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, Paula Ferrada, Rachael A. Callcut, David J. Skarupa, Therese M. Duane, Alberto Garcia, Kenji Inaba, Desmond Khor, Vincent Anto, Jason Sperry, David Turay, Rachel M. Nygaard, Martin A. Schreiber, Toby Enniss, Michelle McNutt, Herb Phelan, Kira Smith, Forrest O. Moore, Irene Tabas, Joseph Dubose

    Research output: Contribution to journalArticle

    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.

    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",
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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

    PY - 2018/2/5

    Y1 - 2018/2/5

    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 - Hypovolemia and hypotension

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    KW - Resuscitation in trauma

    KW - Trauma

    KW - Trauma resuscitation

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