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Circulation First for the Rapidly Bleeding Trauma Patient—It Is Time to Reconsider the ABCs of Trauma Care

To identify the key insights or developments described in this article
1 Credit CME

Uncontrolled hemorrhaging is the leading cause worldwide of preventable death after injury. Trauma is the epitome of a time-sensitive problem because time to hemorrhage control and stabilization of injuries, along with resuscitation, is vital to patient survival. To improve the efficacy of initial resuscitation, especially among those who are less familiar with managing trauma, systematic protocols for initial assessment and resuscitation have been developed. The most widely used and best known is the system developed by the American College of Surgeons’ (ACS’s) Committee on Trauma: the Advanced Trauma Life Support Program (ATLS).1 This protocol uses an airway, breathing, circulation (ABC) sequence for initial evaluation that has been well established for many years. The evidence supporting the systematic ABC approach to injured patients is based on expert consensus, with little literature to support clinical application of the sequence of interventions.1 In many high-resource environments, such as urban trauma centers in the US, this approach is performed simultaneously rather than sequentially. But many other facilities have fewer resources and cannot afford to do the ABCs at the same time. In these low- and middle-income environments, often the resource that is most needed is the human resource. The paradox is that, in these places with fewer resources, penetrating trauma resulting in injuries that bleed rapidly occurs significantly more often.

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Article Information

Corresponding Author: Paula Ferrada, MD, Division of Acute Care Surgery, Inova Health System, 3300 Gallows Rd, Fairfax, VA 22031 (paula.ferrada@inova.org).

Published Online: May 17, 2023. doi:10.1001/jamasurg.2022.8436

Conflict of Interest Disclosures: Dr Dissanaike reported receiving personal fees from Heron Therapeutics outside the submitted work. No other disclosures were reported.

References
1.
American College of Surgeons. Advanced Trauma Life Support. Accessed March 28, 2023. https://www.facs.org/quality-programs/trauma/education/advanced-trauma-life-support/
2.
Shafi  S , Gentilello  L .  Pre-hospital endotracheal intubation and positive pressure ventilation is associated with hypotension and decreased survival in hypovolemic trauma patients: an analysis of the National Trauma Data Bank.   J Trauma. 2005;59(5):1140-1147. doi:10.1097/01.ta.0000196434.88182.77 PubMedGoogle ScholarCrossref
3.
Ferrada  P , Manzano-Nunez  R , Lopez-Castilla  V ,  et al.  Meta-analysis of post-intubation hypotension: a plea to consider circulation first in hypovolemic patients.   Am Surg. 2019;85(2):167-172. doi:10.1177/000313481908500223 PubMedGoogle ScholarCrossref
4.
Ferrada  P .  Shifting priorities from intubation to circulation first in hypotensive trauma patients.   Am Surg. 2018;84(2):e75-e76. doi:10.1177/000313481808400213 PubMedGoogle ScholarCrossref
5.
Ferrada  P , Callcut  RA , Skarupa  DJ ,  et al; AAST Multi-Institutional Trials Committee.  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.   World J Emerg Surg. 2018;13:8. doi:10.1186/s13017-018-0168-3 PubMedGoogle ScholarCrossref
6.
Hörer  TM , Pirouzram  A , Khan  M ,  et al; Damage Control Resuscitation Committee.  Endovascular resuscitation and trauma management (EVTM)—practical aspects and implementation.   Shock. 2021;56(1S)(suppl 1):37-41. doi:10.1097/SHK.0000000000001529PubMedGoogle ScholarCrossref
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Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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