A Circulation-First Approach for Resuscitation of Trauma Patients With Hemorrhagic Shock

Abstract

The original guidelines of cardiopulmonary resuscitation focused on the establishment of an airway and rescue breathing before restoration of circulation through cardiopulmonary resuscitation. As a result, the airway-breathing-circulation approach became the central guiding principle of resuscitation. Despite new guidelines by the American Heart Association for a circulation-first approach, Advanced Trauma Life Support guidelines continue to advocate for the airway-breathing-circulation sequence. Although definitive airway management is often necessary for severely injured patients, endotracheal intubation (ETI) before resuscitation in patients with hemorrhagic shock may worsen hypotension and precipitate cardiac arrest. In severely injured patients, a paradigm shift should be considered, which prioritizes restoration of circulation before ETI and positive pressure ventilation while maintaining a focus on basic airway assessment and noninvasive airway interventions. For this patient population, the most reasonable current strategy may be to target a simultaneous resuscitation approach, with immediate efforts to control hemorrhage and provide basic airway interventions while prioritizing volume resuscitation with blood products and deferring ETI until adequate systemic perfusion has been attained. We believe that a circulation-first sequence will improve both survival and neurologic outcomes for a traumatically injured patient and will continue to advocate this approach, as additional clinical evidence is generated to inform how to best tailor circulation-first resuscitation for varied injury patterns and patient populations.

Faster refill in an urban emergency medical services system saves lives: A prospective preliminary evaluation of a prehospital advanced resuscitative care bundle

“…Delivery of the ARC bundle was also associated with reduced need for prehospital advanced airway management, an intervention known known to increase prehospital time and mortality. 23 Our findings are consistent with the recent combined analysis of the Prehospital Air Medical Plasma (PAMPer) and Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport (STAAMP) trials, which evaluated the use of prehospital blood products and TXA. This study suggested that every 1 minute of delay in the prehospital administration of blood or TXA was associated with a 2% increase in 30-day mortality.…”

“…The 3-minute additional prehospital time observed in the ARC group also allowed for 2 U of PRBCs, calcium, and TXA to be administered, interventions that were associated with improved mortality. Delivery of the ARC bundle was also associated with reduced need for prehospital advanced airway management, an intervention known known to increase prehospital time and mortality 23 …”

25% Human Serum Albumin Improves Hemodynamics and Prevents the Need for Nearly All Pre-Hospital Resuscitation in a Rat (Rattus Norvegicus) Model of Trauma and Hemorrhage

“…We believe that by lowering the isoflurane concentration, we essentially lowered the severity of shock and/or increased the effectiveness of any fluid given, increasing model survivability. Clinically, this supports the idea of prioritizing hemodynamics and basic airway management over advanced airway management requiring intubation and sedation (20).…”

Prioritizing Circulation to Improve Outcomes for Patients with Exsanguinating Injury: A Literature Review and Techniques to Help Clinicians Achieve Bleeding Control

“…Overall, there is a growing body of evidence and discussion suggesting that a circulation-first approach is justified when caring for trauma patients, particularly those in hemorrhagic shock. 20 , 21 Patients in hemorrhagic shock are particularly prone to the circulatory collapse associated with early intubation and require adequate resuscitation before airway control. Larger prospective clinical studies in both military and civilian populations are essential to definitively establish the preferred method of resuscitation.…”