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

AAST Multi-Institutional Trials Committee

Research output: Contribution to journalArticle

3 Citations (Scopus)

Abstract

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 (CAB), compared to those patients treated with the traditional ABC sequence. Methods: This 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. Results: From 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. Conclusion: The 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.

Original languageEnglish (US)
Article number8
JournalWorld Journal of Emergency Surgery
Volume13
Issue number1
DOIs
StatePublished - Feb 5 2018

Fingerprint

Intubation
Multicenter Studies
Respiration
Wounds and Injuries
Shock
Trauma Centers
Resuscitation
Mortality
Vital Signs
Hospital Departments
Standard of Care
Blood Transfusion
Hypotension
Hospital Emergency Service
Comorbidity
Multivariate Analysis
Demography
cellulose acetate-butyrate
Hemorrhage

Keywords

  • Circulation
  • Circulation first
  • Effects of intubation
  • Hypotension and resuscitation
  • Hypotension in trauma
  • Hypovolemia and hypotension
  • Resuscitation
  • Resuscitation in trauma
  • Trauma
  • Trauma resuscitation

ASJC Scopus subject areas

  • Surgery
  • Emergency Medicine

Cite this

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. / AAST Multi-Institutional Trials Committee.

In: World Journal of Emergency Surgery, Vol. 13, No. 1, 8, 05.02.2018.

Research output: Contribution to journalArticle

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abstract = "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 (CAB), compared to those patients treated with the traditional ABC sequence. Methods: This 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. Results: From 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. Conclusion: The 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.",
keywords = "Circulation, Circulation first, Effects of intubation, Hypotension and resuscitation, Hypotension in trauma, Hypovolemia and hypotension, Resuscitation, Resuscitation in trauma, Trauma, Trauma resuscitation",
author = "{AAST Multi-Institutional Trials Committee} and Paula Ferrada and Callcut, {Rachael A.} and Skarupa, {David J.} and Duane, {Therese M.} and Alberto Garcia and Kenji Inaba and Desmond Khor and Vincent Anto and Jason Sperry and David Turay and Nygaard, {Rachel M.} and Schreiber, {Martin A.} and Toby Enniss and Michelle McNutt and Herb Phelan and Kira Smith and Moore, {Forrest O.} and Irene Tabas and Joseph Dubose",
year = "2018",
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T1 - 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

AU - AAST Multi-Institutional Trials Committee

AU - Ferrada, Paula

AU - Callcut, Rachael A.

AU - Skarupa, David J.

AU - Duane, Therese M.

AU - Garcia, Alberto

AU - Inaba, Kenji

AU - Khor, Desmond

AU - Anto, Vincent

AU - Sperry, Jason

AU - Turay, David

AU - Nygaard, Rachel M.

AU - Schreiber, Martin A.

AU - Enniss, Toby

AU - McNutt, Michelle

AU - Phelan, Herb

AU - Smith, Kira

AU - Moore, Forrest O.

AU - Tabas, Irene

AU - Dubose, Joseph

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N2 - 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 (CAB), compared to those patients treated with the traditional ABC sequence. Methods: This 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. Results: From 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. Conclusion: The 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.

AB - 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 (CAB), compared to those patients treated with the traditional ABC sequence. Methods: This 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. Results: From 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. Conclusion: The 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.

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KW - Hypotension in trauma

KW - Hypovolemia and hypotension

KW - Resuscitation

KW - Resuscitation in trauma

KW - Trauma

KW - Trauma resuscitation

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