Circulation first – the time has come to question the sequencing of care in the ABCs of trauma; an American Association for the Surgery of Trauma multicenter trial

Abstract

BackgroundThe 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 (CAB), compared to those patients treated with the traditional ABC sequence.MethodsThis study was sponsored by the American Association for the Surgery of Trauma multicenter trials committee. We performed a retrospective analysis of all patients that presented to trauma centers with presumptive hypovolemic shock indicated by pre-hospital or emergency department hypotension and need for intubation from January 1, 2014 to July 1, 2016. Data collected included demographics, timing of intubation, vital signs before and after intubation, timing of the blood transfusion initiation related to intubation, and outcomes.ResultsFrom 440 patients that met inclusion criteria, 245 (55.7%) received intravenous blood product resuscitation first (CAB), and 195 (44.3%) were intubated before any resuscitation was started (ABC). There was no difference in ISS, mechanism, or comorbidities. Those intubated prior to receiving transfusion had a lower GCS than those with transfusion initiation prior to intubation (ABC: 4, CAB:9, p = 0.005). Although mortality was high in both groups, there was no statistically significant difference (CAB 47% and ABC 50%). In multivariate analysis, initial SBP and initial GCS were the only independent predictors of death.ConclusionThe current study highlights that many trauma centers are already initiating circulation first prior to intubation when treating hypovolemic shock (CAB), even in patients with a low GCS. This practice was not associated with an increased mortality. Further prospective investigation is warranted.Trial registrationIRB approval number: HM20006627. Retrospective trial not registered.

Atención de los pacientes con trauma grave durante los primeros días: evolución entre la urgencia, el pabellón y la unidad de cuidados intensivos

“…El porcentaje de pacientes que cumplieron criterios de CAT coincide con lo publicado 22,23 . La frecuencia de TM fue mayor que lo descrito tradicionalmente en trauma, pero menor a lo reportado por estudios recientes 7 . La relación PFC:GR fue elevada (casi 1:1) y la mayoría de las transfusiones se aportaron el primer día, de acuerdo a las recomendaciones actuales 24 .…”

“…Se encontraron varias diferencias estadísticamente significativas entre pacientes con TEC y otros traumas, pero consideramos que la única clínicamente realmente fue la mayor estadía hospitalaria para el TEC. La posibilidad de que pacientes con TEC versus otros traumas presenten más complicaciones y mayor mortalidad, ha sido reconocida por distintos autores, planteándose la posibilidad de un manejo inicial diferenciado 7,8 .…”

“…Esta visión integral puede ser compleja en etapas iniciales, pues deben tenerse en cuenta los tratamientos específicos de los distintos tipos de trauma. En este sentido, es especialmente desafiante el enfrentamiento de los pacientes que presentan un trauma encefalocraneano (TEC) junto con un shock hemorrágico (SH) secundario a trauma, por lo que algunos autores han planteado la necesidad de revisar los algoritmos tradicionales de manejo inicial del trauma 7,8 .…”

Western Trauma Association critical decisions in trauma: airway management in adult trauma patients

“… 24 25 Postintubation hypotension is associated with increased mortality in trauma patients. 26–28 For patients who arrive hemodynamically unstable or stable with a shock index >0.8, 29 30 several options for simultaneous resuscitation exist including early blood transfusion using a “circulation first” approach, 31 resuscitative endovascular balloon occlusion of the aorta, 32 and intravenous push-dose pressors. 33 34 In particular, if the airway can be maintained with basic maneuvers and the patient is oxygenating and ventilating, placement of a definitive airway with an endotracheal tube can be deferred until the hemodynamic status of the patient can be addressed.…”

The Sequence of Care – Do New Methods Warrant a Shift from the Standard Abc to a Cabc Approach?

“…Internationally, adaptions and alterations have modified the ABC approach to fit a diverse area in which it is currently used causing the ABC algorithm to become almost unrecognisable in some instances. However, the standard ABCDE approach is still widely accepted by experts internationally in emergency medicine (7,14,18,21).…”