Impact of circulation-first resuscitation on survival in trauma patients with hemorrhagic shock: a comparative retrospective cohort study – A TQIP registry analysis

Background: The traditional “airway–breathing–circulation” (ABC) sequence guides trauma resuscitation. In hemorrhagic shock, however, early airway intervention may precipitate hemodynamic collapse, whereas prioritizing circulation may confer benefits. Evidence supporting a circulation–airway–breathing (CAB) approach, in which transfusion precedes airway control, remains limited. This study evaluated whether CAB resuscitation is associated with improved survival compared with ABC in patients with traumatic hemorrhagic shock. Methods: We analyzed 2020–2022 data from the American College of Surgeons Trauma Quality Improvement Program. Patients with systolic blood pressure <90 mmHg on admission who underwent intubation within 30 minutes and transfusion within 1 hour were included. Based on the sequence of interventions, patients were classified into CAB (transfusion first) or ABC (intubation first) groups. Primary outcomes were 24-hour and 30-day mortality, assessed using Cox regression and Kaplan–Meier survival analysis. Results: Of 3184 eligible patients (CAB: n = 1472; ABC: n = 1712), most were male (79.0%), with a median age of 36 years, and injuries were evenly divided between blunt (51%) and penetrating (49%) mechanisms. Median intubation and transfusion times were 8 and 17 minutes in the ABC group and 16 and 7 minutes in the CAB group, respectively. Cardiopulmonary arrest occurred more frequently in the ABC group (17.8% vs. 11.9%; P < 0.001). Overall mortality was lower in the CAB group (20.4% vs. 31.5%; P < 0.001), as were 24-hour mortality (12.6% vs. 21.4%; P < 0.001) and 30-day mortality (19.0% vs. 29.1%; P < 0.001). CAB was independently associated with lower 24-hour mortality [hazard ratio (HR) 0.77; 95% confidence interval (CI), 0.64–0.93] and 30-day mortality (HR 0.81; 95% CI, 0.69–0.94). Conclusion: In patients with traumatic hemorrhagic shock, transfusion prior to intubation was associated with a lower incidence of cardiopulmonary arrest and improved early and late survival. Large multicenter prospective studies are needed to validate these findings and determine whether CAB resuscitation should be incorporated into future trauma care guidelines.