• Joseph Ritondale, Mark Piehl, Sydney Caputo, Jacob Broome, Bryant McLafferty, Augustus Anderson, Cameron Belding, Danielle Tatum, Juan Duchesne, and Damage Control Resuscitation Study Group.
• From the Department of Surgery, Tulane University School of Medicine, New Orleans, LA (Ritondale, Caputo, McLafferty, Anderson, Belding, Tatum, Duchesne).
• J. Am. Coll. Surg. 2024 Apr 1; 238 (4): 367373367-373.

BackgroundAt the 2023 ATLS symposium, the priority of circulation was emphasized through the "x-airway-breathing-circulation (ABC)" sequence, where "x" stands for exsanguinating hemorrhage control. With growing evidence from military and civilian studies supporting an x-ABC approach to trauma care, a prehospital advanced resuscitative care (ARC) bundle emphasizing early transfusion was developed in our emergency medical services (EMS) system. We hypothesized that prioritization of prehospital x-ABC through ARC would reduce in-hospital mortality.Study DesignThis was a single-year prospective analysis of patients with severe hemorrhage. These patients were combined with our institution's historic controls before prehospital blood implementation. Included were patients with systolic blood pressure (SBP) less than 90 mmHg. Excluded were patients with penetrating head trauma or prehospital cardiac arrest. Two-to-one propensity matching for x-ABC to ABC groups was conducted, and the primary outcome, in-hospital mortality, was compared between groups.ResultsA total of 93 patients (x-ABC = 62, ABC = 31) met the inclusion criteria. There was no difference in patient age, sex, initial SBP, initial Glasgow Coma Score, and initial shock index between groups. When compared with the ABC group, x-ABC patients had significant improvement in vitals at emergency department admission. Overall mortality was lower in the x-ABC group (13% vs 47%, p < 0.001). Multivariable regression revealed that prehospital circulation-first prioritization was independently associated with decreased in-hospital mortality (odds ratio 0.15, 95% CI 0.04 to 0.54, p = 0.004).ConclusionsThis is the first analysis to demonstrate a prehospital survival benefit of x-ABC in this subset of patient with severe injury and hemorrhagic shock. Standardization of prehospital x-ABC management in this patient population warrants special consideration.Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.

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