Prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries: a world society of emergency surgery-panamerican trauma consensus statement

Paula Ferrada, Inova Healthcare System, 3300 Gallows Road, Falls Church, VA, USA. paula.ferrada@inova.org.
Saima Shafique, Inova Healthcare System, 3300 Gallows Road, Falls Church, VA, USA.
Megan Brenner, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
Clay Burlew, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
Fausto Catena, University of Bologna, Bufalini Hospital, Cesena, Italy.
Julia Coleman, The Ohio State University, Columbus, OH, USA.
Jamie Coleman, University of Louisville School of Medicine, Louisville, KY, USA.
Demetrios Demetriades, Department of Surgery, Los Angeles County + USC Medical Center, Los Angeles, CA, USA.
Marc Demoya, Medical College of Wisconsin, Froedtert Trauma Center, Milwaukee, WI, USA.
Salomone Di Saverio, AST Ascoli Piceno, Madonna del Soccorso Hospital, Ascoli Piceno, Italy.
Sharmila Dissanaike, University of New Mexico, Albuquerque, NM, USA.
Tom Dransfield, New Orleans EMS, New Orleans, LA, USA.
Joseph DuBose, Dell Medical School, University of Texas - Austin, Austin, TX, USA.
Juan Duchesne, Tulane University School of Medicine, New Orleans, LA, USA.
Adel Elkbuli, Orlando Regional Medical Center, Orlando, FL, USA.
Esteban Foianini, Clinica Foianini, Santa Cruz, Bolivia.
Josephine Gambardella, Inova Healthcare System, 3300 Gallows Road, Falls Church, VA, USA.
Alberto Garcia, Department of Surgery, Fundacion Valle Del Lili University Hospital, Universidad Icesi, Cali, Colombia.
Amy Goldberg, Temple University Hospital, Philadelphia, PA, USA.
Eric Goralnick, Department of Emergency Medicine Mass General Brigham, Harvard Medical School, Boston, MA, USA.
John Holcomb, University of Alabama at Birmingham, Birmingham, AL, USA.
Messing Jonathan, Inova Healthcare System, 3300 Gallows Road, Falls Church, VA, USA.
Bellal Joseph, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
Lenworth Jacobs, University of Connecticut, Farmington, CT, USA.
Jeffrey Kerby, University of Alabama at Birmingham, Birmingham, AL, USA.
Robert Lawerance, Pro EMS, Cambridge, MA, USA.
Stefan Leichtle, Inova Healthcare System, 3300 Gallows Road, Falls Church, VA, USA.
Charles Lucas, Wayne State University - Detroit Receiving Hospital, Detroit, MI, USA.
Gustavo Machain, Universidad Nacional de Caaguazu - Facultad de Ciencias Médicas, Coronel Oviedo, Paraguay.
Jana Macleod, Kenyatta University, Nairobi, Kenya.
Zoe Maher, Temple University Hospital, Philadelphia, PA, USA.
Matthew Martin, Department of Surgery, Los Angeles County + USC Medical Center, Los Angeles, CA, USA.

Document Type

Journal Article

Publication Date

6-2-2025

Journal

World journal of emergency surgery : WJES

Volume

20

Issue

1

DOI

10.1186/s13017-025-00618-2

Abstract

INTRODUCTION: Hemorrhage is one of the leading causes of preventable death in trauma patients. For decades, the Airway-Breathing-Circulation (ABC) approach has been the cornerstone of trauma care. However, emerging evidence suggests that prioritizing airway management in exsanguinating patients may worsen hypotension and increase mortality. This systematic review and meta-analysis aim to evaluate the effectiveness of the Circulation-Airway-Breathing (CAB) approach compared to the traditional ABC sequence in improving survival in trauma patients with severe hemorrhage. METHODS: A systematic review was conducted in accordance with the PRISMA guidelines. Databases including PubMed and Ovid MEDLINE, SCOPUS, web of science and EMBASE were searched for studies published up to September 2024. Eligible studies included observational and comparative studies reporting outcomes of trauma patients with exsanguinating hemorrhage. The Newcastle-Ottawa Scale was used for risk of bias assessment. A meta-analysis was performed using a random-effects model to calculate pooled odds ratios (OR) for mortality, with 95% confidence intervals (CI). Subgroup analysis was conducted to compare the ABC and CAB approaches in prospective and retrospective studies. RESULTS: Six studies (N = 11,855 patients) met the inclusion criteria. The meta-analysis revealed a significant increase in mortality associated with the ABC approach (pooled OR: 3.65, 95% CI: 1.74-7.65). Subgroup analysis of prospective cohort studies found an even higher mortality risk (POR: 9.99, 95% CI: 5.59-17.85) when compared with POR of retrospective studies (POR: 2.42, 95%CI: 1.08-5.36). High heterogeneity (I2 = 92%) was observed across the studies, likely due to variations in patient populations and resuscitation protocols. CONCLUSION: Prioritizing circulation over airway management in trauma patients with exsanguinating injuries significantly reduces mortality compared to the traditional ABC approach. The present consensus paper, conducted according to the WSES methodology, aims to provide a review of the literature comparing the CAB approach to the traditional ABC sequence in trauma patients with exsanguinating hemorrhage, to develop a shared consensus statement based on the currently available evidence.

Department

Surgery

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