that illness or injury. ...
Critically ill patients can present at any time and location, and they demand high quality care. Historical experiences from military, wilderness, and disaster medicine settings have helped shape the modern concept of caring for the most severely ill with limited available resources. We introduce a method to help design a successful critical care medical support endeavor, which includes properly defining components of Navigation, Environment, Resupply, Energy, Unconventional problems, and Support (NEREUS). Additionally, we provide recommendations for optimal team personnel composition, including utilization of paramedics, critical care providers, nurses, and respiratory therapists across the spectrum of care provided at point of injury, en route to definitive care, and definitive care. A review of critical care principles relevant to the austere setting proceeds with a systematic organization according to airway, breathing, circulation, and neurologic management. Lastly, we employ our proposed method of organizing a critical care medical support endeavor to a post-hurricane scenario. In summary, this review provides the historical background, modern definition, and practical framework for successfully administering critical care in scenarios with limited available resources. We emphasize the need to appropriately adapt critical care concepts to meet the unique demands of a specific scenario.
... The change of priorities and the timing of extremity tourniquet application on the eld before the onset of shock is associated with improved survival [6]. This innovative concept introduced by the military is currently also advocated in civilian practice [7]. Most of the published reports on tourniquet use focus on military experience gained from its application by ground troops and eld hospitals [8][9][10]. ...
Background
Future navy officers require unique training for emergency medical response in the isolated maritime environment. The authors issued a workshop on injury classification and extremity bleeding control, using four different commercial extremity tourniquets onboard a training sail ship. The purpose was to assess participants' perceptions of this educational experience and evaluate application simplicity while navigating on high seas.MethodsA descriptive observational study was conducted as part of a workshop issued to volunteer sailors. A post-workshop survey collected participants` perceptions about the workshops' content usefulness and adequacy, tourniquet safety, application simplicity in high seas, and device preference. The studied variables were measured on a one-to-ten Likert scale, while tourniquet preference by frequency count. Frequencies and percentages were calculated for the studied variables, and application simplicity means compared using the ANOVA test (p<0,05).ResultsFifty-one Spanish training naval officers, aged from 20-21, perceived workshop content usefulness, adequacy, and safety level in high sea use at 8.6/10, 8.7/10, and 7.5/10, respectively. As for application simplicity, CAT and SAM-XT were rated equally with a mean of 8.5, followed by SWAT (7.9) and RATS (6.9). The only statistical difference found was for the RATS (p<0.01). Windlass models were preferred by 94%, and elastic tourniquets by 6%. Conclusions
The training sail ship extremity bleeding control workshop was perceived as useful and its content adequate by the participating midshipmen. Windlass tourniquet types were regarded as easier to apply than elastics models and were the preferred model by nine out of every ten participants.
... In recent years this order has been questioned in the management of hypotensive trauma patients, noting that there is no survival benefit compared to the "CAB" model, where fluid replacement is initiated prior to intubation. 18 The objective of this study is to quantify how each prehospital intervention affects the amount of time that EMS spend on-scene with hypotensive trauma patients. Additionally, we sought to evaluate if the use of any interventions influenced all-cause in-hospital mortality. ...
... In recent years, some experts have questioned the classic "ABC" algorithm, noting that there is no survival benefit compared to "CAB" in hypovolemic trauma patients. 18 There is some evidence that prehospital intubation provides no survival benefit over intubation in the emergency department and that it can be harmful in some patients, including those suffering from penetrating trauma or traumatic brain injuries. [24][25][26][27][28][29][30][31][32] Understanding that intubation increases the amount of time that EMS spend on-scene in penetrating trauma and that it can potentially be harmful to certain patients, prehospital intubation of hypotensive penetrating trauma patients should be evaluated more closely. ...
Introduction
There is disagreement in the trauma community concerning the extent to which emergency medical services (EMS) should perform on-scene interventions. Additionally, in recent years the “ABC” algorithm has been questioned in hypotensive patients. The objective of this study was to quantify the delay introduced by different on-scene interventions.
Methods
A retrospective analysis of hypotensive trauma patients brought to an urban level 1 trauma center by EMS from 2007 to 2018 was performed, and patients were stratified by mechanism of injury and new injury severity score (NISS). Independent samples median tests were used to compare median on-scene times.
Results
Among 982 trauma patients, median on-scene time was 5 minutes (interquartile range 3-8). In penetrating trauma patients ( n = 488) with NISS of 16-25, intubation significantly increased scene time from 4 to 6 minutes ( P < .05). In penetrating trauma patients with NISS of 10-15, wound care significantly increased scene time from 3 to 6 minutes ( P < .05). Tourniquet use, interosseous (IO) access, intravenous (IV) access, and needle decompression did not significantly increase scene time.
Conclusion
Understanding that intubation increases scene time in penetrating trauma, while IV and IO access do not, alterations to the traditional “ABC” algorithm may be warranted. Further investigation of prehospital interventions is needed to determine which are appropriate on-scene.
... In India, the underdeveloped prehospital care is yet to move to great lengths. [8] The trauma system in place in our country which includes the prehospital care has not been instrumental in providing primary management to patients. [9] Hence, we have undertaken this study to understand the circulatory status at arrival to the ED. ...
... Ambulances are furnished with advanced technology and skilled paramedics who play a vital role in identifying emergencies and their management. [8] India, however, lacks an effective system of prehospital management that caters to the needs of a patient in a compromised situation. This deficit extends to communication, dispatch, and trained personnel to perform medical interventions. ...
... [5] Ferrada et al. hypothesized that patients in hypovolemic shock would have comparable outcomes with the initiation of bleeding treatment (transfusion) before intubation (compressions, airway, and breathing), compared to those patients treated with the traditional ABC sequence. [8] In developed countries, ambulances are equipped with state-of-the art technology and highly trained paramedics to perform medical interventions, followed by their transport to definitive care, whereas in India, though some ambulances are equipped with life--saving interventional devices, they are often manned by unskilled medical personnel, thereby aiding to the further deterioration of the patient's condition. [9,10] The bystanders are always first on scene; hence, they play a major role in the golden hour of trauma. ...
Background: Circulation forms an integral part of a patient presenting to the emergency department (ED). Appropriate management of
critically ill patients being brought to the ED is of paramount importance, and inappropriate resuscitation during prehospital transfer could be
fatal. Methodology: This prospective study included all priority 1 and trauma patients arriving to the resuscitation room of our ED between
August 2018 and October 2018. Details of prehospital management of the circulatory status in the different types of prehospital transport and
methods used were noted. A comparison was done between ambulances and private vehicles and receiving prehospital care with the help of
univariate analysis. Results: During the study, we recruited 209 patients which comprised trauma (64.1%) and 67 nontrauma (35.9%) priority
1 patients. There was a male predominance (76.7%). Patients were transported by 108 ambulances (9.6%), private ambulances (26.9%), and
private vehicles (car, auto, and other vehicles) (60.3%). Of the 142 trauma patients, 66.1% received hemorrhage control as a part of prehospital
management. Of the 39.4% trauma patients transported through an ambulance, hypotension was observed in 3.6%, upon their arrival to the
ED. Dead and left against medical advice was seen in 0.5% and 1.9%, respectively, whereas 48.8% were discharged stable from the ED.
Conclusion: Ambulances bought in patients with adequate hemorrhage control than other vehicles. With an unstable prehospital management
in place, a significant sample of patients arrived at ED with a compromised circulatory status. Our study clearly highlights the glaring deficiency
in circulatory status at arrival to ED.
