Prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries: a world society of emergency surgery-panamerican trauma consensus statement
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 patie...
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2025-06-01
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| Series: | World Journal of Emergency Surgery |
| Online Access: | https://doi.org/10.1186/s13017-025-00618-2 |
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| author | Paula Ferrada Saima Shafique Megan Brenner Clay Burlew Fausto Catena Julia Coleman Jamie Coleman Demetrios Demetriades Marc Demoya Salomone Di Saverio Sharmila Dissanaike Tom Dransfield Joseph DuBose Juan Duchesne Adel Elkbuli Esteban Foianini Josephine Gambardella Alberto Garcia Amy Goldberg Eric Goralnick John Holcomb Messing Jonathan Bellal Joseph Lenworth Jacobs Jeffrey Kerby Robert Lawerance Stefan Leichtle Charles Lucas Gustavo Machain Jana Macleod Zoe Maher Matthew Martin Napoleon Mendez Carlos Menegozzo Ilenia Merlini Nicholas Namias Mayur Narayan Carlos Ordonez Pablo Ottolino Mayur Patel Zaffer A. Qasim Martha Quiodettis LeAnne Sitari Young Ashanti Ratnasekera David Rayburn Juan Salamea Babak Sarani Thomas Scalea Mark Seamon David Spain Portia Steele Sharven Taghavi Leah Tatebe Felipe Vega George Velmahos Tanya Zakrison Walter L. Biffl Dimitrios Damaskos Federico Coccolini Carlo Vallicelli Ernest E. Moore Luca Ansaloni Yoram Kluger |
| author_facet | Paula Ferrada Saima Shafique Megan Brenner Clay Burlew Fausto Catena Julia Coleman Jamie Coleman Demetrios Demetriades Marc Demoya Salomone Di Saverio Sharmila Dissanaike Tom Dransfield Joseph DuBose Juan Duchesne Adel Elkbuli Esteban Foianini Josephine Gambardella Alberto Garcia Amy Goldberg Eric Goralnick John Holcomb Messing Jonathan Bellal Joseph Lenworth Jacobs Jeffrey Kerby Robert Lawerance Stefan Leichtle Charles Lucas Gustavo Machain Jana Macleod Zoe Maher Matthew Martin Napoleon Mendez Carlos Menegozzo Ilenia Merlini Nicholas Namias Mayur Narayan Carlos Ordonez Pablo Ottolino Mayur Patel Zaffer A. Qasim Martha Quiodettis LeAnne Sitari Young Ashanti Ratnasekera David Rayburn Juan Salamea Babak Sarani Thomas Scalea Mark Seamon David Spain Portia Steele Sharven Taghavi Leah Tatebe Felipe Vega George Velmahos Tanya Zakrison Walter L. Biffl Dimitrios Damaskos Federico Coccolini Carlo Vallicelli Ernest E. Moore Luca Ansaloni Yoram Kluger |
| author_sort | Paula Ferrada |
| collection | DOAJ |
| description | 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 methodology3, 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 |
| format | Article |
| id | doaj-art-8fa4dfea628640ab966ff3ab122bd709 |
| institution | OA Journals |
| issn | 1749-7922 |
| language | English |
| publishDate | 2025-06-01 |
| publisher | BMC |
| record_format | Article |
| series | World Journal of Emergency Surgery |
| spelling | doaj-art-8fa4dfea628640ab966ff3ab122bd7092025-08-20T02:05:45ZengBMCWorld Journal of Emergency Surgery1749-79222025-06-0120111110.1186/s13017-025-00618-2Prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries: a world society of emergency surgery-panamerican trauma consensus statementPaula Ferrada0Saima Shafique1Megan Brenner2Clay Burlew3Fausto Catena4Julia Coleman5Jamie Coleman6Demetrios Demetriades7Marc Demoya8Salomone Di Saverio9Sharmila Dissanaike10Tom Dransfield11Joseph DuBose12Juan Duchesne13Adel Elkbuli14Esteban Foianini15Josephine Gambardella16Alberto Garcia17Amy Goldberg18Eric Goralnick19John Holcomb20Messing Jonathan21Bellal Joseph22Lenworth Jacobs23Jeffrey Kerby24Robert Lawerance25Stefan Leichtle26Charles Lucas27Gustavo Machain28Jana Macleod29Zoe Maher30Matthew Martin31Napoleon Mendez32Carlos Menegozzo33Ilenia Merlini34Nicholas Namias35Mayur Narayan36Carlos Ordonez37Pablo Ottolino38Mayur Patel39Zaffer A. Qasim40Martha Quiodettis41LeAnne Sitari Young42Ashanti Ratnasekera43David Rayburn44Juan Salamea45Babak Sarani46Thomas Scalea47Mark Seamon48David Spain49Portia Steele50Sharven Taghavi51Leah Tatebe52Felipe Vega53George Velmahos54Tanya Zakrison55Walter L. Biffl56Dimitrios Damaskos57Federico Coccolini58Carlo Vallicelli59Ernest E. Moore60Luca Ansaloni61Yoram Kluger62Inova Healthcare SystemInova Healthcare SystemDavid Geffen School of Medicine, UCLAUniversity of Colorado Anschutz Medical CampusUniversity of Bologna, Bufalini HospitalThe Ohio State UniversityUniversity of Louisville School of MedicineDepartment of Surgery, Los Angeles County + USC Medical CenterMedical College of Wisconsin, Froedtert Trauma CenterAST Ascoli Piceno, Madonna del Soccorso HospitalUniversity of New MexicoNew Orleans EMSDell Medical School, University of Texas – AustinTulane University School of MedicineOrlando Regional Medical CenterClinica FoianiniInova Healthcare SystemDepartment of Surgery, Fundacion Valle Del Lili University Hospital, Universidad IcesiTemple University HospitalDepartment of Emergency Medicine Mass General Brigham, Harvard Medical SchoolUniversity of Alabama at BirminghamInova Healthcare SystemDivision of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of ArizonaUniversity of ConnecticutUniversity of Alabama at BirminghamPro EMSInova Healthcare SystemWayne State University - Detroit Receiving HospitalUniversidad Nacional de Caaguazu - Facultad de Ciencias MédicasKenyatta UniversityTemple University HospitalDepartment of Surgery, Los Angeles County + USC Medical CenterUniversidad de San CarlosFaculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São PauloAST Ascoli Piceno, Madonna del Soccorso HospitalUniversity of MiamiRutgers Robert Wood Johnson Medical SchoolDepartment of Surgery, Fundacion Valle Del Lili University Hospital, Universidad IcesiHospital Sótero del RíoVanderbilt University Medical CenterUniversity of Pennsylvania Health SystemHospital Santo TomasTexas Children’s HospitalDrexel College of Medicine, ChristianaCareNew Orleans EMSUniversidad del AzuayDepartment of Surgery, George Washington University School of Medicine and Health SciencesUniversity of Maryland, Shock Trauma CenterUniversity of PennsylvaniaDepartment of Surgery, Stanford UniversityInova Healthcare SystemTulane University School of MedicineNorthwestern UniversityHospital Angeles LomasMassachusetts General Hospital, Harvard Medical SchoolUniversity of Chicago MedicineScripps Clinic/Scripps Clinic Medical GroupRoyal Infirmary of EdinburghGeneral, Emergency and Trauma Surgery Dept, Pisa University HospitalGeneral, Emergency and Trauma Surgery Department, Maurizio Bufalini HospitalErnest E. Moore Shock Trauma Center, University of Colorado DenverUnit of General Surgery I, Ospedali Riuniti of BergamoLanido Medical CenterAbstract 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 methodology3, 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 evidencehttps://doi.org/10.1186/s13017-025-00618-2 |
| spellingShingle | Paula Ferrada Saima Shafique Megan Brenner Clay Burlew Fausto Catena Julia Coleman Jamie Coleman Demetrios Demetriades Marc Demoya Salomone Di Saverio Sharmila Dissanaike Tom Dransfield Joseph DuBose Juan Duchesne Adel Elkbuli Esteban Foianini Josephine Gambardella Alberto Garcia Amy Goldberg Eric Goralnick John Holcomb Messing Jonathan Bellal Joseph Lenworth Jacobs Jeffrey Kerby Robert Lawerance Stefan Leichtle Charles Lucas Gustavo Machain Jana Macleod Zoe Maher Matthew Martin Napoleon Mendez Carlos Menegozzo Ilenia Merlini Nicholas Namias Mayur Narayan Carlos Ordonez Pablo Ottolino Mayur Patel Zaffer A. Qasim Martha Quiodettis LeAnne Sitari Young Ashanti Ratnasekera David Rayburn Juan Salamea Babak Sarani Thomas Scalea Mark Seamon David Spain Portia Steele Sharven Taghavi Leah Tatebe Felipe Vega George Velmahos Tanya Zakrison Walter L. Biffl Dimitrios Damaskos Federico Coccolini Carlo Vallicelli Ernest E. Moore Luca Ansaloni Yoram Kluger Prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries: a world society of emergency surgery-panamerican trauma consensus statement World Journal of Emergency Surgery |
| title | Prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries: a world society of emergency surgery-panamerican trauma consensus statement |
| title_full | Prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries: a world society of emergency surgery-panamerican trauma consensus statement |
| title_fullStr | Prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries: a world society of emergency surgery-panamerican trauma consensus statement |
| title_full_unstemmed | Prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries: a world society of emergency surgery-panamerican trauma consensus statement |
| title_short | Prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries: a world society of emergency surgery-panamerican trauma consensus statement |
| title_sort | prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries a world society of emergency surgery panamerican trauma consensus statement |
| url | https://doi.org/10.1186/s13017-025-00618-2 |
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