Meta-Analysis

. 2025 Jun 2;20(1):47.

doi: 10.1186/s13017-025-00618-2.

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^{1

2}, Saima Shafique³, Megan Brenner⁴, Clay Burlew⁵, Fausto Catena⁶, Julia Coleman⁷, Jamie Coleman⁸, Demetrios Demetriades⁹, Marc Demoya¹⁰, Salomone Di Saverio¹¹, Sharmila Dissanaike¹², Tom Dransfield¹³, Joseph DuBose¹⁴, Juan Duchesne¹⁵, Adel Elkbuli¹⁶, Esteban Foianini¹⁷, Josephine Gambardella³, Alberto Garcia¹⁸, Amy Goldberg¹⁹, Eric Goralnick²⁰, John Holcomb²¹, Messing Jonathan³, Bellal Joseph²², Lenworth Jacobs²³, Jeffrey Kerby²¹, Robert Lawerance²⁴, Stefan Leichtle³, Charles Lucas²⁵, Gustavo Machain²⁶, Jana Macleod²⁷, Zoe Maher¹⁹, Matthew Martin⁹, Napoleon Mendez²⁸, Carlos Menegozzo²⁹, Ilenia Merlini¹¹, Nicholas Namias³⁰, Mayur Narayan³¹, Carlos Ordonez¹⁸, Pablo Ottolino³², Mayur Patel³³, Zaffer A Qasim³⁴, Martha Quiodettis³⁵, LeAnne Sitari Young³⁶, Ashanti Ratnasekera³⁷, David Rayburn¹³, Juan Salamea³⁸, Babak Sarani³⁹, Thomas Scalea⁴⁰, Mark Seamon⁴¹, David Spain⁴², Portia Steele³, Sharven Taghavi¹⁵, Leah Tatebe⁴³, Felipe Vega⁴⁴, George Velmahos⁴⁵, Tanya Zakrison⁴⁶, Walter L Biffl⁴⁷, Dimitrios Damaskos⁴⁸, Federico Coccolini⁴⁹, Carlo Vallicelli⁵⁰, Ernest E Moore⁵¹, Luca Ansaloni⁵², Yoram Kluger⁵³

Affiliations

¹ Inova Healthcare System, 3300 Gallows Road, Falls Church, VA, USA. paula.ferrada@inova.org.
² University of Virginia, Charlottesville, USA. paula.ferrada@inova.org.
³ Inova Healthcare System, 3300 Gallows Road, Falls Church, VA, USA.
⁴ David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
⁵ University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
⁶ University of Bologna, Bufalini Hospital, Cesena, Italy.
⁷ The Ohio State University, Columbus, OH, USA.
⁸ University of Louisville School of Medicine, Louisville, KY, USA.
⁹ Department of Surgery, Los Angeles County + USC Medical Center, Los Angeles, CA, USA.
¹⁰ Medical College of Wisconsin, Froedtert Trauma Center, Milwaukee, WI, USA.
¹¹ AST Ascoli Piceno, Madonna del Soccorso Hospital, Ascoli Piceno, Italy.
¹² University of New Mexico, Albuquerque, NM, USA.
¹³ New Orleans EMS, New Orleans, LA, USA.
¹⁴ Dell Medical School, University of Texas - Austin, Austin, TX, USA.
¹⁵ Tulane University School of Medicine, New Orleans, LA, USA.
¹⁶ Orlando Regional Medical Center, Orlando, FL, USA.
¹⁷ Clinica Foianini, Santa Cruz, Bolivia.
¹⁸ Department of Surgery, Fundacion Valle Del Lili University Hospital, Universidad Icesi, Cali, Colombia.
¹⁹ Temple University Hospital, Philadelphia, PA, USA.
²⁰ Department of Emergency Medicine Mass General Brigham, Harvard Medical School, Boston, MA, USA.
²¹ University of Alabama at Birmingham, Birmingham, AL, USA.
²² Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
²³ University of Connecticut, Farmington, CT, USA.
²⁴ Pro EMS, Cambridge, MA, USA.
²⁵ Wayne State University - Detroit Receiving Hospital, Detroit, MI, USA.
²⁶ Universidad Nacional de Caaguazu - Facultad de Ciencias Médicas, Coronel Oviedo, Paraguay.
²⁷ Kenyatta University, Nairobi, Kenya.
²⁸ Universidad de San Carlos, Ciudad de Guatemala, Guatemala.
²⁹ Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, SP, Brazil.
³⁰ University of Miami, Miami, FL, USA.
³¹ Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
³² Hospital Sótero del Río, Santiago, Chile.
³³ Vanderbilt University Medical Center, Nashville, TN, USA.
³⁴ University of Pennsylvania Health System, Philadelphia, PA, USA.
³⁵ Hospital Santo Tomas, Ciudad de Panama, Panama.
³⁶ Texas Children's Hospital, Houston, TX, USA.
³⁷ Drexel College of Medicine, ChristianaCare, Newark, DE, USA.
³⁸ Universidad del Azuay, Cuenca, Ecuador.
³⁹ Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
⁴⁰ University of Maryland, Shock Trauma Center, Baltimore, MD, USA.
⁴¹ University of Pennsylvania, Philadelphia, PA, USA.
⁴² Department of Surgery, Stanford University, Stanford, CA, USA.
⁴³ Northwestern University, Chicago, IL, USA.
⁴⁴ Hospital Angeles Lomas, Ciudad de Mexico, Mexico.
⁴⁵ Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
⁴⁶ University of Chicago Medicine, Chicago, IL, USA.
⁴⁷ Scripps Clinic/Scripps Clinic Medical Group, San Diego, CA, USA.
⁴⁸ Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK.
⁴⁹ General, Emergency and Trauma Surgery Dept, Pisa University Hospital, Pisa, Italy.
⁵⁰ General, Emergency and Trauma Surgery Department, Maurizio Bufalini Hospital, Cesena, Italy.
⁵¹ Ernest E. Moore Shock Trauma Center, University of Colorado Denver, Denver, CO, USA.
⁵² Unit of General Surgery I, Ospedali Riuniti of Bergamo, Bergamo, Italy.
⁵³ Lanido Medical Center, Natanya, Israel.

PMID: 40457450
PMCID: PMC12128548
DOI: 10.1186/s13017-025-00618-2

Meta-Analysis

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 et al. World J Emerg Surg. 2025.

. 2025 Jun 2;20(1):47.

doi: 10.1186/s13017-025-00618-2.

Authors

Affiliations

¹ Inova Healthcare System, 3300 Gallows Road, Falls Church, VA, USA. paula.ferrada@inova.org.
² University of Virginia, Charlottesville, USA. paula.ferrada@inova.org.
³ Inova Healthcare System, 3300 Gallows Road, Falls Church, VA, USA.
⁴ David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
⁵ University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
⁶ University of Bologna, Bufalini Hospital, Cesena, Italy.
⁷ The Ohio State University, Columbus, OH, USA.
⁸ University of Louisville School of Medicine, Louisville, KY, USA.
⁹ Department of Surgery, Los Angeles County + USC Medical Center, Los Angeles, CA, USA.
¹⁰ Medical College of Wisconsin, Froedtert Trauma Center, Milwaukee, WI, USA.
¹¹ AST Ascoli Piceno, Madonna del Soccorso Hospital, Ascoli Piceno, Italy.
¹² University of New Mexico, Albuquerque, NM, USA.
¹³ New Orleans EMS, New Orleans, LA, USA.
¹⁴ Dell Medical School, University of Texas - Austin, Austin, TX, USA.
¹⁵ Tulane University School of Medicine, New Orleans, LA, USA.
¹⁶ Orlando Regional Medical Center, Orlando, FL, USA.
¹⁷ Clinica Foianini, Santa Cruz, Bolivia.
¹⁸ Department of Surgery, Fundacion Valle Del Lili University Hospital, Universidad Icesi, Cali, Colombia.
¹⁹ Temple University Hospital, Philadelphia, PA, USA.
²⁰ Department of Emergency Medicine Mass General Brigham, Harvard Medical School, Boston, MA, USA.
²¹ University of Alabama at Birmingham, Birmingham, AL, USA.
²² Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, AZ, USA.
²³ University of Connecticut, Farmington, CT, USA.
²⁴ Pro EMS, Cambridge, MA, USA.
²⁵ Wayne State University - Detroit Receiving Hospital, Detroit, MI, USA.
²⁶ Universidad Nacional de Caaguazu - Facultad de Ciencias Médicas, Coronel Oviedo, Paraguay.
²⁷ Kenyatta University, Nairobi, Kenya.
²⁸ Universidad de San Carlos, Ciudad de Guatemala, Guatemala.
²⁹ Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, SP, Brazil.
³⁰ University of Miami, Miami, FL, USA.
³¹ Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
³² Hospital Sótero del Río, Santiago, Chile.
³³ Vanderbilt University Medical Center, Nashville, TN, USA.
³⁴ University of Pennsylvania Health System, Philadelphia, PA, USA.
³⁵ Hospital Santo Tomas, Ciudad de Panama, Panama.
³⁶ Texas Children's Hospital, Houston, TX, USA.
³⁷ Drexel College of Medicine, ChristianaCare, Newark, DE, USA.
³⁸ Universidad del Azuay, Cuenca, Ecuador.
³⁹ Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
⁴⁰ University of Maryland, Shock Trauma Center, Baltimore, MD, USA.
⁴¹ University of Pennsylvania, Philadelphia, PA, USA.
⁴² Department of Surgery, Stanford University, Stanford, CA, USA.
⁴³ Northwestern University, Chicago, IL, USA.
⁴⁴ Hospital Angeles Lomas, Ciudad de Mexico, Mexico.
⁴⁵ Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
⁴⁶ University of Chicago Medicine, Chicago, IL, USA.
⁴⁷ Scripps Clinic/Scripps Clinic Medical Group, San Diego, CA, USA.
⁴⁸ Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK.
⁴⁹ General, Emergency and Trauma Surgery Dept, Pisa University Hospital, Pisa, Italy.
⁵⁰ General, Emergency and Trauma Surgery Department, Maurizio Bufalini Hospital, Cesena, Italy.
⁵¹ Ernest E. Moore Shock Trauma Center, University of Colorado Denver, Denver, CO, USA.
⁵² Unit of General Surgery I, Ospedali Riuniti of Bergamo, Bergamo, Italy.
⁵³ Lanido Medical Center, Natanya, Israel.

PMID: 40457450
PMCID: PMC12128548
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 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.

PubMed Disclaimer

Conflict of interest statement

Declarations. Ethics approval and consent to participate: This is a consensus statement and does not require an ethics declaration. “Ethics declaration: Not applicable”. Competing interests: There are no competing interests or conflicts of interest to declare pertinent to this manuscript.

Figures

**Fig. 1**
Flow chart diagram describing the identification, screening, and selection of studies included in the systematic review and meta-analysis (SR and MA) for assessing the risk of mortality among exsanguinating hemorrhage patients in trauma, (n = 6 studies)

**Fig. 2**
Forest Plot with individual (OR) and pooled effect size (POR) with 95%CI and study’ weights: meta-analysis of the risk of mortality among trauma patients (N = 5 studies)

**Fig. 3**
a Forest plot for exploratory sub-group analysis with prospective cohort studies comparing the risk of mortality between ABC and CAB approach (N = 2). b Forest plot for exploratory sub-group analysis with retrospective cohort studies comparing the risk of mortality between ABC and CAB approach (N = 3)

See this image and copyright information in PMC

References

1. 10th Edition of the Advanced Trauma Life Support ® (ATLS ® ) Student Course Manual. Chicago (IL): American College of Surgeons; 2018.
1. Ferrada P, Dissanaike S. Circulation first for the rapidly bleeding trauma patient—it is time to reconsider the ABCs of trauma care. JAMA Surg. 2023;158(8):884–5. 10.1001/jamasurg.2022.8436. - PubMed
1. Bala M, Kashuk J, Moore EE, Catena F, Leppaniemi A, Ansaloni L, et al. Establishing position papers by the WSES. World J Emerg Surg. 2018;13:1. - PMC - PubMed
1. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schünemann HJ. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–6. 10.1136/bmj.39489.470347.AD. - PMC - PubMed
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Prioritizing circulation over airway to improve survival in trauma patients with exsanguinating injuries: a world society of emergency surgery-panamerican trauma consensus statement

Affiliations

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

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

Publication types

MeSH terms

LinkOut - more resources

Full Text Sources

Medical

Miscellaneous